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Updated: Oct 5 2022

Major Depressive Disorder

  • 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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