Psychiatry assignment 5a BY Dr. Scott Neff, DC DABCO MSOM MPS DABFE FABFE FFABS FAABT FFAAJTS

BEATING DEPRESSION THROUGH MEDICAL INFORMATION MASTERY ANDS POEMs

 INTRO INTO DEPRESSION:

DIAGNOSIS:

Major Depressive Disorder or MDD, is one of the more commonly encountered chronic relapsing psychiatric disorders, which causes significant impairment to those afflicted.  Depression is a feeling of sadness and misery, usually accompanied by lowered self-esteem and ranging from feelings of inadequacy and incompetence to a full-blown delusional state.  Initial episodes often occur in adolescence although, MDD can first develop late in life.  Periods of exacerbation of MDD are marked by anhedonia, feelings of failure, inability to think positively about current life events or the future, and suicidal thoughts.  Both genetic and environmental influences increase an individual’s risk of MDD.  The periods of remission can last for years, during which patients lead quite normal lives.  Relapse has been associated with stressful life events.

Within our nation, lifetime incidence of MDD is 20% in women and 12% in men. Prevalence is as high as 10% in patients observed in a medical setting.  Cultural influences on the presentation of depression can be significant. The practitioner should be aware of differences in the expression of psychological distress in patients from other countries or cultures. Some cultural patterns are mentioned in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR); for example, MDD may be expressed as fatigue, imbalance, or neurasthenia in patients of Asian origin.  MDD is a disorder with significant potential morbidity and mortality, contributing as it does to suicide, medical illness, and disruption in interpersonal relationships, substance abuse, and lost work time.

• Suicide ranks as a leading cause of death in the United States, with a yearly rate of approximately 200,000 attempts. The number of completed suicides for 1998 was 30,575. Suicide continues to rank as the second leading cause of death in adolescents and represents 10-30% of deaths in those aged 20-35 years. MDD plays a role in more than one half of all suicide attempts, while the death rate from suicide among those with affective disorders can exceed 15%. Firearms are the most frequent method used in completed suicides. Risk factors for suicide include (1) male sex; (2) age older than 55 years; (3) concurrent chronic medical illness; (4) social isolation (e.g., divorced, widowed); (5) depression, especially with severe melancholic or delusional symptoms; (6) substance abuse or dependence; (7) family history of suicide and/or MDD; (8) command hallucinations; (9) access to firearms; and (10) white race.

• Studies also show that MDD contributes to higher mortality and morbidity in the context of other medical illnesses, such as myocardial infarction, and that successful treatment of the depressive episode improves medical and surgical outcomes.

Pathophysiology:

The underlying pathophysiology of major depressive disorder (MDD) has not been clearly defined. Clinical and preclinical trials suggest a disturbance in CNS serotonin (ie, 5-HT) activity as an important factor. Other neurotransmitters implicated include norepinephrine (NE) and dopamine (DA).

The role of CNS serotonin activity in the pathophysiology of MDD is suggested by the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of MDD. Furthermore, studies have shown that an acute, transient relapse of depressive symptoms can be produced in research subjects in remission using tryptophan depletion, which causes a temporary reduction in CNS serotonin levels. Serotonergic neurons implicated in affective disorders are found in the dorsal raphe nucleus, the limbic system, and the left prefrontal cortex.

Clinical experience indicates a complex interaction between neurotransmitter availability, receptor regulation and sensitivity, and affective symptoms in MDD. Drugs that produce only an acute rise in neurotransmitter availability, such as cocaine, do not have efficacy over time as antidepressants. Furthermore, an exposure of several weeks' duration to an antidepressant usually is necessary to produce a change in symptoms. This, together with preclinical research findings, implies a role for neuronal receptor regulation over time in response to enhanced neurotransmitter availability.

All available antidepressants appear to work via 1 or more of the following mechanisms: (1) presynaptic inhibition of uptake of 5-HT or NE; (2) antagonist activity at presynaptic inhibitory 5-HT or NE receptor sites, thereby enhancing neurotransmitter release; or (3) inhibition of monoamine oxidase, thereby reducing neurotransmitter breakdown.

The specific cause of MDD is not known. As with most psychiatric disorders, MDD appears to be multifactorial in its origin. For example it is known that Genetic susceptibility plays a role in the development of MDD. Individuals with a family history of affective disorders, panic disorder, and alcohol dependence carry a higher risk for MDD. 

Exposure to certain pharmacologic agents also increases the risk; medications such as reserpine or beta-blockers, as well as abused substances such as cocaine, amphetamine, narcotics, and alcohol are associated with higher rates of MDD.

Finally, chronic pain, medical illness, and psychosocial stress also can play a role in both the initiation and maintenance of MDD. The psychological component of these risk factors is discussed below. However, neurochemical hypotheses point to the deleterious effects of cortisol and other stress-related substances on the neuronal substrate of mood in the CNS.

Sex and age are important considerations when diagnosing MDD.  For example, MDD is discovered more commonly in women, with a prevalence twice that observed in men.   Further, the incidence of clinically significant depressive symptoms increases with advancing age, especially when associated with medical illness or institutionalization. However, depression might not meet criteria for major depression because of somewhat atypical features of depression in elderly persons. Elderly persons experience more somatic complaints, cognitive symptoms, and fewer complaints of sad or dysphoric mood. Of particular importance is the increasing risk of death by suicide, particularly among elderly men.

The DSM-IV-TR diagnostic criteria for a major depressive episode are as follows:

A. At least 5 of the following, during the same 2-week period, representing a change from previous functioning; must include either (a) or (b):

(a) Depressed mood
(b) Diminished interest or pleasure
(c) Significant weight loss or gain
(d) Insomnia or hypersomnia
(e) Psychomotor agitation or retardation
(f) Fatigue or loss of energy
(g) Feelings of worthlessness
(h) Diminished ability to think or concentrate; indecisiveness
(i) Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide

B. Symptoms do not meet criteria for a mixed episode (ie, meets criteria for both manic and depressive episode).

C. Symptoms cause clinically significant distress or impairment of functioning.

D. Symptoms are not due to the direct physiologic effects of a substance or a general medical condition.

E. Symptoms are not better accounted for by bereavement, ie, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Atypical presentations include patients with MDD may not initially present with a complaint of low mood, anhedonia, or other typical symptoms.  In the primary care setting, where many of these patients first seek treatment, the presenting complaints often can be somatic, such as fatigue, headache, abdominal distress, or change in weight. Patients may complain more of irritability than of sadness or low mood.  Elderly persons may present with confusion or a general decline in functioning.  Children with MDD also may present with initially misleading symptoms such as irritability, decline in school performance, or social withdrawal.

Relative to differential diagnosis in patients presenting with alterations in mood, evaluation should include consideration of the following:

• Mood disorders secondary to CNS conditions: These include a broad range of physiologic and structural CNS processes that can produce changes in mood and behavior. Note that MDD can produce measurable cognitive deficits or a worsening of preexisting dementia. This decline in cognitive functioning, which, on formal testing, appears to arise from impaired concentration or motivation, is referred to as pseudodementia or, more currently, as dementia of depression and should remit with successful treatment of the depressive episode. MDD does not cause focal neurologic signs. Such findings should prompt an evaluation for other organic syndromes.

• Alzheimer disease: This disease and other degenerative and vascular dementias can be associated with affective symptoms. Mood disorders are very prominent in Parkinson disease, Huntington disease, multiple sclerosis, stroke, and seizure disorders.

• Neoplastic lesions of the CNS: These lesions also can cause changes in mood and behavior before the onset of focal neurologic signs.

• Inflammatory conditions: Conditions such as systemic lupus erythematosus (SLE) can produce a wide range of neuropsychiatric signs and symptoms, likely because of alterations in the blood-brain barrier and an autoimmune cerebritis.

• Sleep disorders: Obstructive sleep apnea, especially, can cause significant medical and psychiatric symptoms and often is missed as a diagnosis. Patients, and, if necessary, their partners, should be interviewed regarding their sleep quality, daytime sleepiness, and snoring. Polysomnography can help make the diagnosis and guide treatment.

• Infectious processes: These include syphilis, Lyme disease, and HIV encephalopathy, which can cause mood and behavior changes.

• Pharmacologic agents: Substances that can produce changes in mood include antihypertensive medications (especially beta-blockers, reserpine, methyldopa, and calcium channel blockers); steroids; medications that affect sex hormones (e.g., estrogen, progesterone, testosterone, gonadotropin-releasing hormone [GnRH] antagonists); H2 blockers (e.g., ranitidine, cimetidine); sedatives; muscle relaxants; appetite suppressants; and chemotherapy agents (e.g., vincristine, procarbazine, L-asparaginase, interferon, amphotericin B, vinblastine).

• Endocrinologic disorders: Disorders involving the hypothalamic-pituitary-adrenal axis or thyroid are especially likely to produce changes in mood. These include Addison disease, Cushing disease, hyperthyroidism, hypothyroidism, prolactinomas, and hyperparathyroidism.

• Substance use, abuse, or dependence: These can cause significant mood symptoms. This is especially true of alcohol, cocaine, amphetamines, marijuana, sedatives/hypnotics, and narcotics. Inhalant abuse also should be considered, particularly among young male patients. Other substance-related and psychiatric processes either can present with mood disturbance as the primary symptom or can occur together with MDD.

• Seasonal affective disorder: Also known as SAD, this form of MDD shows a seasonal pattern of exacerbation and remission. SAD usually is treated with bright light therapy (BLT), with or without antidepressant medication.

• Dysthymia: This mood disorder presents with low mood as a primary symptom. Dysthymia can predate a depressive episode. The symptoms of dysthymia alone do not meet criteria for MDD and must be present for at least 2 years.

• Eating disorders: People with eating disorders (EDs) also have a high rate of comorbid MDD and require specific treatment approaches. These disorders include bulimia, anorexia nervosa, and ED not otherwise specified. A large percentage of individuals in this last group have binge-eating disorder (BED), which, while not currently listed in the DSM-IV-TR as a specific diagnosis, constitutes most patients with EDs.

• Personality disorders: Certain personality disorders (e.g., borderline personality disorder) may present with mood changes as a prominent symptom. Remember that the presence of a personality disorder can be difficult to determine in the setting of acute affective symptoms. Many patients who are depressed who appear labile, demanding, or pathologically dependent look dramatically different once the depressive episode has been treated adequately.

INITIAL EVALUATION:

Physical: No physical findings are specific to MDD. Diagnosis lies in the history and the mental status examination.

• Appearance and affect

• Most patients with MDD present to their physician with a normal appearance.

• In patients with more severe symptoms, a decline in grooming and hygiene can be observed, as well as a change in weight. Patients may show psychomotor retardation, which is manifest as a slowing or loss of spontaneous movement and reactivity. Together with this, MDD often produces a flattening or loss of reactivity in the patient's affect (ie, emotional expression).

• Psychomotor agitation or restlessness also can be observed in some patients with MDD.

• Mood and thought process

• Patients report a dysphoric mood state, which may be expressed as sadness, heaviness, numbness, or sometimes irritability and mood swings. They often report a loss of interest or pleasure in their usual activities, difficulty concentrating, or loss of energy and motivation. Their thinking often is negative, frequently with feelings of worthlessness, hopelessness, or helplessness. While it is not uncommon for patients with MDD to show ruminative thinking, it is important to evaluate each patient for evidence of psychotic symptoms because this affects initial management.

• Psychosis, when it occurs in the context of unipolar depression, usually is congruent in its content with the patient's mood state; for example, the patient may experience delusions of worthlessness or some progressive physical decline. Symptoms of psychosis should prompt a careful history evaluation to rule out a history of bipolar disorder, schizophrenia or schizoaffective disorder, substance abuse, or organic brain syndrome.

• Cognition and sensorium: Patients with MDD often complain of poor memory or concentration. Most commonly, no significant deficits are found on cognitive examination. If present, such findings may represent pseudodementia; however, they may indicate an underlying dementia or other organic brain syndrome and should be investigated. The level of consciousness (ie, sensorium) should be normal. A fluctuating or depressed sensorium suggests delirium, and the patient should be evaluated for organic contributors.

• Speech: Speech may be normal, slow, monotonic, or lacking in spontaneity and content. Pressured speech should suggest mania, while disorganized speech should prompt an evaluation for psychosis.

• Thought content, suicidality, and homicidality

• The thought content of patients who are depressed usually is consistent with their dysphoric mood. Patients often report feeling overwhelmed or inadequate, helpless, worthless, or hopeless.

• Thought content always should be assessed for hopelessness, suicidal ideation, or homicidal/violent ideation or intent.

• A history of suicide attempts or violence is a significant risk factor for future attempts, and this should be noted in the history.

Pregnancy:

Pregnancy can present a potentially difficult clinical situation when complicated by depression. MDD is quite common in women during the childbearing years. MDD can have a significant negative impact on a woman's experience of pregnancy and parenting, as well as on her functioning as a new parent. As with all medical conditions that arise during pregnancy, the risks and benefits of pharmacotherapy should be evaluated.

While it is preferable to avoid the use of medication during pregnancy, the benefits of prompt medical treatment of MDD often may outweigh the risks of exposure of the fetus to an antidepressant. While untested in controlled trials, there is no clear evidence that available antidepressants are teratogenic. In severe depression during pregnancy, especially in cases of psychosis, agitation, or severe retardation, ECT can be the safest and quickest treatment option.

Depression in the postpartum period is a common and, potentially, very serious problem. Prompt diagnosis and intervention are essential to mitigate the negative impact on the mother and her infant.

More than 80% of women can develop mood disturbances in the postpartum period. Most of these women experience a transient syndrome called baby blues, which is characterized by tearfulness and mood changes that resolve spontaneously in a few days to 2 weeks. However, more than 10% of women meet criteria for MDD during the first year following delivery. Many of these patients are not identified as depressed and do not receive treatment.

Postpartum psychosis, while far less common, does occur, and is more likely to arise in patients with a history of psychosis or bipolar disorder.

Principles of treatment for postpartum MDD are the same as for depression during any other time of life. The patient should be assessed for danger to herself or to her children, as well as for other symptoms such as psychosis or substance abuse. Most antidepressants probably can be used safely during breastfeeding; however, this has not been studied thoroughly, and the same risk-benefit considerations should be applied as when treating depression during pregnancy.

Seasonal affective disorder:

This is a form of MDD that arises during the winter months and resolves during the spring and summer months. Studies suggest that SAD also is mediated by alterations in CNS 5-HT. SAD appears to be triggered by alterations in circadian rhythm and sunlight exposure. Patients with SAD are more likely to report atypical symptoms such as hypersomnia and increased appetite. BLT for SAD is used at an intensity of 10,000 lux for 30-90 minutes daily, usually within an hour of arising in the morning.

As with any effective antidepressant, therapeutic light boxes have the potential to precipitate a manic episode in susceptible individuals. Other common adverse effects include eye irritation, restlessness, and transient headaches. These lamps are not a significant source of UV light. Conventional antidepressants, with or without BLT, also can be used to treat SAD.

Lab Studies:

• No diagnostic laboratory tests are available for diagnosis of MDD. Based on the clinical history and physical findings, focused laboratory studies are useful in excluding potential medical illnesses that may present as MDD. These might include the following:

• CBC count

• Thyroid-stimulating hormone (TSH)

• Antinuclear antibody (ANA)

• Erythrocyte sedimentation rate (ESR)

• Vitamin B-12

• Rapid plasma reagin (RPR)

• HIV test

• Electrolytes and calcium levels and renal function test

• Liver function tests

• Blood alcohol, blood, and urine toxicology screen

• ABG

• Dexamethasone suppression test (Cushing disease)

• Cosyntropin stimulation test (Addison disease)

Imaging Studies:

• CT scan or MRI of the brain

Other Tests:

• EEG

Procedures:

• Lumbar puncture for VDRL, Lyme antibody, cell count, chemistry, and protein electrophoresis

TREATMENT:

It is clear with such delicate conditions as human depression, a strong, trusting relationship and a therapeutic alliance between the physician and patient is the foundation for managing depression.  This has been shown in a referral population, and is reasonable to infer in family practice.  This strong therapeutic alliance facilitates discussion and development for a diagnosis, choice and monitoring of treatment modalities, discussion of referral if needed, and agreement on long term treatment when necessary. 

When depression exists secondary to an underlying medical condition, supportive counseling in the context of care for the underlying condition is always appropriate.  Patients also benefit from seeking out local support groups for people suffering from the condition should be encouraged.  If the depression is severe enough to interfere with the patient's daily life or ability t participate in care for their medical condition, specific pharmacologic care should be initiated.

Upon each patient presentation, current stressors must be assessed, response to care, the presence or absence of suicidal thoughts. 

Patients under care often respond initially to questions about treatment response with a very general statement such as, “I’m doing better.”  It is useful to follow this by eliciting a description of exactly how the patent is “doing better”.  Find out how the patient is responding to stressful situations which under care, because these rarely go away just because treatment was started.  This question will guide the patient into a discussion about how response to previously stressful situations has or has not changed after initiation of treatment or changes in care.

Ask patients whether spouses or significant others have noted changes.  Any specific improvements should be noted n the record which can provide useful markers of relapse for both the physician and the patient. 

Always answer any questions patients may have about their diagnosis as a mental health diagnosis often carries with it fear of “losing one’s mind” or “being crazy”.  Always give reassurance and emphasize he effectiveness of care.

Finally asses risk factors for suicide.  For example, increase age (over 70 years in men, 60 in women), gender (women make more attempts; men are more often successful), poor social support, lack of marital support and absence of children, chronic physical illness or chronic pain, alcoholism or substance abuse, history of prior attempts, specific plan or explicit communication about intent, and family history of successful suicide.

A key to success in MDD patients is education.  Patients should be aware of the rationale behind the choice of treatment, potential adverse effects, and expected results. The involvement of the patient in the treatment plan can enhance medication compliance and referral to counseling. Over the long term, patients also may become aware of signs of relapse and may seek treatment early

Points to consider when selecting a medication include:

• History of good response to previous use
• Successful use of an agent in a close relative (e.g., use a parent or sibling may chance compliance)
• Comorbidity (presence of chronic pain or severe sleep disturbance may indicate use of a TCA)
• Coexisting medical conditions (avoid TCAs in patients with known cardiac conduction disturbances)
• Atypical features of the illness (hypersomnia may suggest use of an SSRI)
• Cost

A wide range of effective treatments is available for MDD.  General Principals follow:

• Initial pharmacotherapy: All antidepressants on the market are potentially effective. Usually, 2-6 weeks at a therapeutic dose level are needed to observe a clinical response. The choice of medication should be guided by anticipated safety and tolerability, which aid in compliance; physician familiarity, which aids in patient education and anticipation of adverse effects; and history of prior treatments. Treatment failures often are caused not by clinical resistance, but by medication noncompliance, inadequate duration of therapy, or inadequate dosing.
• SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). This group has the advantage of ease of dosing and low toxicity in overdose. Common adverse effects include GI upset, sexual dysfunction, and changes in energy level (ie, fatigue, restlessness).
• Selective serotonin/norepinephrine reuptake inhibitors (SNRIs) include venlafaxine (Effexor) and duloxetine (Cymbalta). Safety, tolerability, and side effect profiles are similar to that of the SSRIs, with the exception that the SNRIs have been associated (rarely) with a sustained rise in blood pressure. SNRIs can be used as first-line agents, particularly in patients with significant fatigue or pain syndromes associated with the episode of depression. The SNRIs also have an important role as second-line agents in patients who have not responded to SSRIs.
• St. John's wort (Hypericum perforatum)

• While St. John's wort is considered a first-line antidepressant in many European countries, it has gained popularity in the United States only recently. Uses include treatment of mild-to-moderate depressive symptoms.
• Research indicates that it acts as an SSRI and not as a monoamine oxidase inhibitor (MAOI) as previously believed.
• The dosage is 300 mg 3 times a day with meals to prevent GI upset. If no clinical response occurs after 3-6 months, encouraging the use of another medication is essential.

• Atypical antidepressants include bupropion (Wellbutrin), nefazodone (Serzone), mirtazapine (Remeron), and trazodone (Desyrel). This group also shows low toxicity in overdose and may have an advantage over the SSRIs by causing less sexual dysfunction and GI distress.
  • Bupropion is associated with a risk of seizure at higher doses, especially in patients with a history of seizure or EDs.
  • Mirtazapine is a potent antagonist at 5-HT2, 5-HT3, alpha2-, and histamine (H1) receptors and, thus, can be very sedating. Adverse effects such as drowsiness and weight gain may tend to improve over time and with higher doses.
  • Trazodone is very sedating and usually is used as a sleep aid rather than as an antidepressant.

• Tricyclic antidepressants (TCAs) include amitriptyline (Elavil), nortriptyline (Pamelor), desipramine (Norpramin), clomipramine (Anafranil), doxepin (Sinequan), protriptyline (Vivactil), trimipramine (Surmontil), and imipramine (Tofranil).
  • This group has a long record of efficacy in the treatment of depression and has the advantage of lower cost. They are used less commonly now because of the need to titrate the dose to a therapeutic level and because of their considerable toxicity in overdose.
  • Adverse effects largely are due to their anticholinergic and antihistaminic properties and include sedation, confusion, dry mouth, orthostasis, constipation, urinary retention, sexual dysfunction, and weight gain. Caution should be used in patients with cardiac conduction abnormalities.

• MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate).
  • MAOIs are widely effective in a broad range of affective and anxiety disorders.
  • Because of the risk of hypertensive crisis, patients on these medications must follow a low-tyramine diet. Other adverse effects can include insomnia, anxiety, orthostasis, weight gain, and sexual dysfunction.

• Nonpharmacologic treatments
  • Electroconvulsive therapy (ECT) is a highly effective treatment for depression and may have a more rapid onset of action than drug treatments. Advances in brief anesthesia and neuromuscular paralysis have improved the safety and tolerability of this modality. Risks include those associated with brief anesthesia, postictal confusion, and, more rarely, short-term memory difficulties. ECT is used when a rapid antidepressant response is needed, when drug therapies have failed, when there is a history of good response to ECT, or when there is patient preference. ECT is particularly effective in the treatment of delusional depression.
  • Light therapy: Broad-spectrum light exposure has long been in use for the treatment of SAD. Some evidence now exists that it may have some efficacy in nonseasonal depression or as an augmenting agent with antidepressant medication.
  • Transcranial magnetic stimulation: This modality is in investigational stages for the treatment of MDD. Initial results suggest that it may be an effective intervention without the risks and adverse effects of ECT.
  • Vagus nerve stimulation also is in investigational stages and has shown some efficacy in treatment-resistant depression.

Once a specific medication has been chosen, give enough time to adequately assess its effectiveness.  Included in this is willingness to increase the dose o a level at which the drug is effective.  Allow at least 4 to 6 weeks of care at a known effective dose before abandoning the drug.  If there is no response by 6 weeks, switch medication and/or consider referral. 

Initially, continue care for 9 to 12 months. At that point, consider discontinuance of the medication (via taper), but be aware that one third of MDD patients will relapse within 1 year.  For those patients who do, consider chronic therapies in an effort to pent or decrease the severity of relapses. 

• A psychiatrist must be involved in the care of patients in whom more severe symptoms develop and for whom a more intensive level of care will be needed (e.g., suicidal ideation, psychosis, mania, severe decline in physical health). Expertise in pharmacotherapy, other somatic therapies, and psychotherapy should be readily available. Collaboration of psychiatrists and family practitioners/internists is of particular importance in patients with acute and chronic medical issues. A psychologist can be involved if psychological testing or more intensive specialized psychotherapy (e.g., interpersonal therapy, cognitive behavior therapy) is needed.

• Remember that psychotherapy is an invaluable treatment modality in the management of MDD, addressing as it does both potential precipitating and maintaining factors of the depressive episode. In moderate-to-severe depression, psychotherapy is most effective once the somatic and melancholic symptoms have improved with medication. While psychotherapy can help with the interpersonal and cognitive dysfunction that can arise from, and predispose to, depressive illness, long-term psychotherapy does not appear to have a major role in treating MDD.  Thus, with the patient's consent, communication with the patient's psychotherapist can be invaluable in guiding medical treatment of MDD. The therapist can provide information regarding clinical progress, symptoms, and adverse effects. This can facilitate timely and appropriate medical interventions. 

The following are examples from various classes of antidepressants and augmenting agents that are used with TCAs or SSRIs to augment therapeutic effect in resistant depression.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

CHRONIC EVALUATION:

The successful treatment of MDD requires good follow-up care after the acute episode is resolved as MDD tends to be a recurrent condition. This ongoing care usually takes place in an outpatient setting.  It is now known that while some patients experience a single episode, observing recurrences over time is more common (50-80%). A percentage of individuals have relapses of sufficient frequency to warrant long-term use of antidepressants as a preventive therapy. Other patients can discontinue treatment after resolution of an episode and can restart treatment when symptoms reappear. Most studies suggest that, once an episode is resolved successfully, treatment should be continued for 6 months to 1 year to reduce the risk of relapse of symptoms. The decision to continue treatment beyond that time depends on patient preference and past history of recurrences.

Finally chronic evaluation is very helpful in preventing complications while on therapy.  For example, potential complications of MDD may develop across the biopsychosocial spectrum.  Completed suicides number more than 30,000 per year in the United States. Other adverse outcomes may arise from attempts at self-injury, untreated medical conditions, or physical decline due to inanition. Medical and surgical prognosis and recovery also are affected adversely by concurrent MDD.  Finally in this vein, MDD, particularly when chronic or untreated, can contribute to unemployment or failure in school, social isolation, substance abuse, and marital/family dysfunction.  Thus, the patient follow through on their own care and present for the chronic evaluation, can help them maintain a wonderful and productive life.

Medical Text References:

1. Sloane, Philip D et al, Essentials of Family Medicine, 4^th Edition, Lippincott-Williams & Wilkins, pages 345-356
2. Andreoli Thomas E et al, Cecil Essentials of Medicine, 4^th Saunders, pages 752-755.
3. Kasper Dennis L et al, Harrison’s Principles of Internal Medicine, 16^th edition, Mc Graw Hill, pages 2553-2556
4. Beers, Mark H et al, The Merc Manual of Diagnosis and Therapy, 17^th Edition, Merck Research Laboratories, pages 1351-1358
5. Brunton Laurence L et al, Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 11^th edition, Mcgraw-Hill, pages 431-453

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By Scott Neff DC DABCO MSOM MPS DABFE FABFE FFABS FAABT FFAAJTS for Psychiatry Clerkship in Medicine December 9, 2010