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<< The Depressed Patient And Suicidal Patient In The Emergency Department: Evidence-Based Management And Treatment Strategies

Nomenclature And Classification

In the United States, classification of psychiatric conditions has been largely based on the Diagnostic and Statistical Manual IV-TR (DSM-IV-TR).7 Major depressive disorder (MDD) is defined as an episode consisting of 5 or more symptoms (see Table 1), lasting for most of the day, nearly every day, for a minimum of 2 consecutive weeks, with at least 1 symptom to be either loss of interest/pleasure or depressed mood.

A conceptual approach to thinking about the varied symptoms of depression is to group them into 3 broad categories: (1) emotions (depressed mood, loss of interest or pleasure), (2) ideation (worthlessness or guilt, death, or suicide), and (3) neurovegetative or somatic symptoms (sleep, appetite or weight, energy, psychomotor, concentration). A common mnemonic to help remember the 9 symptoms is “SIG:ESCAPE”: Sleep, Interest, Guilt, Energy, Suicidality, Concentration, Appetite, Psychomotor, Emotion (depressed mood).

There are multiple subtypes of major depression. Among the most commonly encountered in the ED are the following:

  • Major depression with melancholic features: This subtype is marked by the presence of nearconstant and profound depression often associated with severe neurovegetative symptoms (hypersomnia, near loss of appetite). Major depression with melancholic features is also notable for thought-process disturbances such as ruminative thinking, often dwelling on negative themes of worthlessness and value of life. This subtype of depression is concerning for its increased rate of suicide attempts.8
  • Major depression with psychotic features: This subtype includes patients with major depression and psychotic features that are most commonly delusions/auditory hallucinations. These delusions are often mood-congruent and consistent with the depressed mood (ie, voices emphasizing the patient’s worthlessness).
  • Seasonal affective disorder (SAD): This subtype involves recurrent major depressive episodes in a seasonal pattern, which may respond to light therapy in addition to (or instead of) psychotherapy or  medications.

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Last Modified: 10/19/2017
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