Go back

INDEX

    Depression

    Psychiatric and Behaviour

    Last Reviewed on May 21, 2024
    Read Disclaimer
    By Monika Wojtera,Bhavneet Jhajj, Ivjot Samra

    First 5 Minutes

    • A structured risk assessment should be conducted including risk of self-harm, suicide or risk of harm to others.
    • No tool is 100 percent accurate.

    Context

    Emergency Department visits for mental health have increased by 20% over the past decade.

    Factors contributing to ED visits for mental health reasons include:

    • Age 12 to 24 years
    • Immigrants
    • Low socioeconomic status
    • Identifying as gender non-binary
    • Co-occurring substance use disorders
    • Experiencing homelessness or marginal housing
    • Elderly (may be misdiagnosed as early dementia)

    Long-term consequences of depression include increased mortality and morbidity rates.

    Diagnostic Process

    Various presentations:

    • Non-specific somatic complaints such as headache, chronic pain, weakness, fatigue.
    • Suicidal ideation or attempt.
    • Under the influence of substances.

    The PHQ-2 screening tool can be used to assess key symptoms related to depression. It has comparable specificity and sensitivity to the PHQ-9.

    Two questions can be asked: “Over the last 2 weeks, how often have you been bothered by any of the following problems”

    • Little interest or pleasure in doing things (Anhedonia).
    • Feeling down, depressed or hopeless.

    Each PHQ-2 question is scored from 0 to 3

    • Not at all = 0
    • Several days = 1
    • More than half the days = 2
    • Nearly every day = 3

    If score of 3 or higher, the patient requires a thorough assessment or PHQ-9.

    Recommended Treatment

    Communication tips for interacting with depressed patients in the ED:

    • Establish rapport.
    • Respond with empathy.
    • Avoid leading questions and utilize open-ended questions.
    • Assess whether a patient requires further consultation from a psychiatrist.
    • Obtain collateral information to assist in evaluation.
    • Ask screening questions for suicidality.

    SAD PERSONS is one approach to assess suicide risk. No tool accurately determines suicide risk.

    S – Male Sex = 1 point
    A – Age < 19 or > 45 years = 1 point
    D – Depression = 2 points
    P – Previous Attempt = 2 points
    E – Excess alcohol or substance use = 1 point
    R – Rational thinking loss = 2 points
    S – Social supports lacking = 1 point
    O – Organized plan = 2 points
    N – No spouse = 1 point
    S – Sickness = 1 point

    • It allots a point of one for: male sex, age < 19 or > 45, previous attempts / psychiatric care, excessive alcohol / drug use, individuals that are separated / divorces / widowed and lack of social supports.
    • It allots two points for: depression / hopelessness, loss of rational thinking, attempts (serious or organized) and stated future intent.
    • Based on an individual’s total score they are risk stratified as follows:
      • 0-2 = send home with follow-up
      • 3-4 = close follow-up, consider hospitalization
      • 5-6 = strongly consider hospitalization
      • 7-10 = hospitalize

    1st line medication recommendations for depression SSRIs and SNRIs (dosage varies depending on specific medication) but may include:

    • Agomelatine (Valdoxan 25-50mg)
    • Bupropion (Wellbutrin 150-300mg)
    • Mirtazapine (Remeron 15-45mg)

    Relative differences between first line medications are small and there are no absolutes when choosing one to prescribe over the other.

    Consider providing resources for counselling, especially for isolated patients or those with a lack of social supports (e.g., family, friends)

    Table 1. Emergency department management of patients with depression

    Table 1. Emergency department management of patients with depression.

     

    Criteria For Hospital Admission

    • Admit if the patient poses a risk of harm to themselves or others.
    • Also consider admission in patients with severe symptoms of depression, even if without active suicidal ideation, potentially on an involuntary basis.

    Criteria For Safe Discharge Home

    • Patients may be discharged when they are deemed to pose a low risk of harm to themselves or others.
    • Patients should receive instructions and resources on managing their medications, activities of daily living and follow-up with appropriate services (e.g., Psychiatric or GP follow-up, housing, financial needs).

    Quality Of Evidence?

    Justification

    Depression management guidelines in the Emergency Department.

    Low

    Diagnosis and screening of depressive disorders.

    Moderate

    Related Information

    OTHER RELEVANT INFORMATION

    Reference List

    1. Shyman L, Sukhorukov R, Barbic D, Mathias S, Chau S, Leon A, et al. Social Determinants of health and depression in adults presenting to the Emergency Department. Canadian Family Physician. 2021 Dec;67(12). doi:10.46747/cfp.6712e337


    2. Kuo DC, Tran M, Shah AA, Matorin A. Depression and the suicidal patient. Emergency Medicine Clinics of North America. 2015 Nov;33(4):765–78. doi:10.1016/j.emc.2015.07.005


    3. Moore GP, Moore MJ. Assessment and emergency management of the acutely agitated or violent adult [Internet]. 2023 [cited 2024 Jan 27]. Available from: https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult


    RESOURCE AUTHOR(S)

    COMMENTS (0)

    Add public comment…