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 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)
QUESTIONS 1 of 10 1 2 3 4 5 6 7 8 9 10 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 1 Psychotherapy 20% (1/5) 2 Citalopram 0% (0/5) 3 Paroxetine 0% (0/5) 4 Electroconvulsive therapy 80% (4/5) 5 Sertraline 0% (0/5) M 11 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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 Type & Select Correct Answer 1 Add lithium 0% (0/7) 2 Continue current medication 86% (6/7) 3 Increase dose of current medication 14% (1/7) 4 Switch to bupropion 0% (0/7) 5 Switch to paroxetine 0% (0/7) M 11 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (1) Login to View Community Videos Login to View Community Videos Major Depression with Psychotic Features Thomas Heineman Psychiatry - Major Depressive Disorder D 11/9/2012 104 views 4.0 (1) Psychiatry | Major Depressive Disorder Psychiatry - Major Depressive Disorder Listen Now 14:10 min 10/15/2021 23 plays 0.0 (0)