Updated: 10/5/2022

Major Depressive Disorder

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  • Snapshot
    • A 51-year-old female presents to her PCP with a depressed mood. Upon further screening, the patient shares concerns of difficulty with sleep, concerns about making mistakes in her life, and observations of decreased ability to focus at work as an administrative assistant for the past 3 months. She no longer enjoys her favorite hobbies anymore. She goes on to express guilt about the death of some of her family members. She denies any suicidal or homicidal thoughts. Physical exam is unremarkable, but the patient remarks a low appetite that has led to 3 pounds of weight loss.
  • Introduction
    • Mood state, syndrome, and/or mental disorder characterized by dysphoria (sad/irritable)
    • Most common psychiatric disorder
    • Epidemiology
      • 18% prevalence in the United States
      • females affected twice as often as males
      • not associated with economic status or race
      • incidence decreases with increasing age
        • however, associated with presence of multiple medical comorbidities
    • Classifications (DSM-V)
      • unipolar major depression (major depressive disorder)
      • persistent depressive disorder (previously called dysthymia)
        • no scientifically meaningful distinction between chronic depression and dysthymia
        • symptom persistence for > 2 years
      • disruptive mood dysregulation disorder
        • new diagnosis for children up to 18 years with persistent irritability and behavior dyscontrol
        • created due to concerns of overdiagnosis of bipolar disorder
      • premenstrual dysphoric disorder
      • substance/medication induced depressive disorder
      • depressive disorder due to another medical condition
      • unspecified depressive disorder
  • Presentation
    • Symptoms
      • SIG E CAPS
        • Sleep decreased
        • Interest decreased (anhedonia)
        • Guilt increased
        • Energy decreased
        • Concentration decreased
        • Appetite decreased
        • Psychomotor retardation
        • Suicidal ideations
  • Evaluation
    • Routine outpatient screening now recommended by USPSTF
      • Patient Health Questionnaire-2 (PHQ-2) can be used
        • if positive, follow up with PHQ-9
        • assess for suicidal ideation, plan, and intent
    • Diagnostic criteria
      • core symptom criteria have not changed in DSM-V
      • one or more major depressive episodes
        • a depressive episode must contain five or more of the above symptoms
      • for episodes > 2 week period separated by 2 month period
      • impairment of daily living
      • medical causes has been ruled out (e.g., hypothyroidism, adrenal insufficiency, Huntington's disease, hypercortisolism, mononucleosis, Parkinson's disease, stroke, lupus, TBI, vitamin B12 deficiency)
    • Subtype specifiers
      • anxious distress
      • atypical features
        • appetite increased
        • reactive to pleasurable stimuli
        • hypersomnia
        • heavy feelings in limbs
        • longstanding pattern of hypersensitivity to rejection
      • catatonia
        • symptoms improve with benzodiazepines (i.e., lorazepam)
      • mixed features
        • at least three symptom criteria for mania/hypomania
  • Treatment
    • Routine outpatient screening now recommended by USPSTF
      • Patient Health Questionnaire-2 (PHQ-2) can be used
        • if positive, follow up with PHQ-9
    • 1st line: psychotherapy + pharmacotherapy
      • psychotherapy
        • cognitive-behavioral therapy or interpersonal psychotherapy
      • pharmacotherapy
        • selective serotonin reuptake inhibitors (SSRI)
          • first line drug
          • fewer side effects overall
          • need > 4 weeks to take effect
          • sudden cessation of therapy can lead to SSRI discontinuation syndrome
        • SNRI, atypical agents (bupropion, mirtazapine)
          • second line drugs
          • first line if also treating neuropathy
          • bupropion preferred for smoking cessation, is weight neutral, and does not have sexual side-effects
        • TCAs and MAO inhibitors
          • third line
          • particularly effective when atypical symptoms present
    • Electroconvulsive therapy
      • for refractory cases, depression with psychotic features, or if immediate symptom resolution is required
      • most common side effect is amnesia 
  • Prognosis
    • Prognosis
      • medical therapy effective in up to 70% of patients though must allow sufficient time for success and treat for minimum of 6 months
        • results observable typically in 2 weeks
        • follow-up usually at 2 weeks because risk of suicide is greatest following initial use of antidepressants
      • if patient has had 1 episode of major depression, pharmacotherapy can be discontinued after 6 months of no symptoms
        • can be monitored using PHQ-9 (not PHQ-2)
      • complications
        • pseudodementia
          • dementia secondary to depression
            • rule out organic causes before making this diagnosis (such as a TSH level)
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(M3.PY.16.23) A 27-year old gentleman presents to the primary care physician with the chief complaint of "feeling down" for the last 6 weeks. He describes trouble falling asleep at night, decreased appetite, and recent feelings of intense guilt regarding the state of his personal relationships. He says that everything "feels slower" than it used to. He endorses having a similar four-week period of feeling this way last year. He denies thoughts of self-harm or harm of others. He also denies racing thoughts or delusions of grandeur. Which of the following would be an INAPPROPRIATE first line treatment for him?

QID: 103314

Psychotherapy

20%

(1/5)

Citalopram

0%

(0/5)

Paroxetine

0%

(0/5)

Electroconvulsive therapy

80%

(4/5)

Sertraline

0%

(0/5)

M 11 B

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(M3.PY.15.25) A 38-year-old woman presents to her primary care physician for complaints of insomnia. She states that for the last 8 months, she has had difficultly falling asleep. Additionally, she awakens in the middle of the night or early morning and cannot fall back to sleep. When further questioned, she reports decreased appetite with a 12-lb. weight loss in the last 6 months. She was recently demoted at her work as a baker due to trouble focusing and coordinating orders and excess fatigue. She feels she is to blame for her families current financial status given her demotion. She is given a prescription for fluoxetine at this visit with follow-up 2 weeks later. At the follow-up visit, she reports no improvement in her symptoms despite taking her medication consistently. What is the most appropriate next step in management?

QID: 103316

Add lithium

0%

(0/7)

Continue current medication

86%

(6/7)

Increase dose of current medication

14%

(1/7)

Switch to bupropion

0%

(0/7)

Switch to paroxetine

0%

(0/7)

M 11 E

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(M2.OMB.4878) A 55-year-old man presents to his primary care physician with persistent symptoms of depression. He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce. Since then, he notes that his symptoms are roughly unchanged. His other medications include albuterol. His temperature is 99.3°F (37.4°C), blood pressure is 132/88 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals a depressed affect. His neurologic exam is non-focal. A serum thyroid stimulating hormone (TSH) resulted from his last visit and is noted to be 4.8 µU/mL (normal: 0.5-5 µU/mL). Which of the following is the most appropriate next step in management?

QID: 216593

Administer levothyroxine

0%

(0/0)

Change medication to bupropion

0%

(0/0)

Change medication to escitalopram

0%

(0/0)

Increase dose of current medication

0%

(0/0)

Maintain dose of current medication

0%

(0/0)

M 11

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(M2.OMB.4876) A 45-year-old man with a past medical history of obesity presents with a concern about his sexual performance. He has a history of depression which is well managed with fluoxetine. He states that since starting the medication, his sexual drive has increased, yet he is unable to achieve orgasm. As a result, he refuses to take the medication anymore. He has a past medical history of diabetes and notes that his home blood glucose readings have been higher lately. His temperature is 98.3°F (36.8°C), blood pressure is 127/82 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals an obese man in no acute distress with a normal affect and non-focal neurologic exam. The physician agrees to change the patient’s antidepressant. Which of the following is the most appropriate treatment for this patient?

QID: 216591

Bupropion

0%

(0/0)

Electroconvulsive therapy

0%

(0/0)

Escitalopram

0%

(0/0)

Mirtazapine

0%

(0/0)

Phenelzine

0%

(0/0)

M 11

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(M2.OMB.4879) A 60-year-old man presents to his primary care physician with weight gain. He states that ever since his wife died 4 months ago, he has been eating and sleeping more and no longer engages in any activities he once enjoyed such as hiking or fishing. He feels guilty for not spending more time with his wife before she died. He was recently fired for making several major bookkeeping mistakes at work as an accountant as he had trouble focusing. The patient is requesting oxycodone at this appointment as he states he has burning pain in his legs that feels worse now than it has in years past. The patient has a past medical history of obesity, poorly controlled diabetes, hypertension, and peripheral vascular disease. His temperature is 98.7°F (37.1°C), blood pressure is 129/82 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals a stable gait and reduced sensation symmetrically over the lower extremities. He complains of electric pain when touching his lower extremities. His affect seems depressed. Which of the following is the most appropriate treatment for this patient?

QID: 216594

Amitriptyline

0%

(0/0)

Bupropion

0%

(0/0)

Escitalopram

0%

(0/0)

Phenelzine

0%

(0/0)

Venlafaxine

0%

(0/0)

M 11

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