Depression

Definition/Description

Depression 2.jpg

Depression is defined according to Goodman and Fuller as a morbid sadness, dejection, or a sense of melancholy distinguished from grief. Depression falls under the broader category of Major Depressive Disorders which are characterized by a single isolated episode lasting weeks to months. Major depressive disorders are viewed as an adjustment disorder which occurs due to external circumstances such as stress, trauma or loss. Other major depressive disorders include dysthymia and seasonal affective disorder.[1]

Prevalence

Depression is the most commonly seen mood disorder within a therapy practice and is often associated with other physical illnesses and psychological conditions.[2]  In 2006, the Center for Disease Control conducted a study looking at the prevalence of depression. They found that approximately 15.7% of people reported being told by a health care provider that they had depression at some point in their lifetime. Men and women ages 25 to 44 have the highest occurrence of depression with the elderly population being the next highest age group affected.[3]   

Image:Map1_depression.gif


Characteristics/Clinical Presentation

It is important to note that as many as one third of people experiencing depression do not feel sad or blue. Many experience somatic symptoms such as fatigue, joint pain, headaches, gastrointestinal disturbances, or chronic back pain. In Goodman and Synder, they report that 80 to 90% of the most common gastrointestinal disorders are associated with depressive or anxiety disorders. People with depression commonly have trouble sleeping, including early morning and frequent nocturnal awakenings. In the elderly population, sleep disturbances are the first symptom of depression especially when linked with acute confusion, falling, bowel and bladder problems, or syncope. Clinical signs and symptoms can include: [4]

  • Persistent sadness, low mood, or feelings of emptiness
  • Frequent or unexplained crying spells
  • A sense of hopelessness
  • Feelings of guilt or worthlessness
  • Problems in sleeping
  • Loss of interest or pleasure in ordinary activities or loss of libido
  • Fatigue or decreased energy
  • Appetite loss (or over eating)
  • Difficulty in concentrating, remembering, and making decisions
  • Irritability
  • Persistent joint pain (arthralgia)
  • Headache
  • Chronic back pain
  • Bilateral neurologic symptoms of unknown cause (e.g., numbness, dizziness, weakness)
  • Thoughts of death or suicide
  • Pacing and fidgeting
  • Chest pain and palpitations
  • Significantly increased muscular tension
  • Restricted breathing
  • Reduced flexibility during movement
  • Limited trunk rotation
  • Reduced arm swing during gait
  • Reduced coordination between UE and LE movement

There may also be associated behavior changes that can include: compulsive, reckless or violent behavior, argumentative or oppositional behavior, increased pain complaints, patients may have a preoccupation with themselves, they may also have negative attitudes about their physical appearance and ability [5], be critical toward family members (fault finding) or be unaffectionate with their partner or spouse. Other somatic symptoms that are associated with mood disorders in non-medicated people include:

  • Muscle Pain (myalgia)
  • Excess Perspiration
  • Dry Mouth or Excessive Salivation
  • Rapid Breathing
  • Blurred Vision
  • Constipation
  • Tinnitus
  • Dry Skin
  • Flushing
  • Slurred Speech
  • Amenorrhea, Polymenorrhea
  • Digestive Problems

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Associated Co-morbidities [4]

Image:Conditions_Associated_with_Depression.GIF

Patients with these disorders are at higher risk for developing depression due to the disease pathology or medications associated with treating these disorders.

Medications

Depression may be caused by medications a patient is taking to treat another medical problem. Sedatives, hypnotics, cardiac drugs, anti-hypertensives, anticonvulsants, hormones and steroids are some drug categories that can cause depression. Also recreational drugs such as alcohol and illegal drugs can cause signs and symptoms of depression. Some examples are as follows:[2]

Psychoactive Agents: Amphetamines, Cocaine, Benzodiazepines, Barbiturates, Neuroleptics

Antihypertensive Drugs: Beta Blockers (especially Propranolol), Alpha Adrenergic Antagonists, Methyldopa (Aldomet), Hydralazine (Apresoline)

Analgesics: Salicylates, Propoxyphene (Darvocet-N), Pentazocine (Talwin), Morphine, Meperidine (Demerol)
Cardiovascular Drugs: Digoxin (Lanoxin), Procainamide (Pronestyl), Disopyramide (Norpace)
Anticonvulsants: Phenytoin (Dilantin), Phenobarbital

Hormonal Agents: Corticosteroids, Oral Contraceptives, Anabolic Steroids

Miscellaneous: Alcohol, Illicit Drugs, Histamine H2 Receptor Antagonists (especially Cimetidine or Tagamet), Metoclopramide (Reglan), Levodopa (Dopar, Larodopa), Nonsteroidal Anti-inflammatory Drugs (NSAIDs), Anti-neoplastic Agents (Vinblastine), Disulfiram (Antabuse), Cytokines (Interferons)

Diagnostic Tests

The Diagnostic and Statistical Manual of Mental Disorders V

The Diagnostic and Statistical Manual of Mental Disorders is the current reference used by mental health professionals to diagnose mental disorders. This publication is often referred to as the DSM or DSM-V.

Diagnosing Major Depressive Disorders

According to the Diagnostic and Statistical Manual of Mental Disorders edition IV (DSM-IV), Major Depressive Disorder can be diagnosed when 5 out of the 9 following symptoms occur during a single 2-week period:
1. Depressed mood or irritable, either self-reported or observed by others
2. Decreased interest or pleasure in most activities
3. Weight change of >5% or appetite change
4. Change in sleep habits
5. Change in activity level
6. Fatigue or loss of energy
7. Feeling guilty or worthless
8. Difficulty with concentration
9. Thoughts of death or suicide

These symptoms must also cause distress in daily life, must not be attributed to any other issue, and must not occur in the presence of a manic or hypomanic episode.

The DSM-V suggests that anxiety symptoms of irrational worry, unpleasant worrying, difficulty relaxing, feeling tense, and/or a dooming fear of something bad happening may indicate the presence of depression.

Depressive episodes can occur as part of the disorder or as an isolated incidence ranging from mild to severe. Depression can also mimic or be a secondary symptom of other issues such as substance abuse, some medical illnesses, other psychiatric disorders, or grief from a loss.

Those suffering from depression can develop issues with relationships, academics/work, stress management, and self-esteem because of the illness. [1][6]

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Persistent Depressive Disorder [1]

Persistent Depressive Disorder is a condition that represents the consolidation of the DSM-IV diagnoses of chronic major depression and dysthymic disorder. In accordance to the DSM-V, Persistent Depressive Disorder can be diagnosed with the presence of these 8 symptoms:
1. Depressed mood for more days than not, either self-reported or observed by others, for at least 2 years in adults or 1 year in children/adolescents
2. Experience 2 or more of the following while depressed:
a. Poor appetite or overeating
b. Insomnia or hypersomnia
c. Low energy or fatigue
d. Low self-esteem
e. Poor concentration or difficulty making decisions
f. Feelings of hopelessness
3. During the 2-year period (1 year for children/adolescents), the individual had not experienced a
period of relief from the symptoms from Criteria 1 and 2 for more than 2 months at a time.
4. Criteria for Major Depressive Disorder may continue to be present
5. The criteria for a manic, hypomanic, or cyclothymic disorder have never been met.
6. The symptoms cannot be better explained by a specified or unspecified schizophrenic disorder or
other psychotic disorders.
7. The symptoms cannot be better explained by the effects of a substance or another medical
condition
8. The symptoms cause clinically significant distress or impairment in daily life

Because these patients have been experiencing symptoms for so long, they may not think to report it without direct questioning.

Diagnosing Depressive Disorder with Seasonal Pattern [1]


This diagnosis is a subcategory of depressive disorders and was previously referred to as Seasonal Affective Disorder. It is characterized by a pattern the appearance and disappearance of depressive symptoms that follow a seasonal pattern. The cycle must have occurred within the same 2 year period and cannot be better described by seasonally linked stressors (starting school, holidays, etc.)

It is more common for patients with Depressive Disorder with a Seasonal Pattern to experience an onset of symptoms during winter months, especially when younger in age, but it is possible that an onset may occur during any of the four seasons.

Premenstral Dysphoric Disorders [1]

While not technically considered a Depressive Disorder, Premenstrual Dysphoric Disorder (PMDD), can often present similar to that of depression and can affect treatment plans. Symptoms of PMDD will begin to appear within 1-week pre-menses, begin to improve once menses begins, and resolve once menses ends. In order to be diagnosed with PMDD, symptoms but be reported during at least 2 cycles with > 5 of the following present and at least 1 symptom from 1-4:
1. Affective lability
2. Irritability
3. Depressed mood
4. Anxiety and tension
5. Decreased interest
6. Poor concentration
7. Fatigue
8. Appetite change
9. Hypersomnia/insomnia
10. Overwhelmed
11. Breast tenderness/joint swelling/bloating/weight gain

Outcome Measures

There are also several questionnaires that can be used to help determine if a patient is at risk for developing or has depression. The results of the questionnaire can help direct a patient’s referral to more qualified health care professionals. The following are a few examples of depression questionnaires.

The Beck Depression Inventory Second Edition: 21 item self-report form that is intended to assess the existence and severity of symptoms of depression in adults and adolescents 13 year and older. The patient should answer the questions based on how they have felt for the last 2 weeks. There is a version of this test that can be used for medical patients that is a seven item self-report measure of depression in adolescents and adults that reflects the cognitive and affective symptoms of depression while excluding somatic and performance symptoms that might be attributable to other conditions. When scoring the Beck the higher the score the higher the feelings of depression are. All of the Beck Scales have been validated in assisting health care professionals in making focused and reliable client evaluations.


Geriatric Depression Scale - 15 (short form): 15 yes/no question self-report form that the patient answers based off how they have felt over the last week. Each question is worth one point. The GDS-15 with a cutoff score of 6 has 94% sensitivity and 85% specificity in community dwelling older adults. With a cutoff score of 5 the GDS-15 has 72% sensitivity and 78% specificity in home care patients[7].


Zung Self-Rated Depression Scale: 20 question self-report form that the patient answers based off how often the statement describes how they have felt in the last several days. Each question is scored on a scale of 1 to 4 with higher scores indicating more feelings of depression. The maximum score for the ZSDS is 80 with a recommended cutoff score of 50 indicating strong feelings of depression.


Modified Zung Self-Rated Depression Scale(mZSDS): The mZSDS is a 23 question self-report questionnaire rated on a scale of 0 to 3 with higher scores indicating more feelings of depression. The recommended cutoff score for the mZSDS is 33 indicating strong feelings of depression[8]


Patient Health Questionnaire-2 (PHQ-2): A patient reported questionnaire that standardizes the 2 cardinal symptoms of major depression, depressed mood and decreased interest in activities. The questionnaire consists of two questions each rated on a scale from 0-3 with zero being not at all, and 3 being experienced nearly everyday. The total score is calculated by adding the two component scores together. It is recommended that patients with a score of 3 or greater should be referred for further evaluation. This test has 87% sensitivity and 78% specificity.


Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 can be used in conjunction with the PHQ-2. The difference between the two tests is that the PHQ-9 takes all 9 symptoms of major depression into account. Scoring for the PHQ-9 range from 0-27, with increasing scores indicating increased severity of depression. It is recommended that patients with a score of 10 or greater should be referred for further evaluation. This test has 88% sensitivity and 88% specificity.


The Cornell Scale for Depression in Dementia (CSDD): The CSDD is for patients unable to provide reliable self reports of emotional symptoms. It consists of two 19 item interviews, one with someone close to the patient, like a family member or caregiver, and one with the patient. The interviews are compared and the presence of symptoms is determined based on clinical judgement. This test has been validated to rate depression symptoms over the entire range of cognitive impairment. Each item is scored 0-2. A score of 0 indicates absence of the item, a score of 1 indicates that the item is mild or intermittent and a score of 2 indicates there is severe presence of the item. When scoring, scores of less than 6 indicate the absence of significant depression symptoms, scores of 11-18 indicate that major depression is probable, and scores of greater than 18 indicate that major depression is present. If the clinician believes that the patient is suffering from depression, the patient should be referred [7].


Symptoms Checklist 90-Revised: A 90 item self report questionnaire that takes 10-15 minutes to complete and helps to identify symptoms of psychopathology. Each item in the questionnaire is graded on a 0-4 scale with 0 being not at all bothered and 4 being extremely bothered. The questionnaire provides nine primary symptom dimension scores and three scores relating to global distress indexes. The primary symptom dimension scores include somatization, obsessive compulsivity, interpersonal sensitivity, depression, anxiety, hostility, phobia related anxiety, paranoid ideations, psychoticism, and a section for additional items. The global indexes include a wellness index, a hardiness index and a symptom free index. In relation to the depression scale and somatization scale respectively, feelings of worthlessness and feeling that everything is an effort had the greatest single item validity in identifying patients with depressive and somatization of symptoms. The cut score for each of these items was a 2 [9].

Causes

 [10]

There are several theories on why depression occurs based on biochemical mechanisms, neuroendocrine mechanisms, sleep abnormalities, genetics and psychosocial factors.[2]

Biochemical Mechanisms: an imbalance in the neurotransmitters norepinephrine and serotonin. Depression is caused when norepinephrine, dopamine and serotonin are produced in inadequate amounts or the receptor sites for these transmitters are not functioning properly. Excessive amounts of norepinephrine and dopamine results in a mania state commonly found in those with bipolar disorder. (See Video Below)

Neuroendocrine Mechanisms: this results when there are abnormalities in the limbic hypothalamic-pituitary-adrenal (HPA) axis. There can be an over secretion of cortisol, suppressed nocturnal secretion of melatonin, and decreased prolactin production in response to tryptophan administration. There are also associations to some forms of depression when testosterone, follicle stimulating hormone and luteinizing hormone levels are low. Knowing this information may result in a clinical lab test that can diagnose depression based off of low or high serum levels found in a blood test.

Sleep Abnormalities: sleep changes are consistently associated with depression but there is some debate on whether sleep disturbances cause depression or if depression causes sleep disturbances. Those prone to depression will have decreased REM latency (the time between falling asleep and the first REM period), longer first REM period, less continuous sleep, and early morning awakenings.

Genetics: there does appear to be a genetic linkage of major depressive disorder in that it occurs up to three times more often in first degree biologic relatives of people with this disorder.

Psychosocial Factors: this includes things like major life events and perceived stress. While it is not clear if these things cause depression or are just a factor in determining those who are likely to develop depression. Often an episode of depression will follow a severe psychosocial stressor such as the death of a loved one. Also these types of stressors play a larger role in the first and second episodes of depression and a lesser role in a more chronic form of depression.

Systemic Involvement [4]

 Data From: Smith NL: The effects of depression and anxiety on medical illness, University of Utah, School of Medicine, Stress Medicine Clinic, Sandy, Utah, 2002.

Medical Management (Current Best Evidence)

The medical management of depression revolves largely around the use of pharmacotherapy, psychosocial therapy and electroconvulsive therapy (ECT) also known as shock therapy.[2]  ECT utilizes an electrical impulse sent to the brain producing a controlled seizure which then alters the concentration of neurotransmitters in the brain, producing an effect that is similar to how antidepressants work. This form of therapy is not used as much as a first choice of treatment but may be beneficial to patients who are severely suicidal, self-mutilating, catatonic, or unable to eat or function. ECT may be used as a last resort if a more conservative treatment of antidepressants and psychosocial therapy has failed to make improvements in the patient’s symptoms. The most common treatment utilized first when treating patients with depression is through pharmacotherapy.

When treating depression using pharmacotherapy, all of the antidepressants drugs work based off the theory that depression occurs because of an imbalance of neurotransmitters in the brain. Based off this idea, most antidepressants work in a similar manner by blocking the reuptake of either serotonin or norepinephrine back into the presynaptic nerve. This allows excess neurotransmitter to build up in the synaptic cleft between the nerves which in turn leads to a down-regulation of the postsynaptic receptors. It is this down-regulation which is then theorized to relieve the symptoms of depression.[1] There are three main categories of medications, Tricyclic Antidepressants, Selective Serotonin Reuptake Inhibitors and Monoamine Oxidase Inhibitors.

Tricyclic Antidepressants (TCAs)

This category of medications was originally designed as an antipsychotic drug but were found to be helpful only with reducing depression symptoms in those patients with schizophrenia, but did not reduce psychosis. TCAs work in a similar manner described above in that they block the reuptake of serotonin and norepinephrine into the presynaptic nerve. Some TCAs also block the reabsorption of dopamine by competing with binding sites. Picking a TCA for treatment is based off how much sedatation is desired and the subsequent side effects. Administration of TCAs to treat depression is 60% effective in relieving the symptoms of depression. Because TCAs also bind to several different receptors in the brain which is then responsible for a variety of side effects including the following:

  • dry mouth
  • constipation
  • urinary retention
  • blurred visions
  • tachycardia
  • sedation
  • weight gain
  • orthostatic hypotension
  • dizziness
  • decreased libido
  • abnormal ejaculation
  • impotence
  • prolongation of QT interval on ECG (arrhythmias)
  • sudden death

These side effects tend to be more pronounced in the elderly. The use of TCAs also makes the effects of alcohol and other sedatives more profound. TCAs have a very small toxic window, about 5 times the normal daily dose. If an over dose occurs the patient may experience: metabolic acidosis, arrhythmias and conduction deficits, tremors, delirium, and bowel and bladder paralysis. Also complicating the situation is the long half life of TCAs making the patient at risk for cardiac events 3 or 4 days after an initial overdose.[1]

Selective Serotonin Reuptake Inhibitors (SSRIs)

This category of drug has revolutionized how doctors treat depression. This was one of the first drugs that was developed to purposely affect only the serotonin receptors for the specific purpose of limiting serotonin reuptake. This category of drugs do not bind to other neuroreceptors which then limits their side effects, especially cardio toxic events. Also SSRIs have a higher toxic window as compared to TCAs, although the specific amount has yet to be determined. SSRIs are indicated for use in patients with major depression but can also be used to treat obsessive compulsive disorder, social phobia, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, premenstrual syndrome, and eating disorders. SSRIs work by desensitizing the serotonin receptors in the brain, making them more receptive to serotonin molecules as well as blocking the reuptake of serotonin leading to a down regulation. The half lives of SSRIs varies depending on the medication. Some drugs have a much longer half life, which is good for patients with low compliance to taking their medications but also then limits there ability to change medications. Side effects can include:

  • nausea
  • anorexia
  • weight loss
  • bleeding
  • erectile dysfunction
  • delayed ejaculation in men
  • anorgasmia in women
  • anti-diuretic syndrome resulting in hyponatremia (nervousness, agitation, depression)
  • serotonin syndrome (change in mental state, restlessness, hyperreflexia, diaphoresis, shivering, tremors)
  • akathisia
  • dystonia
  • dyskinesia
  • tardive dyskinesia
  • parkinsonism
  • bruxism
  • restlessness
  • agitation
  • anxiety
  • headaches
  • insomnia

Abrupt discontinuation of any antidepressant drug can result in withdrawal symptoms. The most common withdrawal symptoms are GI related, flu-like symptoms, disequilibrium, extra pyramidal symptoms, anxiety, crying spells, irritability, confusion, and sleep disturbances. Another potential issue with SSRIs is its use in children. Studies conducted by the FDA found that children were more likely to show significant emotional instability in the form of crying, mood alterations, suicidal thoughts, and attempted suicide. These studies had several flaws that make it harder to know if prescribing SSRIs to children puts them at increased risk for suicide. At this point SSRIs have been an effective way to treat depression in children as long as they are closely monitored. Children experience similar side effects as adults with the exception of the suppression of growth hormone. Growth hormone appears to be suppressed while on SSRIs to the point that a hormone replacement therapy may be necessary. Also the long term effects of these medications are unknown.[1]

Monoamine Oxidase Inhibitors (MAOIs)

Unlike TCAs and SSRIs, MAOIs work by slowing down the destruction of neurotransmitters in the nerve synapse. MAO-A and MAO-B are enzymes that are responsible for the break down of norepinephrine, dopamine and serotonin. MAOIs work by blocking the action of these enzymes, allowing more neurotransmitter to be present in the synapse terminal. These drugs are not readily used anymore because of several drug-drug interactions and their adverse affects. Some adverse effects include[1]:

  • CNS excitation
  • restlessness
  • irritability
  • sleep loss
  • tremor
  • confusion
  • dry mouth
  • urinary retention
  • hypertensive reactions when consuming tyramine (cheese, beer, red wine, raisins, and avocados)

Physical Therapy Management (Current Best Evidence)

One of the biggest things a physical therapist can do for their patients is to be aware of the signs and symptoms of depression and some of the common disorders associated with depression. If the therapist is sensitive to the signs and symptoms of depression they can document it in the plan of care and then notify the physician so the patient can get the appropriate medical treatment, if necessary. Also, because patients with depression may be emotionally unstable, recognizing the signs and symptoms of depression can help you in approaching different situations and then redirecting the patient toward other activities, instructions or more positive topics of conversation.

Exercise has been shown to benefit patients with mild to moderate mood disorders, especially anxiety and depression. When performing aerobic exercise your body releases endorphins from the pituitary gland which are responsible for relieving pain and improving mood. These endorphins can also lower cortisol levels which have been shown to be elevated in patients with depression. Additionally, exercise increases the sensitivity of serotonin in the same way antidepressants work, allowing for more serotonin to remain in the nerve synapse. Exercise can be aerobic or resistive in nature, as both have been shown to be beneficial in a variety of patient types. Anyone with depression can participate in an exercise program no matter how old or young they are, as long as proper supervision is provided. Exercise is an excellent option for treatment when taking anti-depressants is not an option due to their side effects. Depression symptoms can be decreased significantly after just one session but the effects are temporary. An exercise program must be continued on a daily basis to see continued effects. As a person continues to exercise they may experiences changes in their body type which can help to improve self esteem and body image issues they may have been having. Some other benefits of regular physical exercise include:[2]

  • reduces/prevents functional declines associated with aging
  • maintains/improves cardiovascular function
  • aids in weight loss and weight control
  • improves function of hormonal, metabolic, neurologic, respiratory, and hemodynamic systems
  • alteration of carbohydrate/lipid metabolism results in favorable increase in high-density lipoproteins
  • strength training helps to maintain muscle mass and strength
  • reduces age-related bone loss; reduction in risk for osteoporosis
  • improves flexibility, postural stability, and balance; reduction in risk of falling and associated injuries
  • psychological benefits (preserves cognitive function, alleviates symptoms/behaviors of depression, improves self awareness, promotes sense of well-being)
  • reduces disease risk factors
  • improves functional capacity
  • improves immune function
  • reduces age-related insulin resistance
  • reduces incidence of some cancers
  • contributes to social integration
  • improves sleep pattern

youtu.be/ejoZm9CkC38

Because of depression’s effect on the neuromusculoskeletal system, research has shown that treating a patient’s underlying depression can lead to better improvements in their pain. Physical therapists can implement other strategies into their practice to further improve the effects of therapy beyond the benefits of exercise. Research has determined that a further decrease in depression symptoms can be obtained in the clinic by utilizing principles from the following:

  • Mindfulness[2]
  • Cognitive Behavioral Physical Therapy [3][4]
  • Norwegian Psychomotor Physical Therapy [5]

                                                                                                     Meditation.png

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Differential Diagnosis

Depression is a disease that tends to hide itself among other diseases. The chart presented above, in the associated co-morbities section, lists numerous diseases that are associated with depression. If you are treating patients with these diagnoses, it would be wise for you to watch for changes in emotional and behavioral status. Also, because depression tends to present with somatic pain, rather than emotional responses, physical therapists should be aware of red flags that could signal their complaints are of non-musculoskeletal origin. If the physical therapist is unable to reproduce or relieve the patients pain the cause of the pain may be of non-musculoskeletal origin and the patient should be referred on to the appropriate health care provider. Also performing a thorough screening of the patient and their past medical history will help to guide your decision on whether the patient’s complaints are with in the scope of practice for physical therapists.

Guidelines for Physical Referral[4]

General Systemic

  • unknown cause of pain
  • lack of significant objective neuromusculoskeletal signs and symptoms
  • lack of expected progress with physical therapy intervention
  • development of constitutional symptoms or associated signs and symptoms any time during the episode of care
  • discovery of significant past medical history unknown to physician
  • changes in health status that persist 7 to 10 days beyond expected time period
  • client who is jaundiced and has not been diagnosed or treated

For Women

  • low back, hip, pelvic, groin, or sacroiliac symptoms without know etiologic basis and in the presence of constitutional symptoms
  • symptoms correlated with menses
  • any spontaneous uterine bleeding after menopause
  • for pregnant women: vaginal bleeding, elevated blood pressure, increased Braxton-Hicks contractions during exercise

Vital Signs (report findings)

  • persistent rise or fall of blood pressure
  • blood pressure elevation in women taking birth control pills
  • pulse amplitude that fades with inspiration and strengthens with expiration
  • pulse increase of 20 beats per minute lasting more than 3 minutes after rest or changing position
  • difference in pulse pressure of more than 40mmHg
  • persistent low grade fever, especially if associated with constitutional symptoms
  • unexplained fever without other systemic symptoms, especially those taking corticosteroids

Cardiac

  • more than 3 sublingual nitroglycerin tablets required to gain relief from angina
  • increase in angina intensity after stimulus has been removed
  • changes in pattern of angina
  • abnormally severe chest pain
  • anginal pain that radiates to jaw/left arm
  • abnormally cool or sweaty upper back
  • heart palpitations or arrhythmias present
  • worsening dyspnea
  • fainting without any warning

Cancer

  • changes in bowel or bladder habits
  • a sore that does not heal in 6 weeks
  • unusual bleeding or discharge
  • thickening or lump in breast or elsewhere (painful or painless)
  • indigestion or difficulty in swallowing
  • nagging cough or hoarseness
  • proximal muscle weakness
  • changes in deep tendon reflexes
  • bone pain, especially on weight bearing that persists more than 1 week and is worse at night
  • any unexplained bleeding from any area

Pulmonary

  • shoulder pain aggravated by respiratory movements
  • shoulder pain that is aggravated by supine positioning
  • shoulder or chest pain that subsides with auto splinting
  • signs of asthma or abnormal bronchial activity during exercise
  • weak and rapid pulse accompanied by fall in blood pressure
  • presence of associated signs and symptoms such as persistent cough, dyspnea, or constitutional symptoms

Genitourinary

  • abnormal urine output (color, odor, amount, flow of urine)
  • any blood in urine
  • cervical spine pain accompanied by incontinence

Gastrointestinal

  • back pain and abdominal pain at the same level, especially when accompanied by constitutional symptoms
  • back pain of unknown cause in a person with a history of cancer
  • back pain or shoulder pain in a person taking NSAIDS, especially when accompanied by GI upset or blood in stools
  • back or shoulder pain associated with meals or back pain relieved by a bowel movement

Musculoskeletal

  • symptoms that are out of proportion to the injury or symptoms persisting beyond the expected time for the nature of the injury
  • severe or progressive back pain accompanied by constitutional symptoms, especially fever
  • new onset of joint pain following surgery with inflammatory signs (red, hot, swollen and tender)


In the older adult musculoskeletal problems can be caused from drugs or depression. This makes diagnosis and treatment of symptoms difficult. Family members can confuse the signs and symptoms of depression with those of dementia. When comparing depression and dementia, you tend to see faster declines in mental function, difficulty concentrating and memory loss in patients with depression. Patients who have dementia are more disorientated and have trouble with short term memory. Also they tend to be indifferent to their memory loss.[4]

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Case Reports

Moras, Karla; Telfer, Leslie A.; Barlow, David H.  Efficacy and specific effects data on new treatments: A case study strategy with mixed anxiety-depression. Journal of Consulting and Clinical Psychology. Vol 61(3), Jun 1993, 412-420.

Depression_Case_Study


Resources

Geriatric Depression Scale (Short Form)

Beck Depression Inventory II

Zung Depression Scale

National Depression Screening Day

Depression and Bipolar Support Alliance

National Mental Health Association


Recent Related Research (from Pubmed)

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Diagnostic and Statistical Manual of Mental Disorders (5th Ed). Washington DC: American Psychiatric Association; 2013
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Goodman CC, Fuller KS. The Psychological Spiritual Impact on Health Care. In: 3rd ed: Pathology Implications for the Physical Therapist. St. Louis: Saunders Elsevier; 2009: 110-115.
  3. 3.0 3.1 Centers for Disease Control and Prevention. Anxiety and Depression. CDC Features. March 13, 2009. Available at: http://www.cdc.gov/Features /dsBRFSS Depression Anxiety/. Accessed on March 2, 2010.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Goodman CC, Snyder TK. Pain Types and Viscerogenic Pain Patterns. In: 4th ed: Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis: Saunders Elsevier; 2007: 153-157.
  5. 5.0 5.1 Jacobsen LN, Lassen IS, Friis P, Videbech P, Licht RW. Bodily symptoms in moderate and severe depression. Nordic Journal of Psychiatry. 2006;60(4):294–8.
  6. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. Washington DC: American Psychiatric Association; 1995.
  7. 7.0 7.1 Viera ER. Depression in Older Adults: Screening and Referral. Journal of Geriatric Physical Therapy. 2014Jan;37(1):24–30.
  8. Walsh RM, Abbott JH. Screening for depression in a musculoskeletal outpatient physical therapy clinic: Point prevalence and comparison of two instruments. Journal of Back and Musculoskeletal Rehabilitation. 2008Jan;21(3):171–4.
  9. Hart DL, Werneke MW, George SZ, Deutscher D. Single-item screens identified patients with elevated levels of depressive and somatization symptoms in outpatient physical therapy. Quality of Life Research. 2011Jul;21(2):257–68.
  10. Depression - it's causes. Available from: http://www.youtube.com/watch?v=yJKSfRKBzw0 [last accessed 4/10/17]