Diagnosis and Treatment of Depression in the Intensive Care Unit Patient

John Querques

Theodore A. Stern

I. GENERAL PRINCIPLES

A. Major depressive disorder is a psychiatric condition that affects mood and neurovegetative functions (e.g., sleep, appetite).

1. While experiencing a depressed mood transiently can be a normal and expected part of life, having the full constellation of symptoms meeting the criteria for major depressive disorder is never a normal or appropriate reaction to a stressful situation.

2. Left untreated, major depression increases rates of morbidity and mortality, especially from cardiac conditions.

B. Definition.

1. Major depressive disorder is a syndrome characterized by five or more of the symptoms listed in Table 144-1 for 2 weeks or more.

2. One of the five symptoms must be either depressed mood or anhedonia (i.e., an absence of pleasure).

3. The mnemonic SIG: E CAPS (i.e., label: energy capsules) is a helpful guide to remember these defining criteria (Table 144-1).

II. DIAGNOSIS

A. Clinical features. The manifestations of depression include affective, behavioral, and cognitive abnormalities (i.e., the ABCs of depression) (Table 144-2). Though a depressed patient may be psychomotorically slowed and have scant facial expression, his or her sensorium will be intact. This helps to distinguish depression from delirium, in which the patient will have a reduced level of wakefulness, alertness, and/or attentiveness. The hypomanic or manic patient will have an elevated, expansive, or irritable mood rather than a dysphoric one.

B. Differential diagnosis. Depression in the intensive care unit (ICU) can occur as a primary affective disorder (e.g., major depressive disorder), a mood disorder associated with a specific medical condition or its treatment, or a psychological reaction to an acute medical illness.

TABLE 144-1 Mnemonic for the Diagnostic Criteria for a Depressive Episode—SIG: E CAPS

Depressed mood

Sleep (increased or decreased)

Interest (decreased)

Guilt (preoccupation with feeling guilty or worthless)

Energy (decreased)

Concentration (decreased)

Appetite disturbed (increased or decreased) or weight gain or loss

Psychomotor agitation or retardation

Suicidal thinking or thoughts of death

Adapted from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.

TABLE 144-2 Affective, Behavioral, and Cognitive Features of Depression—the ABCs

Affective symptoms
	Depressed mood Hopelessness Crying Irritability Anger Decreased interest
Behavioral symptoms
	Insomnia Anorexia Apathy Increased sleep Increased appetite Decreased energy Psychomotor agitation Psychomotor retardation Noncompliance Deliberate self-harm Impulsivity Poor eye contact Increased or intractable pain
Cognitive symptoms
	Guilty rumination Decreased concentration Suicidal thinking or thoughts of death Confusion Dementia-like symptoms Somatic preoccupation
Adapted from Geringer ES, Querques J, Kolodziej MS, et al. Diagnosis and treatment of depression in the intensive care unit patient. In: Irwin RS, Rippe JM, eds. Intensive care medicine, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2012:2087-2099.