The Jesalva Algorithm: Principle #3- Screen for the most common disorders

1.  Major Depressive Disorder:  There are various depression scales that are available that have screening questions for depression. These include HAM-D, MADRS, Beck Depression Inventory, Zung, etc.

However, I ask my screening questions in a way that is more conversational so as to continue a dialogue rather than a formal Q&A type of interview.
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Key questions should query about level of energy/motivation, irritability or tearfulness, sleep and appetite changes, social withdrawal towards friends and family, feelings of hopelessness and worthlessness, suicidal thoughts or suicide attempts.
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2.  Bipolar Disorder:Undiagnosed and untreated Bipolar disorder (BPD) is a major reason why TRD exists.  In my clinical practice, BPD-1 is not very common.   However, milder forms of BPD such as BPD-2, cyclothymic disorder and bipolar spectrum disorder tend to be more common.  The symptoms of these milder forms tend to be much more subtle and, therefore, much more difficult to diagnose.  The clinician has to have a higher index of suspicion in order to diagnose them correctly.

The Mood Disorder Questionnaire (MDQ) and the Bipolar Spectrum Disorder Scale (BSDS) are the 2 scales that I use to diagnose BPD. 

3.  Anxiety Disorders:Anxiety disorders are especially challenging because they are ubiquitous and their symptoms can mimic different senses and organ systems.

I find that the most common anxiety disorder in my practice is Generalized Anxiety Disorder (GAD).  Symptoms that characterize this disorder include “worrying, overthinking, overanalyzing”, thinking about the worst case scenario, doing the “what if’s”, being self critical, self conscious, having self doubt.  Some physical symptoms include being fidgety, restless, “always on the go”, needing to be constantly busy, nail biting, picking.  There are also some GI, cardiovascular and neurological symptoms as well.

Another key component is that anxiety can impair someone’s short term memory (STM), concentration and attention span.  This may make patients feel that they have early onset “dementia” .  However, STM and concentration span usually improve with improvement in anxiety.

4.  ATTENTION DEFICIT DISORDER (ADD):

I use the term ADD rather than ADHD since I usually don’t see the HYPERACTIVITY in most adults and adolescents.  The “hyperactivity” in this population is usually the anxiety and fidgetiness that I described earlier.
ADD is a disease that starts in childhood.  I usually ask for symptoms of ADD THROUGHOUT the life span and NOT just during adulthood.  I ask questions about distractability, getting easily bored, procrastination, multi-tasking, underachievement, behavioral problems in school, etc…


One important note is to rule out ADD in the ABSENCE of anxiety.  Often times the symptoms of poor attention and concentration can be mimicked by anxiety especially if the anxiety starts early in life.


5.  SUBSTANCE USE DISORDER:

Abuse of drugs and alcohol is a major issue in TRD.  Patients who abuse tend to under report their use.  What is important for me is the extent of their abuse because some patients have a secondary substance use disorder that improves with treating the primary disorder. 
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That is, I often ask them about “why” they use it and a lot of time they self medicate with drugs and alcohol.  As an example, drugs that slow down the brain are usually drugs that patients with anxiety use to self medicate.  Therefore, central nervous depressants (CNS) like MJ, Xanax, pain medications, heroin, tend to be popular with anxious addicts while CNS stimulants like amphetamines, cocaine may be more popular with depressed patients and patients with untreated ADD.