Assessment of the Depressed or Anxious Patient in Medical Settings

Key Points

• Patients with anxiety and depressive disorders often present with somatic complaints.

• Risk assessment includes identifying modifiable risk factors and developing a corresponding treatment plan.

• "Contracts for safety" have no empiric data to support their effectiveness in risk management.

• Worsening symptoms or suicidal ideation may require psychiatric hospitalization.

Diagnosing anxiety and depressive disorders may prove especially challenging in medical settings. The majority of patients suffering from such illnesses will more frequently present with somatic complaints, while only a minority will present with purely psychological symptoms and concerns (Bridges and Goldberg, 1985). Difficulties in diagnosis may be secondary to a patient's inability to articulate psychological problems, reticence to speak of emotional difficulties, the short time allowed for patient visits, or a primary care physician's relative lack of training in assessing and treating mental health disorders. Many presenting complaints may be consistent with symptoms of coexisting medical illnesses, further complicating assessment and likely requiring additional etio-logic investigation. Of new patients presenting to an urban clinic, for example, only 17% presented with purely psychological symptoms. Of the remaining patients, 32% presented with pure somatization, 27% presented with symptoms for a coexisting medical illness, and 24% presented with an initial physical complaint that they were later able to relate to a psychological problem (Bridges and Goldberg, 1985). However, clinical clues in patients with physical complaints may identify a subgroup of patients who warrant further evaluation for an anxiety or depressive disorder. This includes patients who present with multiple physical symptoms (six or more), have higher ratings of symptom severity and lower ratings of overall health, and have an encounter that the physician perceives as "difficult" (Kroenke et al., 1997).

Assessment of anxious or depressed patients requires establishing specific psychiatric diagnosis(es), providing a thorough risk assessment (i.e., suicidality, homicidality, ability or inability to care for self), assessing the severity of the illness, identifying specific target symptoms to track over time, assessing factors that are likely complicating or exacerbating the illness (e.g. medical disorders, substance abuse), and gathering collateral information whenever possible from family, friends, or other providers (Box 47-6). Distinguishing bipolar from unipolar depression, as discussed previously, is one of the most important distinctions when establishing diagnosis. In addition, clinicians should look for the presence of comorbid anxiety disorders, because patients with such disorders often require lower initial antidepressant dosing and may have their anxiety symptoms paradoxically worsen as treatment is initiated unless lower doses are used (Table 47-2). Education on the medical nature of depression and anxiety may prove extremely helpful, because both patients and families often believe that psychiatric illness is evidence of "weakness" or indicative of some other personal failing. Information on prognosis and the expected treatment course may lessen pressure and expectations for rapid improvement and let the patient know when to expect medication benefit.

Physicians should assess the severity of illness and develop a list of target symptoms to track and measure over time, to better evaluate treatment response. Tracking specific symptoms particular to an individual patient's depression improves objective assessment of change. Often, patients' neurovegetative symptoms will improve before the subjective experience of their mood improving. Assessing sleep, appetite, energy level, anxiety, and concentration allows the physician to select a more appropriate antidepressant or anxiolytic by targeting specific symptoms. This may include using a sedating antidepressant such as mirtazapine for patients with insomnia or a more activating antidepressant such as bupropion for patients with lethargy or somnolence. Measurement tools that are symptom specific and sensitive to change over time (e.g., PHQ-9, QIDS-SR) may help the physician track such changes. In addition, assessing overall functionality (ability to shower, pay bills, shop, prepare meals) is equally important in establishing the degree of impairment caused by the patient's mood disorder.

Box 47-6 Initial Assessment of Anxious or Depressed Patients

1. Establish diagnosis.

2. Perform risk assessment. Suicide risk

Risks to others

3. Establish severity of illness. Ability to care for self Functioning/functional impairment

4. Identify specific target symptoms.

Neurovegetative symptoms (e.g., sleep, appetite, concentration) Use of measurement scales (e.g., QIDS)

5. Assess factors complicating illness. Alcohol or /drug use

Comorbid or contributing medical conditions

6. Gather input from family and friends if possible.

Table 47-2 Dosing for Common Antidepressant and Antianxiety Agents

Usual Daily Starting Dose (mg)

Medication

Anxiety

Depression

Daily Dose Range

Selective Serotonin Reuptake Inhibitors (SSRIs)

Citalopram

10

20

10-60

Escitalopram

5

10

5-30

Fluoxetine

10

20

20-80

Fluvoxamine

25

50

100-300

Paroxetine

10

20

20-60

Sertraline

25

50

50-200

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Desvenlafaxine

50

50

50-100

Duloxetine

30

30

30-120

Venlafaxine

37.5

75

150-300

Tricyclic Antidepressants (TCAs)

Amitriptyline

25

50

100-300

Imipramine

25

50

100-300

Nortriptyline

10

25

50-200

Desipramine

25

50

100-300

Norepinephrine-Dopamine Reuptake Inhibitors

Bupropion

150

300-450

Norepinephrine-Serotonin Modulators

Mirtazapine

15

30

30-60

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