| History: The individual may report sadness, anxiety, fatigue, loss of appetite, and insomnia, among other symptoms. A thorough history includes a review of current and previous symptoms, previous depressive episodes, recent disturbing thoughts or events, and psychological problems that could predispose to depression; an evaluation of mood, memory, and changes in relationships; a corroborative history from friends, family members, or employers; and any family history of depression or suicides. A careful, nonjudgmental inventory of substance abuse is made, as well as a review of all current and prior medications, especially antihypertensive agents (such as calcium channel blockers and beta blockers), analgesics, and certain migraine medicines, for which depression is a side effect. Because certain clinical conditions and diseases have been associated with depression, a thorough history includes an account of neurologic disorders (poststroke disorders, Parkinson's disease, Alzheimer's disease, multiple sclerosis, epilepsy, encephalitis, brain tumors), endocrine disorders (diabetes mellitus, hypothyroidism, hyperthyroidism and hyperparathyroidism), and other disorders (coronary artery disease, post–heart attack conditions, cancer, autoimmune diseases such as fibromyalgia, rheumatoid arthritis, and lupus, and chronic fatigue syndrome). Conversely, individuals with major depression may seek medical care for headache, abdominal pain, body aches, low energy, malaise, or problems with sexual function.
It is also important to consider the possibility, particularly in medicolegal contexts, that the history offered by the patient may not reflect the underlying facts. In cases in which there is such a consideration, careful inspection of the record for other signs of symptom exaggeration, such as the presence of positive Waddell signs, or a history that varies widely from one examiner to another, or erratic performance on a functional capacities evaluation, can be tip-offs. Psychological tests that contain internal validity scales and symptom validity tests can be useful in separating those people presenting with a depressive problem and those people merely representing themselves as presenting with a depressive problem. Physical exam: Complete physical examination and medical workup are indicated to rule out underlying medical conditions (e.g., neurological, endocrine, or vascular conditions) that may disturb or deplete levels of serotonin and norepinephrine. Illnesses that are frequently associated with depression include hypo- and hyperthyroidism and other glandular disturbances, cancer, and post-stroke and post–heart attack conditions. Tests: Major depression is diagnosed primarily through observation and history. However, routine laboratory tests (e.g., CBC, electrolytes, and serum calcium) may be done to evaluate metabolic disturbances and vascular disorders, TSH may be done to identify hypo- or hyperthyroidism, and more specialized endocrine tests may be helpful in establishing the diagnosis. EEG may be performed to exclude epilepsy, and CT imaging may also be requested to identify or rule out relatively rare causes such as brain tumor or a clinically silent stroke. Psychological tests such as the Minnesota Multiphasic Personality Inventory–2 (MMPI-2) and the Beck Depression Inventory (BDI) may be useful in establishing a baseline of reported symptoms and monitoring response to treatment. Specialized neurological testing may be recommended. |