INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Unipolar depression is one of the more commonly encountered psychiatric disorders. While many effective treatments are available, this disorder is often underdiagnosed and undertreated. Primary care providers should strongly consider the presence of depression in their patients; studies suggest a high prevalence of affective disorders among patients seeking medical attention in the office setting.

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.

Frequency

United States

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.

International

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.

Mortality/Morbidity

MDD is a disorder with significant potential morbidity and mortality, contributing as it does to suicide, medical illness, 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 (eg, 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.

Race

Depression is less common in the black population.

Sex

MDD is diagnosed more commonly in women, with a prevalence twice that observed in men. In prepubertal children, boys and girls are affected equally.

Age

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. Rates in women and men are highest in those aged 25-44 years. For more information about childhood depression, see Mood Disorder: Depression.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

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

• Atypical presentations
• • 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 may also present with initially misleading symptoms such as irritability, decline in school performance, or social withdrawal. Depression can occur in preschool children (Sheikh, 2006). René Spitz described what he called anaclitic depression in infants being raised in an orphanage (Spitz, 1946). Childhood depression seems to be a more severe form of the same disorder in adults. Evidence-based treatment guidelines are limited. Of teenagers diagnosed with MDD, bipolar disorder is diagnosed in 50% of them as they grow into adulthood. Further research is needed in this area.
• The differential diagnosis in patients presenting with alterations in mood is extensive and 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 (eg, estrogen, progesterone, testosterone, gonadotropin-releasing hormone [GnRH] antagonists); H2 blockers (eg, ranitidine, cimetidine); sedatives; muscle relaxants; appetite suppressants; and chemotherapy agents (eg, 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.
  • Axis I or II disorder: In cases in which another Axis I or II disorder is present, a careful psychiatric review of systems should elicit the alternative or additional diagnosis.
  • 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.
  • Anxiety disorders: Patients with anxiety disorders are at higher risk for developing comorbid depression. In such patients, it is important to identify the anxiety disorder because they often require specific treatment approaches. Commonly encountered anxiety disorders include panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, posttraumatic stress disorder, and phobia.
  • 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 (eg, 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.

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. Racing thoughts could also be an indication of mania or hypomania.
• 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.

Causes

The specific cause of MDD is not known. As with most psychiatric disorders, MDD appears to be multifactorial in its origin.

• Biological contributors
• • Genetic susceptibility plays a role in the development of MDD. Individuals with a family history of affective disorders (7%), panic disorder, and alcohol dependence (8%) carry a higher risk for MDD.
  • Certain neurologic illnesses increase the risk of MDD. Examples include Parkinson disease, stroke, multiple sclerosis, and seizure disorders.
  • 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.
  • 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.
• Psychosocial contributors: While MDD can arise without any precipitating stressors, stress and interpersonal losses certainly increase risk. Psychodynamic formulations find that significant losses in early life predispose to MDD over the lifespan of the individual, as does trauma, either transient or chronic.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Dementia due to HIV disease
Thyrotoxicosis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

A wide range of effective treatments is available for MDD. Brief psychotherapy (eg, cognitive behavioral therapy, interpersonal therapy) has been shown in clinical trials to be an effective treatment option, either alone or in combination with medication. Medication alone also can relieve symptoms. However, the combined approach generally provides the patient with the quickest and most sustained response.

• 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. Venlafaxine and duloxetine are discussed in more detail in the Medication section.
• 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.

Consultations

Consultation 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 (eg, 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 (eg, interpersonal therapy, cognitive behavior therapy) is needed.
• With the patient's consent, communication with the patient's therapist 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.

Diet

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.

Activity

Physical activity and exercise contribute to recovery from MDD. Patients should be counseled regarding stress reduction.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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. Available medications from each class are listed in Treatment.

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.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In 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.

Drug Category: Antidepressants

Have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of NE and serotonin. SSRIs are metabolized via the cytochrome P-450 system and may have drug interactions on that basis. The degree of enzyme inhibition varies among SSRIs. Effects on blood levels and bioavailability of coadministered drugs account for most clinically significant SSRI-drug interactions.

Drug Category: CNS stimulants

Used in patients with resistant depression.

Drug Category: Thyroid hormones

May modulate the effect of antidepressants.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care is indicated in MDD when there is a risk of harm to the patient, to others, or when the patient's symptoms are sufficiently severe to warrant initiation of treatment in a more controlled setting. These commonly include situations of depression with psychotic features, progressive inanition, suicidality, or inability to care for oneself at home. When ECT is indicated as therapy, many practitioners initiate treatment on an inpatient basis, although outpatient initiation of therapy is increasingly common.
• The current climate of insurance controls on treatment typically does not allow prolonged inpatient stays in the treatment of MDD. Hospitalization is used more commonly to control acute severe symptoms, with early discharge to home or to lower levels of care such as partial hospitalization.

Further Outpatient Care

• The successful treatment of MDD requires good follow-up care after the acute episode is resolved. This ongoing care usually takes place in an outpatient setting.
• MDD tends to be a recurrent condition. 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.
• 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.

Complications

• Potential complications of MDD may develop across the biopsychosocial spectrum.
• Medical: 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.
• Psychosocial: MDD, particularly when chronic or untreated, can contribute to unemployment or failure in school, social isolation, substance abuse, and marital/family dysfunction.

Prognosis

• 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.

Patient Education

• Education plays an important role in the successful treatment of MDD. 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.
• For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education article Depression.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Treatment-resistant depression
• • The most common medical pitfall in the treatment of MDD is the management of treatment resistance. A certain percentage of patients fail to improve adequately with first-line therapy. At this point, it becomes important to reassess the patient, the diagnosis, and the treatment plan, and to have a number of strategies available to offer patients.
  • Assessment should include (1) adequacy of medication dose, duration of treatment, and compliance; (2) accuracy of diagnosis and possible medical conditions; and (3) possible comorbid psychiatric conditions such as substance abuse, anxiety disorders, or personality disorders.
  • Assuming that (1) the assessment of the diagnosis is correct, (2) there are no significant complicating diagnoses, and (3) the current treatment has been at a therapeutic dose for a sufficient amount of time, possible interventions for persistent symptoms can include the following:
    • Increasing the medication dose to the maximum tolerated
    • Changing to a different antidepressant
    • Adding psychotherapy or more intensive care if not already completed
    • Augmenting the current medication
    • Considering the use of ECT
  • Augmentation combinations can include the following:
    • Lithium plus any antidepressant
    • Buspirone plus a TCA or SSRI
    • Triiodothyronine added to any antidepressant
    • A TCA added to an SSRI
    • Methylphenidate or dextroamphetamine added to any antidepressant other than an MAOI
    • The addition of bright-light therapy to any antidepressant
• Another common pitfall in the treatment of MDD involves the risk of suicidal or homicidal behavior. Routinely interviewing patients at each visit for suicidal or homicidal ideation and documenting the assessment are important. Legitimate concern regarding the patient's safety, or his or her possible danger to others, takes precedence over confidentiality. In such circumstances, the physician has a duty to act either to prevent self-injury suicide or to warn an identified potential target of violence.
• Another common pitfall is misdiagnosing bipolar depression as MDD, which leads to insufficient or inadequate treatment if not switching to an outright manic episode. Some patients with treatment-resistance depression may fall under this phenomena. The Mood Disorders Questionnaire is helpful in this differentiation between unipolar and bipolar depression (Hirschfeld, 2000). Screening Assessment of Depression-Polarity (SAD-P) found presence of delusions during a current episode of major depression, a number of prior episodes of depression, and a family history of major depression or mania to be highly correlated with bipolar major depression (Solomon, 2006).

Special Concerns

• 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