Case Vignette

• Rowena, 36 y/o, housewife

• Consulted at the health center
• Complaint: difficulty sleeping
x 2 weeks
• Associated symptoms: always
feeling low, sad, with
decreased appetite and felt
easily tired.
Case Vignette
• Diagnostic consideration: Depression

• Rowena felt above symptoms (sadness,

feeling low, decreased appetite,
difficulty sleeping) most of the time and
that she could no longer enjoy watching
her favorite telenovela and would rather
stay inside her room by herself unable
to do her usual housework.
Case Vignette
• History of Present Illness:
• A month ago, her husband, an overseas worker,
stopped communicating with her.
• Since then, she had ruminating thoughts about
possible reasons for her husband's behavior and
said she might have said something that offended
him the last time they talked.
• She felt helpless given the distance between them
and worried about the consequences of this
incident to their relationship since she depended
on him totally for financial support.
Case Vignette
• When asked about thoughts of death, she
replied, "I can't imagine killing myself but there
are days I wish I just don't wake up in the
morning."
• Coping strategy: praying and effort to resist her
symptoms by thinking about her children's
welfare.
• Her feelings have decreased when her mother,
who lived with them, had taken an active role in
encouraging her and helping her in the
household chores.
Depression
• “Sad mood”
• It is one of the most common
reaction to an experience of loss of
someone or of something familiar of
human experiences
• One says: “I was very sad” or “My
spirits are low”
Depression
• Reaction to loss of someone or
of something of value to the
person, such as in death or
disasters.
• People in such extreme life
experiences, need to be assisted
through their sadness and
feelings of helplessness because
of the realities of the adversity.
• Considered a “syndrome”
• depressed feeling
• difficulty sleeping
• loss of appetite
• feelings of hopelessness
• inability to concentrate
• or thoughts of committing self-harm
• but the person is still able to function or do her ordinary
work/ no impairment in previous functioning
Depression
• It becomes an illness when:
• symptoms persist and disturb the
person's functioning
• the depressed person is unable to
work or is able to do so only with
greatest difficulty.
• the capacity for enjoyment is lost
• hopelessness is felt,
• thoughts of self-harm may come to
mind.
Depression
Depression: Risk Factors

•Biological
•Psychological
•Social
•Spiritual
Biological/ Genetic Factors

• First degree relatives: 2 to 3x the

risk of developing depression than
the general population.

• Family history of depression:

important to ask
Biological Factors
• Disturbances in certain
monamine neurotransmitters

• serotonin and norepinephrine.

• acetylcholine
• epinephrine
• dopamine
Biological Factors
• Other hypotheses:
abnormalities in
neuroendocrine regulation
• Short term/ Acute stress
response: Adaptive
• Long term/Chronic stress:
Maladaptive
 Psychological Factors

• Generally, depression is closely

related to experiences of loss:
• death
• separation from a loved one
• loss of homes and livelihood as in
disasters
 Psychological Factors

• Coping style: Risk factor in

depression
• For example: if the basic
psychological response of the
individual involves feelings of guilt
and self-blame for a significant
event, then this makes him prone to
depression.
 Psychological Factors

• Way of thinking and assessment

of events: may make someone
more prone to developing
depression.
• Depressed feelings may lead to
distorted thoughts or feelings
regarding a situation
Social Factors
• A difficult social situation
• Inability to provide for basic
needs for self and family
• Inaccessibility to basic goods
and services
• Natural catastrophes
• Armed conflict and other
disasters
Social Factors

• Imagine a state of chronic deprivation and

feelings of hopelessness of a person in
difficult social and economic circumstances.
• Person may become depressed due to such
situations, and are the most common type of
depression that the we may encounter.
Spirituality Factors

• Through all the feelings of loss, sadness,

helplessness and withdrawal, the person
suffers anguish, and may ask:
• "Why is this happening to me?
• Why me?
• Why am I being abandoned?"
Spirituality Factors

• In difficult times, a person consider and

regard his relationship with a Supreme
Being, his God.

• The spirit within him provides inner strength

and meaning in the face of his loss.
Identifying Depression

• Signs and symptoms of

depression revealed on
person's:
• feelings,
• thoughts,
• and behavior
Identifying Depression: Feelings
• tearful although some are not able to cry
• worthless and useless- leading him to feel that
life is not worth living.
• remorseful and regretful and overwhelmed by
guilt
• complain of being edgy, anxious and tense
• easily irritated
• taking offense even at the slightest
provocation
• express feelings of being alone
Identifying Depression: Thoughts

•slowed down with poor concentration

•feelings of inadequacy and his thoughts of
self blame are worsened
•Thoughts of self harm/suicide
Identifying Depression: Behavior

•sluggish and without initiative

•spend hours doing nothing, preoccupied
with his thoughts
•complain of excessive tiredness at the end
of the day
•sleep is disturbed and he wakes up very
early.
•Loses his appetite, weight loss without
dieting
Identifying Depression: Behavior
On many occasions:
•Depressed patient consults practitioner
with vague physical complaints
•headaches that come and go (no physical
basis can be found upon examination)
•some complain excessive tiredness and
weakness during the day or anxiety
symptoms
Depression and Medical Illness

• 15% of medically ill patients have signs

and symptoms of depression.
• Depression may result as:
• a reaction to being ill
• a direct result of the medical illness
itself
• a response to the medications the
patient takes for the illness
Depression: as a Reaction to Medical Illness
(Adjustment Depressions)
• Common medical conditions that are
associated with developing a
depressive episode:
• coronary heart disease
• cancer
• chronic pain
• stroke
• brain injury
• DM
• HIV
• and TB
Depression: as a Reaction to Medical Illness
(Adjustment Depressions)
• When detected, it is usually helpful to ask the
patient what he understands about the illness
and its treatment.

• In answering this question, misconceptions

and misinterpretations are usually revealed,
which the health worker, should help correct.
Depression: Caused by Medical Illness
(Organic Depressions)
• Medical illnesses that create changes in the body
that may directly cause depressive symptoms:
• Alcoholism
• Cancer, diabetes mellitus, HIV/AIDS
• Anemia
• Stroke
• Electrolyte abnormalities
• Heavy metal poisoning
Depression: Caused by Medications and
Psychoactive Substances
• Eliciting information on medications and
other drugs is a crucial part of the
assessment of a depressed patient.
• Antihypertensive medications (Reserpine,
Methyldopa, Beta blockers, diuretics, oral)
• Contraceptives
• Steroids
• Metoclopromide
• NSAIDS
• Anti-cancer drugs
Depression: Caused by Medications and
Psychoactive Substances

• Can be detected by carefully eliciting the

relationship between time of intake of the
drug and the onset of the symptoms.
• When a relationship is observed or
established, the physician should be informed
so that a replacement medication can be
prescribed.
Depression: Caused by Medications and
Psychoactive Substances

Common drugs of abuse:

•Alcohol
•Opiates
•Withdrawal from amphetamine and cocaine
Depression: in the Elderly
• Elderly patients usually become
depressed due to:
• one or more medical illnesses
• reaction to several medication
taken
• problems experienced unique
to the elderly phase of life
Depression: in the Elderly
• Depressed elderly patients may
show
• more of abnormalities in
memory, orientation and
judgment
• may often be mistaken for
dementia, or worse as a normal
component of the aging process.
 Depression: in the Elderly
Question  Depression Dementia
Did the symptoms take months or years to develop No Yes

Does the patient frequently answer “ I don’t know” Yes No

Can the patient remember remote events better than No Yes

recent events?

Is the patient aware of his lapses in memory? Yes No

Is there a personal or family history of depression? Yes No

Are the mental status findings inconsistent when Yes No

repeated?
Depression: in the Elderly

• In giving medications to elderly:

“start low, go slow.”

 DSM 5 CRITERIA FOR MAJOR DEPRESSIVE DISORDER
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from
previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others.
(Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day.
(Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others)
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic
disorders.
E. There has never been a manic episode or a hypomanie episode
Depression: Management- Patient

• The minimum requirement for

one to help a depressed person is
to listen.
Depression: Management- Patient
1. Sadness
•Do not tell the patient to snap out of his
depression or that his sad feelings and thoughts
are only his mind.
•These feelings of helplessness are real and
oppressive for the depressed person.
•Thus, he should be allowed to talk about it and
even cry about it.
Depression: Management- Patient
2. Remorse and Guilt
•Clarify the feelings of remorse and guilt
•Assure him that he is not as bad as he thinks
he is.
Depression: Management- Patient
3. Anxiety and Irritability
•These can be distressing and may mask
depressed feelings.
•Assure the patient that as he feels better, the
anxiety and irritability will also diminish.
Depression: Management- Patient
4. Thoughts of Death/ Self-harm
•Ask the patient about these thoughts.
•Ask details about the plan like how often
does he think about them.
•What methods does he think of using
Depression: Management- Patient
5. Loss of initiative, tiredness
•Ask the patient to accomplish concrete tasks
for the day and to do something that may
make him feel better.
Depression: Management- Patient
6. Inability to sleep and loss of appetite and
weight loss
•Consultation with a psychiatrist or a
physician trained in mental health is required
when these symptoms are persistent for more
than two weeks.
Depression: Management- Patient’s Family

• The family/caregivers should be motivated

to participate actively in helping the patient.
• They are in the best position to:
• prevent suicide attempt/ self-harm,
• to plan and organize patient's activities,
• to provide environmental calm and support
for the patient
Depression: Management- Patient’s Family
• The health worker will find it useful to discuss
with a responsible family member the
following psychoeducational approaches:
1. The nature, course, and prognosis of the
patient's illness or emotional state.
2. The attitude that they should take with
regards to the patient (patience and empathy).
Depression: Management- Patient’s Family
• The role of the health worker is to help this
person or his family seeks support from the
community, or community agencies, in
managing their deprivation and find realistic
solution for their difficulties.
Depression: Management
Summary of the Steps in Managing Depression
1. Allow the patient to talk; listen with empathy.
2. Ask about suicidal thoughts. If there are any, refer to a
psychiatrist.
3. Refer to physician for anti-depressant medication, if necessary.

4. Talk to family and discuss immediate plans to help patient.

5. Explore possibilities of community support in finding realistic
solutions.