Updated: 6/23/2021

Major Depressive Disorder

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Snapshot
  • A 51-year-old female presents to her PCP with a sore throat. 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 three months. She occasionally feels anxious about repeating past mistakes, which she cannot articulate. She goes on to express guilt about the death of some of her family members. She reports having experienced bouts of intense energy and uncontrollable thinking during which she felt very productive at work without need for sleep just prior to her current state. She denies any suicidal or homicidal thoughts. She denies any family history of depression or bipolar disorder. She denies worsened symptoms with menses. Physical exam is unremarkable, but the patient remarks a low appetite that has led to 3 pounds of weight loss. The PCP diagnoses the woman with major depressive disorder with mixed features and with anxious distress. The patient is started on escitalopram and scheduled for a follow-up appointment in two weeks.
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)

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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
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Psychotherapy

25%

(1/4)

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Citalopram

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3

Paroxetine

0%

(0/4)

4

Electroconvulsive therapy

75%

(3/4)

5

Sertraline

0%

(0/4)

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
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Add lithium

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Continue current medication

67%

(2/3)

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Increase dose of current medication

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(1/3)

4

Switch to bupropion

0%

(0/3)

5

Switch to paroxetine

0%

(0/3)

M 11 E

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Evidence (16)
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EXPERT COMMENTS (37)
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