Depression in Patients with Comorbidity

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Table of Contents

Depression
A Patient Case Scenario of Depression and Type 2 Diabetes
Non-Suicidal Self-Injurious Behavior
Risk of Harm to Others
Assessment
Appropriate Screening Tools
Plan of Care
Conclusion
References

In psychiatric health, mental disorders may occur together with physical disorders. This phenomenon can be attributed to the physical ailments that cause anguish and culminate in psychological disorders. These illnesses can also affect an individual’s capacity to take good care of themselves through proper diet and exercise thereby leading to the manifestation of physical diseases. For these reasons, health care providers should screen patients presenting with physical disorders for possible psychiatric illness.

The purpose of this paper is to describe depression as a mental health disease, including its etiology, prevalence, signs and symptoms, and assessment instruments that facilitate the diagnosis of the disease. A case study of a patient with depression alongside a physical illness is also described. A proposed assessment and plan of care for the patient is explained. The impact of issues about neurobiology, developmental stage, socioeconomic standing, gender, and neurobiology on psychological health is factored into the discussion.

Depression

Depression may be described as a psychological illness that harms a person’s feelings, thoughts, and actions. This disease causes people to lose interest in activities that they once found enjoyable. Different emotional and physical problems may develop due to depression. Therefore, it is important to diagnose and treat it as soon as possible.

Etiology

Depression does not have a single cause but often occurs as a result of interactions among various attributes. Genetic makeup can alter the chemistry of the brain and hamper its capacity to uphold a stable mood. Studies show that the likelihood of twins having depression ranges from 40 to 50% (Kandler & Ostendorf, 2016). On the other hand, having a close family member, particularly a first-degree relation with depression elevates one’s likelihood of developing the condition.

Life’s pressures and social problems also increase one’s chances of developing depression. For instance, losing one’s parents or close family members during the early phases of life renders an individual susceptible to developing depression when they grow older. Physical discomfort, for example, chronic pain as a result of physical injury or other medical conditions can interfere with the normal sleep pattern and predispose a person to depression.

Additional examples of psychosocial risk factors for depression encompass seclusion and adverse life events such as loss of employment. Depression can be induced chemically through the use of certain pharmacological agents such as steroids. Additionally, studies show that substance abuse can elicit major depressive disorder (Edlund et al., 2015).

Prevalence

Depression is a widespread mental health disorder in many developed nations, including the United States. It is reported to be a major cause of disability. In the past few decades, there has been a significant increase in the manifestation of depressive indications. World prevalence statistics show that the lifetime incidence of the disorder is between 20 and 25% in females and 12% in males (Wang et al., 2017). Generally, the manifestation of clinically consequential depression is proportional to age, especially in medical conditions that require hospitalization.

Depression plays a vital role in the quality of life and continued existence of populations. It makes up approximately 50% of all psychiatric diagnoses and up to 12% of patients who are admitted to hospitals (Wang et al., 2017). The prevalence of the disease is greater among patients compared to the rest of the population. This observation is attributed to the fact that illnesses compel individuals to incur vast financial expenses, which increases their stress levels thus predisposing them to depression.

Other factors that may contribute to depression among patients is low levels of satisfaction with healthcare facilities and poor doctor-client relationships. The World Health Organization (WHO) projected that depression will become the second-largest disease globally by the year 2020 (Lim et al., 2018).

Signs and Symptoms

Patients with depression present with several symptoms, which are often used in the diagnosis of the disease. DSM-5 outlines that a diagnosis of depression is made when a person shows at least five symptoms for two weeks. These signs encompass feeling sad most of the time in a day for several days and a significant decline in one’s interest in daily activities of living or deeds that one previously derived pleasure doing. One of these two symptoms must be present.

Other indications include losing or gaining substantial body weight over a short time without any deliberate efforts, reduced physical activity or thought patterns (as shown by psychomotor retardation), exhaustion on a day to day basis, loss of the ability to concentrate or make sound decisions, and feeling guilty or worthless disproportionately. Memories of past failures often trigger the feelings of extreme contriteness or insignificance. In extreme cases of depression, suicidal ideations may be present. These symptoms may interfere significantly with important activities such as sleeping and appetite or lead to psychomotor agitation, which is typified by unnecessary movements such as pacing up and down (Hasin et al., 2018).

Changes in temperament often affect the social life and work of an individual to an extent that is noticeable by other people. For example, a depressed person may stop going to work or school or register dismal work performance or low academic achievement. However, given that other causes such as substance abuse or specific medications can contribute to dejected disposition, it is important to consider these factors when diagnosing depression and avoid making a diagnosis of the disease based on observed substance abuse. Furthermore, depression cannot be identified in people with certain mental illnesses such as schizoaffective, manic, and hypomanic disorders (Verduijn et al., 2017).

Other Assessment Instruments

Apart from the already described DSM-5 criteria, the diagnosis of depression can be done using other documented instruments such as self-report screening tools. An example of such a tool is the Center for Epidemiologic Studies-Depression Scale (CES-D), which consists of 20 items that allow a patient to evaluate their feelings, thoughts, and insights over the past week (González et al., 2017).

The Patient Health Questionnaire-9 (PHQ-9) is another valuable depression scale that is made up of 9 items that can attract a maximum score of 3 points each (Manea, Gilbody, & McMillan, 2015). The scores are indicative of the extent of depression with 27 marks showing severe depression, whereas low scores point towards mild disease. Proficient clinicians with adequate experience with psychiatric patients can also use the Hamilton Depression Rating Scale (HAM-D) to monitor the extent of depression before, in the course of treatment, or to evaluate the efficacy of therapy. This tool comprises 21 items. However, only the first 17 elements determine the score and subsequent decisions (Tolton, Steffens, & Chan, 2019).

A total score of 0 to 7 is considered normal while scoring between 8 and 13 is indicative of mild depression. Scoring between 14 and 18 shows moderate depression, whereas 19 to 22 points towards severe depression. Patients who obtain more than 23 points using this instrument are thought to have very severe depression. The main advantage of HAM-D is its ability to distinguish between four levels of depression.

A Patient Case Scenario of Depression and Type 2 Diabetes

Chief Complaint

The patient presented to the clinic with complaints of blurred vision and difficulties concentrating. Moreover, he explained that he was very tired all the time, had lost significant weight, and felt like ending his life because it had no meaning.

Subjective

The patient is a 44-year-old Caucasian male. He is oriented to place, time, and space. The patient reports feeling sad and depressed over the last three weeks. He states that he is guilty about his wife’s death and regrets sending her on an errand where she met her death. He admits that he has contemplated ending his life several times and has even considered taking an overdose of pain medications to die peacefully in his sleep.

However, he denies homicidal hallucinations or aggression. The patient says that he takes alcohol every other day but does not use any illicit drug. He admitted that due to his current loss of interest in life, he has not been compliant with his medications. Even though studies show that the prevalence of depression in females is often higher than in males (Wang et al., 2017), this case shows a serious case of depression in a male subject, which underscores the magnitude of depression in males (Salk, Hyde, & Abramson, 2017).

Social History

The patient is a widower with two children aged 6 and 4 years. He works as a lawyer at a prestigious law firm. He lost his wife 3 months ago in a road accident and has been unable to come to terms with the fact that he will have to raise their two children alone. He is currently living with his younger sister who is helping out with the kids. The patient is a non-smoker. However, he admits that he consumes alcohol regularly to ease his stress.

Before his wife’s death, he was an occasional drinker. However, he has since turned to heavy alcohol consumption. Consequently, his employer is unhappy with his work performance, which has become sloppy and has caused the company to lose two important clients within the last one month. His colleagues reported that he no longer hangs out with them in the evenings after work. He has changed from his usual jovial self and rarely speaks unless he is addressed.

The patient is a first-born child in a family of three children. He also lost his mother through a short illness at the age of 16. His father did not remarry, which forced him to take over parental responsibilities for his siblings. He was worried that his first-born child would have to undergo similar experiences. In his culture, mothers are expected to play a nurturing role for their children. Therefore, he believed that the absence of a mother affected the normal growth and development of a child.

Normality is regarded as behavioral patterns or personality features that align with a specific benchmark of upright and proper behavior. The patient experienced some form of abnormal development due to his mother’s absence. He was forced to take up certain parental responsibilities at an early age. These experiences highlight the importance of normal development and cultural values in the emotional health of a person (Winnicott, 2018).

Medical History

The patient was diagnosed with type 2 diabetes at the age of 41 and has been managing his condition appropriately through a healthy diet, regular exercise, and medication adherence. He has no pertinent surgical or family history. His current drugs include metformin (GLUCOPHAGE) 500 mg tablets to be taken orally twice a day. However, he ran out of his medications and has not bothered to get a refill. The patient has no known food or drug allergy.

Columbia-Suicide Severity Rating Scale: Ideation Definitions and Prompts

Wish to be dead (Past Month): Yes.
Suicidal Thoughts (Past Month): Yes.
Suicidal Thoughts with Method Without Specific Plan or Intent to Act (Past Month): Yes.
Suicidal Intent without Specific Plan (Past Month): No.
Suicide Intent with Specific Plan (Past Month): No.
Suicide Behavior Question (Lifetime): Yes.

If Yes to Question 6 Ask: Were any of these in the past 3 months?: No.

Suicide Risk: Moderate risk.

Non-Suicidal Self-Injurious Behavior

Self-injurious Behaviors: No.

Risk of Harm to Others

Risk of Harm to Others: No.

HARMS Assessment Completed: Yes.

Mental Status Examination Mood: Depressed Affect: Congruent Behavior: Cooperative Judgment: Below average Speech: Clear Insight: Limited Thought processes: Lucid The motivation for treatment: Average Memory: Intact Orientation: Fully oriented x 4.

Assessment

The patient has five symptoms of depression as delineated by the DSM-5 criteria. They include feelings of sadness, guilt, suicidal ideations, loss of interest in day-to-day activities, loss of weight, and fatigue. Therefore, a diagnosis of depression can be made. Nonetheless, he also has a history of type 2 diabetes, which has indicators such as loss of weight and fatigue. His other signs such as blurred vision and high levels of fatigue are common in diabetic patients with hyperglycemia. Therefore, there is a need to perform a blood sugar test to verify the extent of the condition. The patient’s glycemic control over the past six months should be determined through a hemoglobin A1c test. Moreover, his alcohol consumption problems point towards a likelihood of alcohol use disorder.

Appropriate Screening Tools

Several complications have been identified in the case study, including suicidal ideations, alcohol use problems, and depression. Therefore, there is a need to incorporate appropriate screening tools to ascertain the extent of these conditions. The HAM-D screening tool is appropriate for determining the patient’s extent of depression. Given that he has a medical history of type 2 diabetes (a physical problem), it is important to consider using screening tools that account for the disorder. The most recommended instrument in the evaluation of alcohol use in diabetic patients is the CAGE screening tool, which is a simplified four-question instrument (Nienov, Matte, Dias, & Schmid, 2017).

When a patient answers in the affirmative to at least two out of the four questions, it is an indication that further assessment is required. Based on the findings of the CAGE assessment, the clinician can decide whether or not to administer the TAPS tool that is reported to yield optimal outcomes when planning the treatment of patients with concurrent alcohol use disorder and type 2 diabetes (McNeely et al., 2016).

Plan of Care

The treatment of depression encompasses the use of medications (antidepressants) and psychological interventions. Antidepressants are usually the first-line treatment of severe depression or when psychological treatments have been unsuccessful. The patient’s suicidal ideations point toward severe depression. He should receive sertraline (ZOLOFT) 100 mg at an oral dose of one daily. Sertraline is a selective serotonin reuptake inhibitor (SSRI), which works on the neurobiology of depression by increasing the levels of serotonin that are available to work in the brain (Dean & Keshavan, 2017).

An imbalance in the levels of serotonin is implicated in the development of depression due to its role in the control of mood, sleep, appetite, and general social behavior. Combinations of antidepressants often yield better outcomes than a single drug. Therefore, the patient can receive mirtazapine (REMERON SOL-TAB) 15 mg disintegrating tablet to be taken at an oral dosage of one tablet daily at night. Nevertheless, this drug combination can elicit side effects such as confusion, hallucination, fever, shaking, altered vision, and drastic changes in blood pressure. Therefore, the patient should be monitored for any of these adverse upshots.

Cognitive Behavioral Therapy (CBT) is an example of an evidence-based psychological approach to the management of depression in patients across the lifespan. CBT entails working with a therapist to identify negative thought patterns and changing them to attain a positive outlook on life. The patient should also begin CBT sessions to help him develop a positive attitude to life and stop blaming himself for his wife’s death.

These sessions would help him to modify his displays of behavior and improve adherence to medications. A combination of pharmacological and psychological treatment is ideal due to its reported outcomes in patients with depression (Bateman, Gunderson, & Mulder, 2015).

The uptake of hypoglycemic agents that are taken orally is hampered by alcohol. For instance, heavy alcohol users should not take metformin because it prompts lactic acidosis (Pasquel et al., 2015). It is also necessary to avoid alcohol-initiated hepatopathy by lowering the amounts of hypoglycemic agents that are metabolized in the liver. Therefore, the patient should receive an alternative oral hypoglycemic agent such as pioglitazone 15 mg tablets at an oral dose of 15 to 30 mg with meals. The patient’s alcohol consumption problem has not gotten out of hand and should be addressed sufficiently during the CBT sessions. However, the clinician can consider administering naltrexone to help with alcohol dependence.

Conclusion

Depression is a common mental health problem in the population that co-occurs with many physical illnesses and substance abuse disorders. Comorbidity elevates the magnitude of presenting symptoms, which leads to increased health care costs and low quality of life. Additionally, the coexistence of certain disorders may complicate the diagnosis and assessment of each disease. Thus, the use of predefined diagnostic measures such as the DSM-5 criteria and additional assessment tools makes it possible to confirm psychiatric diagnoses and determine their severity to guide proper treatment and lead to enhanced patient outcomes.

References

Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The Lancet, 385(9969), 735-743.

Dean, J., & Keshavan, M. (2017). The neurobiology of depression: An integrated view. Asian Journal of Psychiatry, 27, 101-111.

Edlund, M. J., Forman-Hoffman, V. L., Winder, C. R., Heller, D. C., Kroutil, L. A., Lipari, R. N., & Colpe, L. J. (2015). Opioid abuse and depression in adolescents: Results from the National Survey on Drug Use and Health. Drug and Alcohol Dependence, 152, 131-138.

González, P., Nuñez, A., Merz, E., Brintz, C., Weitzman, O., Navas, E. L.,… Perreira, K. (2017). Measurement properties of the Center for Epidemiologic Studies Depression Scale (CES-D 10): Findings from Hchs/sol. Psychological Assessment, 29(4), 372-381.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry, 75(4), 336-346.

Kandler, C., & Ostendorf, F. (2016). Additive and synergetic contributions of neuroticism and life events to depression and anxiety in women. European Journal of Personality, 30(4), 390-405.

Lim, G. Y., Tam, W. W., Lu, Y., Ho, C. S., Zhang, M. W., & Ho, R. C. (2018). Prevalence of depression in the community from 30 countries between 1994 and 2014. Scientific reports, 8(1), 2861.

Manea, L., Gilbody, S., & McMillan, D. (2015). A diagnostic meta-analysis of the Patient Health Questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression. General Hospital Psychiatry, 37(1), 67-75.

McNeely, J., Wu, L. T., Subramaniam, G., Sharma, G., Cathers, L. A., Svikis, D.,… O’grady, K. E. (2016). Performance of the tobacco, alcohol, prescription medication, and other substance use (TAPS) tool for substance use screening in primary care patients. Annals of Internal Medicine, 165(10), 690-699.

Nienov, O. H., Matte, L., Dias, L. S., & Schmid, H. (2017). Peripheral polyneuropathy in severely obese patients with metabolic syndrome but without diabetes: Association with low HDL-cholesterol. Revista da Associação Médica Brasileira, 63(4), 324-331.

Pasquel, F. J., Hinedi, Z., Umpierrez, G. E., Klein, R., Adigweme, A., Coralli, R.,… Lopez, F. A. (2015). Metformin-associated lactic acidosis. The American Journal of the Medical Sciences, 349(3), 263-267.

Salk, R. H., Hyde, J. S., & Abramson, L. Y. (2017). Gender differences in depression in representative national samples: Meta-analyses of diagnoses and symptoms. Psychological Bulletin, 143(8), 783-822.

Tolton, D., Steffens, D., & Chan, G. (2019). patient versus clinician rated depression scores: A comparison of participant scores on the Carroll Depression Scale and the Hamilton Depression Rating Scale. The American Journal of Geriatric Psychiatry, 27(3), S124-S125.

Verduijn, J., Verhoeven, J. E., Milaneschi, Y., Schoevers, R. A., van Hemert, A. M., Beekman, A. T., & Penninx, B. W. (2017). Reconsidering the prognosis of major depressive disorder across diagnostic boundaries: Full recovery is the exception rather than the rule. BMC Medicine, 15(1), 215. Web.

Wang, J., Wu, X., Lai, W., Long, E., Zhang, X., Li, W.,… Wang, D. (2017). Prevalence of depression and depressive symptoms among outpatients: A systematic review and meta-analysis. BMJ Open, 7(8), e017173. Web.

Winnicott, D. W. (2018). The maturational processes and the facilitating environment: Studies in the theory of emotional development. London: Routledge.

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