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Interviewer: If you talk to your primary care health provider because you have a concern about depression, they'll likely ask a series of questions that will help them with the diagnosis. The series of questions is referred to as SIGECAPS or SIGECAPS. And today, we're going to learn more about it so you can have an informed discussion with your health provider about your mental health, if that's something you need to do.

Dr. Matt Chatbot is a primary care provider at University of Utah. He's also board-certified in internal medicine and pediatrics. So first, let's just start off with what is SIGECAPS or SIGECAPS? The letters are S-I-G-E-C-A-P-S.

How SIGECAPS Helps in Diagnosing Depression

Dr. Chatbot: So basically, this is a list of symptoms that often happen for people with major depressive disorder. So in no particular order:

• Sleep
• Interest, or lack of interest
• Guilt
• Energy, or lack of energy
• Concentration, or lack of concentration
• Appetite, either a lack of appetite or too much appetite
• Psychomotor retardation, refers to just moving slowly without really intending to
• Suicide, or really, in this case, suicidal ideation, thoughts that you'd be better off dead or maybe just don't want to be alive.

That forms a basis of our history taking for major depressive disorder.

Adapting SIGECAPS for Children

Interviewer: All right. Does it work for kids too as well as it works for adults? I mean, you work with both patients.

Dr. Chatbot: It is different in kids. Kids are going to express these things differently. Certainly, there are different questionnaires that are used in different developmental stages. So I can't say that it universally applies to kids, but, generally speaking, the same concepts apply. 

Defining Depression

Interviewer: You said it diagnoses major depressive disorder. I think we need to kind of quickly define what that is. Are there a lot of different types of depression? Or is this the most common type of depression? I mean, what is a major depressive disorder?

Dr. Chatbot: Yeah, and that's maybe an overly technical way to describe what most people would say is depression. There are different qualifiers that you can put on it in a medical context, like dysthymia, which is a little less severe and more constant, and maybe is sort of closer to part and parcel of your personality. Major depressive disorder is what medical people talk about when they are talking about depression that is bad enough that we should be treating it and is having significant effects on somebody's life.

Accuracy of SIGECAPS in Identifying Depression

Interviewer: How accurate is this series of questions that you ask that's referred to as SIGECAPS? Is it pretty accurate to figure out if somebody is suffering from depression? Like if I came into your office and I'm like, "I don't know. Maybe I am, maybe I'm not." After you get done asking these questions, do I have a pretty good idea?

Dr. Chatbot: Yeah, we have a pretty good idea. Some of them, as you can imagine, overlap with other stuff, right? Sleeping problems, appetite problems. So it's really what we call it sensitive and not specific. So it's going to pick up everybody or most everybody with depression. But some of the people picked up by this questionnaire might also have other things. So it's a starting point. It's a jumping-off point for the rest of the history, for sure.

Interviewer: Yeah. And I hear it's pretty accurate. Is that true?

Dr. Chatbot: I think it's very accurate. This is a part of the definition of the thing that we're looking for. So, yeah, this is what your provider is going to use to answer the question.

Interviewer: What are the strengths of this particular series of questions?

Dr. Chatbot: I think this set of questions does a good job of identifying symptoms of depression that are not things that you would say to yourself, "I'm depressed." People will often say, "Well, yeah, I can't sleep and I'm eating way too much." And they might not immediately put that together for an emotional cause. But this questionnaire does a good job of tying all those things together and creating a sort of structure to say, "Yeah, these are very likely to be a problem due to depression."

Considerations and Weaknesses of SIGECAPS

Interviewer: Are there any weaknesses that somebody should be aware of when it comes to SIGECAPS?

Dr. Chatbot: Each of these symptoms is pretty broad and can be a bunch of other stuff. So while it will almost always find depression, it might find other things as well. So I think it's the start of the conversation. It's not the end of the conversation. So, for example, thyroid disorders can make you feel really low energy to the point where you can't concentrate and you have a lack of interest in your normal things, and it might be a hormonal issue. Similarly, anemia could check a lot of these same boxes. So it casts a pretty broad net. And that's I think maybe the thing to know about is that if things are really going well, there's going to be more investigation after this to say, "Is there some other biological thing that we should be talking about, or is this really depression?" And then that's got its own set of treatments.

Next Steps After Diagnosing Depression

Interviewer: Yeah. Once you figure out that you believe you're dealing with a patient who has depression, then where do you go from there? Do you refer them? Is there something you can do at that point? What's next?

Dr. Chatbot: So the vast majority of behavioral health and psychiatric treatment actually happens through generalists and primary care providers because there are not enough psychiatrists in the world. So I will generally embark on treatment before anything else. So the first thing is to really quantify, like you mentioned, how severe is this. Certainly, if somebody is imminently suicidal, that's a very different situation than someone who's really just lost interest in the usual things that bring them happiness, and really trying to parse that out with the patient. 

Quantifying Severity and Treatment Decisions

Some of the other questionnaires that we have put a number score to these SIGECAPS sort of symptoms, and that helps to say, "Are we in a severe, moderate, or mild situation?"

The other way to quantify this, in my mind, people express depression differently. As I mentioned to how sleep is one of the symptoms, but that can look really different for each person. Some people just want to hide in bed, pull the covers over their heads, and sleep 12 hours or more a day, and some people are the inverse and can't sleep at all. So some of the treatments that we use can be a little more activating or a little more sedating.

Balancing Medication and Therapy Options

So trying to tailor our treatment regimen to the version of SIGECAPS that this person is having is really where we start. There's a conversation about medicine, and I think the other conversation is certainly therapy or talking about it. And I always pitch this to patients as like, "Well, at the end of the day, we really have two tools, talking about it and medicines." And if we're not at least considering both options, then we're probably doing a bad job, right?

So I get some people who will say like, "Man, I'd rather die than talk to a therapist. That sounds like the worst. Can't you just give me a pill?" And I'll say, "Well, yes, I can give you a pill. But if we're not also working on some form of therapy, we're probably not doing a great job at this."

And to some degree, the inverse is also true for people with severe enough issues. I've heard it the opposite, to say like, "I just want to do therapy, and I don't like the idea of putting a chemical in my body." And sometimes we can get away with that, and I can understand that sentiment. But if it's bad enough, often use that argument again to say like, "Look, we're not doing all the things that evidence shows that can help."

I think sometimes there's a stigma around either or both of those treatments, and really trying to break down any misconceptions that are there is a lot of like the first conversation that I have with people about it is like, "Okay. So what's your stance on therapy? What's your stance on medicines? And then let's talk about it." There's never one-size-fits-all exactly. But the best outcomes usually come from a combination of both.

Follow-Up and Monitoring Progress

Interviewer: Do you then have the patient check back in with you at a certain amount of time, or what are the next steps after that?

Dr. Chatbot: For sure. I would say all of the treatments here are slow-moving on the order of weeks or maybe a month or a month and a half. So, generally speaking, I follow up with people every four to six weeks until I'm convinced that we're sort of at a cruising altitude, you know, we're doing well, we're stable, and we're not making major changes. Lots of caveats there in terms of like, "Well, how fast can we get into therapy?" It could be hard to get into therapy, right? Some people might be on waiting lists for a bit. But if we're talking strictly about medicines, all these medicines take weeks, more like four to six weeks to really see the full effect.

So I always talk about a lot of patients, when it comes to these treatments, the biggest complaint I get is, "I don't know. I don't feel different yet." And I'll be like, "Well, it's only been three days. We've got to keep it up." Those persistent follow-ups in the four to six-week range are part of my usual. It can certainly depend on where you are. Then little dose adjustments, maybe even changing medicines altogether is very much the sort of standard of care for this.

Seeking Professional Help for Depression

Interviewer: If somebody looked up SIGECAPS online, would they be able to get a pretty good idea themselves, if they did not have medical training, whether or not they might have depression? Or is it a little bit more complicated than that for the reasons you've already identified, that it could be other medical conditions that are causing some of these things?

Dr. Chatbot: I think it's a little complicated. But I think the average person who looked at this list of symptoms would probably be able to get a sense. And I would say this is one of those things that should encourage you to get into the doctor's office if you're having some significant portion of these. It's a very treatable thing that can and should be talked about, so.

Interviewer: And really, if you're having issues with any of these things, whether it's sleep, interest, energy, I mean, it might not be depression, but it's probably still a good reason to see a professional because who wants to live with those things?

Dr. Chatbot: For sure. Yeah, I think sometimes there's a little bit of fatalism like, "Oh, this is just me. This is just life. It's not anything anybody can deal with." And I think we can. We can help. And generally, providers are not groaning and rolling their eyes when people come in with these things. These are things that we want to help with. And there are good treatments increasingly, so.