Depression and Anxiety: Diagnosis

A detailed history, including psychiatric history, medication use, substance abuse, and social history, should be taken for all patients. Physical examination should include a thorough neurologic examination and should rule out disorders that are associated with depression or anxiety, especially cardiac and endocrine disease.

Particular attention should be paid to medication history, as many medications may contribute to depressive and anxiety disorders. Isotretinoin, for example, is under investigation for its contribution to depression and suicidal ideation, and some older antihypertensive medications cause depression that is indistinguishable from primary depression.

All patients should be asked about suicidal ideation. In patients deemed at risk, immediate psychiatric attention is necessary, which may include hospitalization. The lifetime risk of suicide in depressed patients is about 15%.

Physiological or laboratory testing is generally not necessary, except to evaluate for medical disorders (eg, electrocardiogram, thyroid function tests, complete blood count, blood chemistries). A urine toxicology screen may be appropriate in some patients to evaluate for drug use.

Diagnosis of Major Depressive Disorder

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnosis of a major depressive episode includes at least five of the following symptoms occurring on most days within the same 2-week period, and representing a change from previous functioning, causing significant distress or impairment, and not accounted for by effects of a medication, substance abuse, or bereavement²:

• Depressed mood most of the day, nearly every day.
• Markedly diminished interest in or pleasure from most activities.
• Significant weight loss or gain, or change in appetite.
• Altered sleep patterns (insomnia or hypersomnia).
• Psychomotor agitation or retardation observable to others.
• Fatigue or loss of energy.
• Feelings of worthlessness or excessive guilt.
• Diminished ability to think or concentrate; indecisiveness.
• Recurrent thoughts of death or suicidal ideation, plan, or attempt.

Diagnosis of Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by excessive anxiety and worry occurring more days than not for at least 6 months. The patient finds it difficult to control the worry and has at least three of the following symptoms:

• Restlessness.
• Fatigue.
• Difficulty concentrating or mind going blank.
• Irritability.
• Muscle tension.
• Sleep disturbance.

The anxiety or physical symptoms cause clinically significant distress or impairment in social, occupational, or other areas of function, and the disturbance is not due to a medical condition or substance abuse.²