Depression

What does it look like?

Depression is characterized by feelings of sadness, emptiness, or hopelessness; loss of interest or pleasure in activities; insomnia or hypersomnia; loss of appetite or appetite increase; difficulty with concentration; thoughts and feelings of worthlessness or guilt; and may be accompanied by thoughts of death or suicide. 

Although sadness and grief is a common reaction to the current pandemic and quarantine, if such feelings impact functioning and are present more often than not for the past 2 weeks, depression may be present. 

What are the signs and symptoms of depression? 

Sadness is only one small part of depression and some people with depression may not feel sadness at all. Different people have different symptoms. Some symptoms of depression include:

  1. Persistent sad, anxious, or “empty” mood
  2. Feelings of hopelessness or pessimism
  3. Feelings of guilt, worthlessness, or helplessness
  4. Loss of interest or pleasure in hobbies or activities
  5. Decreased energy, fatigue, or being “slowed down”
  6. Difficulty concentrating, remembering, or making decisions
  7. Difficulty sleeping, early-morning awakening, or oversleeping
  8. Appetite and/or weight changes
  9. Thoughts of death or suicide or suicide attempts
  10. Restlessness or irritability
  11. Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Does depression look the same in everyone?

No. Depression affects different people in different ways. For example:

Women have depression more often than men. Biological, lifecycle, and hormonal factors that are unique to women may be linked to their higher depression rate. Women with depression typically have symptoms of sadness, worthlessness, and guilt.

Men with depression are more likely to be very tired, irritable, and sometimes angry. They may lose interest in work or activities they once enjoyed, have sleep problems, and behave recklessly, including the misuse of drugs or alcohol. Many men do not recognize their depression and fail to seek help.

Older adults with depression may have less obvious symptoms, or they may be less likely to admit to feelings of sadness or grief. They are also more likely to have medical conditions, such as heart disease, which may cause or contribute to depression.

How do I screen for it?

Patient Health Questionnaire-9 PHQ: Patient Health Questionnaire

Interpretation:

1-4: No depression
5-9: Mild depression
10-14: Moderate depression
15-19: Moderately severe depression
20-27: Severe depression

MiChart Name: UM AMB PHQ9

For scores between 5-14, provide self-help resources. Consider pharmacotherapy for those scoring > 9, and if needed, consultation with Behavioral Health Collaborative Care, or consideration of referral for psychotherapy. If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu. Medication treatment considerations can be found here [insert link]. Medication treatment considerations can be found here [insert link].

What are the treatment options?

Mild depression can often be treated with supportive psychotherapy or cognitive behavioral therapy (CBT). In treating depression, CBT aims to identify and challenge automatic negative assumptions (e.g. “I’m worthless,” “things will never get better”) through behavioral exercises and patient charting. There is also a focus on changing maladaptive behaviors that perpetuate depression in a process called behavioral activation.

For cases of moderate-severe depression, antidepressant treatment is warranted in addition to offering psychotherapy. Escitalopram and sertraline are often preferred initial agents because of their ease of dosing, relative lack of drug-drug interactions, and cardiovascular safety. Venlafaxine, duloxetine, mirtazapine, and bupropion are other medications that are often safe and common in primary care practice.

Self-Help Resources

1. Michigan Medicine Depression Center Toolkit

For: Adults, adolescents
Cost: Free
Description: 

  • Provides information, tools, support, and resources for people who are experiencing problems with mood, stress/anxiety, those who have been recently diagnosed with depression or bipolar disorder, and those receiving treatment for mood disorders. 
  • Also offers help to family members and caregivers of those who suffer from mood disorders
  • Created by experts from the University of Michigan Depression Center, with the help of individuals with lived experience of mood and anxiety disorders and a group of external professionals.

2. Mood Coach - Download app at Apple App store 

For: Adults
Cost: Free
Description: 

  • Mood Coach is an app for Veterans, Service members, and others to learn and practice Behavioral Activation. 
  • Designed to help boost mood through participation in positive activities. 
  • Can be used on its own or to augment face-to-face care with a healthcare professional. It is not intended to replace therapy for those who need it.
  • This app provides:
    1. Scheduling of positive activities for selected values
    2. An activity log for tracking your progress
    3. A daily mood rating tool
    4. Education about depression, posttraumatic stress disorder, and Behavioral Activation
    5. The PHQ-9 assessment for tracking symptoms of depression

3. Mood Gym

For: Adults
Cost: $27 for 12-month access
Description: 

  • Moodgym is like an interactive self-help book which helps you to learn and practice skills which can help to prevent and manage symptoms of depression and anxiety. 
  • Studies of use in primary care settings demonstrate effectiveness in reducing depression and anxiety symptoms.