City Health Information
Volume 33 (2014) New York City Department of Health and Mental Hygiene No. 1; 1-8
 

IN THIS ISSUE

 

Diagnosing and Managing the Mental Health
Needs of Adults Exposed to Disaster
  • Educate patients about physical and emotional symptoms of normal stress reactions.
  • Ask patients about their exposure and reactions to disaster.
  • Identify patients who may have posttraumatic stress disorder, depression, generalized anxiety disorder, or a substance use disorder and use standard screening tools for further evaluation.
  • Encourage patients to take advantage of psychotherapy, pharmacotherapy, or both.

 

MAJOR DEPRESSIVE DISORDER

Major depressive disorder is a disabling condition that affects many aspects of a person's life and overall functioning (Resources—City Health Information: Depression). People exposed to traumatic events such as Hurricane Sandy may be at increased risk for developing depression, with or without PTSD (5-7). Depression is typically characterized by many or all of the following: feelings of extreme sadness; loss of interest or pleasure in doing things; guilt; helplessness; hopelessness; aches, pains, or digestive problems; insomnia; inability to concentrate; irritability; loss of appetite; and thoughts of suicide and/or death (21). Depression may occur only once in a lifetime, but is more commonly a recurring condition. Providers should diagnose depression through observation and active listening, as patients may not be aware that they are suffering from depression and may only report unexplained physical complaints (eg, headache or pain) (22).

Screening

When interviewing any patient, observe, listen, and ask questions about the patient's mood, level of functioning, energy, motivation, and any work-related or social problems. Use the Patient Health Questionnaire-2 (PHQ-2) to screen for depression simply and quickly (23). If the patient screens positive on the PHQ-2, consider evaluating the patient further with the Patient Health Questionnaire-9 (PHQ-9). This 9-item questionnaire can reliably detect and quantify the severity of depression and can be used to help monitor response to treatment (24). If the response to question 9 ("Thoughts that you would be better off dead, or hurting yourself in some way") on the PHQ-9 is positive, evaluate the patient for suicide risk. See Resources—City Health Information: Depression for the PHQ-9 and guidance on suicide risk assessment.

Treatment

The comprehensive management of depression may include pharmacologic treatment and nonpharmacologic approaches such as psychotherapy, patient education, and increased physical activity (25,26). Advise patients to maintain good sleep hygiene and avoid alcohol, tobacco, and caffeine (25). Consider the patient's treatment preference, severity of symptoms, psychosocial stressors, comorbid conditions, and availability of resources when choosing treatment (25). Patients with psychosis, suicidal ideation, or severe functional impairment usually need medication and may require hospitalization (25). Monitor patients frequently for treatment effectiveness, suicidality, and adverse effects if they are taking antidepressant medication.

Psychotherapy (25). Cognitive behavioral therapy and interpersonal psychotherapy, with or without medication, can be considered as initial treatments in patients with mild to moderate depressive disorder. Antidepressant medications in combination with psychotherapy should be considered for patients with moderate to severe major depressive disorder.

Exercise (26). Aerobic exercise improves symptoms of depression and, at recommended amounts, may by itself be an effective treatment for mild to moderate major depressive disorder. The amount of exercise needed for this effect is equivalent to at least 30 minutes of moderate-intensity physical activity on most or all days of the week (Resources—CDC Physical Activity Resources for Physicians). Exercise also has many other benefits such as improving cardiovascular health and reducing arthritis pain.

Pharmacotherapy. Selective serotonin reuptake inhibitors (Box 4) or other agents are generally preferable to tricyclic antidepressants when treating depression. It is easier to titrate the doses of bupropion, mirtazapine, and venlafaxine, and they have less severe side effects, allowing for a quicker response, better adherence, fewer office visits, and lower cost. During treatment with an SSRI, patients may complain of feeling jittery, increased anxiety, nausea or gastrointestinal upset, or sexual problems such as delayed ejaculation in men and anorgasmia in women. Other adverse effects seen with many antidepressants include insomnia or sedation, headaches, and weight changes. Advise patients that while benefits may be delayed or appear slowly, adverse effects can occur immediately. However, the adverse effects are usually mild and, except for sexual side effects, improve with time or can be managed by adjusting or changing medications. Mirtazapine seems to have the fewest sexual side effects, but it may cause potentially significant weight gain. Bupropion has no sexual side effects and does not cause weight gain.

PHQ-2–PATIENT HEALTH QUESTIONNAIRE-2

Screen for depression by asking the following 2 questions:

Over the past 2 weeks, have you been bothered by:

  • Little interest or pleasure in doing things?
  • Feeling down, depressed, or hopeless?

A "yes" to either question requires further evaluation.

PDF version of PHQ-2

BOX 4. PHARMACOTHERAPY FOR DEPRESSION (25)

Available antidepressant medications include

  • SSRIs: citalopram (Celexa®), escitalopram (Lexapro®), fluoxetine (Prozac®, Prozac® Weekly™), paroxetine (Paxil®, Paxil CR®), sertraline (Zoloft®);

  • Other agents: bupropion (Wellbutrin®, Wellbutrin SR®, Wellbutrin XL®), duloxetine (Cymbalta®), mirtazapine (Remeron®, Remeron SolTab®), venlafaxine (Effexor®, Effexor XR®).

PDF version of Box 4

 

Continue to GENERALIZED ANXIETY DISORDER on the next page >