Psychiatry assignment 5a BY Dr. Scott Neff, DC
DABCO MSOM MPS DABFE FABFE FFABS FAABT FFAAJTS
THROUGH MEDICAL INFORMATION MASTERY ANDS POEMs
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
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
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
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
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.
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.
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)
(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
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
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
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,
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
physical findings are specific to MDD. Diagnosis lies in the history and
the mental status examination.
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.
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
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 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
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
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.
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
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.
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:
Thyroid-stimulating hormone (TSH)
Antinuclear antibody (ANA)
Erythrocyte sedimentation rate (ESR)
Rapid plasma reagin (RPR)
Electrolytes and calcium levels
and renal function test
Blood alcohol, blood, and urine
Dexamethasone suppression test
Cosyntropin stimulation test
CT scan or MRI of the brain
Lumbar puncture for VDRL, Lyme
antibody, cell count, chemistry, and protein electrophoresis
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.
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.
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.
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
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
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)
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
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).
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
St. John's wort (Hypericum
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
Research indicates that it acts
as an SSRI and not as a monoamine oxidase inhibitor (MAOI) as
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
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.
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
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
Vagus nerve stimulation also is
in investigational stages and has shown some efficacy in
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
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.
Medical Psychiatry and Psychotherapy:
can be important at many stages of the treatment process. Certainly,
consultation should be sought if treating physicians exhaust the options
with which they feel comfortable.
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.
Dietary restrictions are necessary only when prescribing
MAOIs. Foods high in tyramine, which can produce a hypertensive crisis
in the presence of MAOIs, should be avoided. These foods include soy
sauce, sauerkraut, aged chicken or beef liver, aged cheese, fava beans,
air-dried sausage and similar meats, pickled or cured meat or fish,
overripe fruit, canned figs, raisins, avocados, yogurt, sour cream, meat
tenderizer, yeast extracts, caviar, and shrimp paste. Beer and wine also
should be avoided.
Physical activity and
exercise contribute to recovery from MDD. Patients should be counseled
regarding stress reduction.
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.
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
October 2003, the US Food and Drug Administration (FDA) issued a public
health advisory regarding reports of suicidality in pediatric patients
being treated with antidepressant medications for major depressive
disorder. This advisory reported suicidality (both ideation and
attempts) in clinical trials of various antidepressant drugs in
pediatric patients. The FDA has asked that additional studies be
performed because suicidality occurred in both treated and untreated
patients with major depression and thus could not be definitively linked
to drug treatment.
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.
With appropriate treatment, 70-80%
of individuals with MDD can achieve a significant reduction in
symptoms, although as many as 50% of patients may not respond to the
initial treatment trial.
Untreated at 1 year, 40% of
individuals with MDD will continue to meet criteria for the
diagnosis, while an additional 20% will have a partial remission.
Partial remission and/or a history of chronic MDD are risk factors
for recurrent episodes and treatment resistance.
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
Medical Text References:
- Sloane, Philip D et al, Essentials of Family Medicine, 4th
Edition, Lippincott-Williams & Wilkins, pages 345-356
- Andreoli Thomas E et al, Cecil Essentials of Medicine, 4th
Saunders, pages 752-755.
- Kasper Dennis L et al, Harrison’s Principles of Internal Medicine,
16th edition, Mc Graw Hill, pages 2553-2556
- Beers, Mark H et al, The Merc Manual of Diagnosis and Therapy, 17th
Edition, Merck Research Laboratories, pages 1351-1358
- Brunton Laurence L et al, Goodman & Gilman’s The Pharmacological
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By Scott Neff DC DABCO MSOM MPS DABFE FABFE FFABS
FAABT FFAAJTS for Psychiatry Clerkship in
December 9, 2010
"The most acceptable service to God is doing
good to man" Ben