DEFINITION EPIDEMIOLOGY DIAGNOSIS TREATMENT
- A combination of medication and individual psychotherapy is usually best.
- Psychoeducation and supportive therapy can be administered in the acute phase of severe MDD. The focus is support and education. Extremely severe depression makes any formal psychotherapy very difficult, until some improvement in concentration and hopefulness develops.
- Family involvement and supervision can be very helpful at times (to prevent a suicide attempt, non-suicidal self injury, substance use, and disordered eating behavior). Family participation can be very helpful to provide critical history, as well as to help patients remember and interpret what clinicians have told them or instructed them to do.
- Phases of depressive illness:
- Acute: inform the patient of the diagnosis; educate, support, and assure safety
- Hospitalization is needed if there are life-threatening medical problems, psychosis, or moderate-to-high risk of suicide.
- In more severe cases, medications are usually required.
- For the most severe cases, ECT has a high probability of success.
- Education for the family should emphasize that the patient’s mood symptoms are due to a treatable illness, that the patient must continue taking his/her medication and come to appointments, and that suicide is not acceptable.
- Improvement: serial mental status assessments, support, identification of stressors and relationship issues (important in all stages of illness)
- Maintain effective medical treatment.
- Carefully reduce purely symptomatic medications (e.g., benzodiazepines).
- Recovery: long-term medication management (at least 6-12 months)
- More intensive psychotherapies are more effective.
- Preventive strategies to reduce the likelihood and severity of future episodes.
- Acute: inform the patient of the diagnosis; educate, support, and assure safety
- Remission rates are low (~30%), but ~60% of moderate and severe cases of MDD will improve significantly with antidepressant treatment.
- Antidepressants include SSRIs, TCAs, SNRIs, MAOIs, buproprion, and mirtazapine.
- Antidepressant choice depends on history of response, family history of response, tolerability, adverse effects, and likelihood of adherence.
- Clinical trials show little difference in efficacy or tolerability among SSRIs and other classes of antidepressants.
- SSRIs are first-line choice
due to minimal side effect profile.
- In order to "fail" an anti-depressant trial, a patient must remain on a therapeutic dose of anti-depressant for 6-8 weeks.
- Failure of one SSRI, does not mean failure of all SSRIs, so patient should trial another SSRI.
- If a patient fails two SSRIs, the next choice can be an SNRI, TCA, or adjunct anti-depressant (e.g. buproprion or SNRI) or augmenting agent.
- Combination therapy with a reuptake inhibitor and an antagonist of presynaptic α2-autoreceptors may be superior to monotherapy, and may be beneficial as first-line therapy for severe depression or treatment nonresponders.[6]
- Fluoxetine may be safer in children and adolescents, and is the only SSRI consistently show to be effective in this population.
- Mood symptoms should be carefully monitored as anti-depressants can trigger manic episodes.
- Mood stabilizers can augment the effects of antidepressants and help prevent a switch to mania.
- Antipsychotics are combined with antidepressants to treat psychotic depression and treatment-resistant depression. One should be cautious about long-term use and dose should be decreased as permitted.
- Benzodiazepines can be used during the acute phase for anxiety and insomnia. Avoid in elderly due to risk of delirium.
- To improve medication compliance with an outpatient, have a follow-up visit one week after starting, ask about side effects, and re-educate about the time required for a valid therapeutic trial (8 weeks).
- Over 70% of patients who stop taking anti-depressant in 5 weeks or fewer after they become symptom-free will relapse, so careful monitoring of medication compliance is important.
- Supportive therapy is important and well-received in severe, acute phases of illness.
- CBT, interpersonal therapy, and problem-solving therapy are all helpful and delay relapse for mild and moderate depression.
- Psychotherapy alone is not first-line treatment for severe depression, or in psychotic or bipolar forms.
- Remission rates with ECT are 60-80% in severe MDD.
- ECT can be first-line treatment for severe MDD with psychosis, psychomotor retardation, or catatonic features; medication resistance; or pregnancy.
- Supplemental treatments include regular sleep, bright light therapy, physical activity, healthy eating habits, no alcohol or drugs, distracting activities, and a regular schedule.
WHEN TO REFER
- PCPs manage the majority of patients with MDD.
- A UK study showed that PCPs identified depression in almost half of cases.
- 35% to 50% of MDD cases go unrecognized; in addition, MDD is often untreated when diagnosed.[7]
- MDD overdiagnosis and overtreatment are also common in community settings.[8]
- Referral to a psychiatrist is indicated if patient requires adjunct anti-depressant treatment, has co-morbid psychiatric diagnoses including substance abuse, anxiety, panic attacks, or psychotic features such as hallucinations or delusions, or has thoughts of death or harming others.
- A person who is actively suicidal should be referred to the closest emergency department for hospitalization.
FOLLOW UP
- Individual psychotherapy needs will change as the patient improves.
- There is an increased risk of suicide in first 30 days, and also in first year following hospitalization for MDD.
COMMENTS
- MDD is associated with other specific psychiatric disorders, notably substance dependence, panic and generalized anxiety disorders, and several personality disorders. If present, these will need to be addressed during treatment.
- 90% of completed suicides have a diagnosed psychiatric disorder; 70-80% meet criteria for MDD; and comorbid alcohol use disorder is common (15-30%).
- If the patient has long-term overuse of addictive substances, specific treatment is usually required.
- Elderly patients often manifest depression as somatic symptoms (e.g. fatigue, abdominal pain, headache, confusion, memory loss).
- Increased prevalence estimates of MDD (28% increase) and anxiety disorders (26% increase) during the early phase of the COVID-19 pandemic may be inflated. Robust trauma research has shown that resilience or recovery typically follow negative life events (e.g., bereavement or disaster exposure).[9]
References
- Hasin DS, Goodwin RD, Stinson FS, et al. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62(10):1097-106. [PMID:16203955]
DePaulo, Jr., J.R, & and Ablow, K. (1989). In McGraw-Hill (Ed.), How to cope with depression. A complete guide for you and your family. Ballantine Books.
- Gilbody S, Sheldon T, House A. Screening and case-finding instruments for depression: a meta-analysis. CMAJ. 2008;178(8):997-1003. [PMID:18390942]
- Whooley MA, Avins AL, Miranda J, et al. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997;12(7):439-45. [PMID:9229283]
- Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284-92. [PMID:14583691]
- Henssler J, Alexander D, Schwarzer G, et al. Combining Antidepressants vs Antidepressant Monotherapy for Treatment of Patients With Acute Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022. [PMID:35171215]
- Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374(9690):609-19. [PMID:19640579]
- Mojtabai R. Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom. 2013;82(3):161-9. [PMID:23548817]
- Daly M, Robinson E. Depression and anxiety during COVID-19. Lancet. 2022;399(10324):518. [PMID:35123689]
- DePaulo JR and Horowitz L, Understanding Depression, Wiley Press, 2002.
- DeRubeis RJ, Zajecka J, Shelton RC, et al. Prevention of Recurrence After Recovery From a Major Depressive Episode With Antidepressant Medication Alone or in Combination With Cognitive Behavioral Therapy: Phase 2 of a 2-Phase Randomized Clinical Trial. JAMA Psychiatry. 2020;77(3):237-245. [PMID:31799993]
- Delgadillo J, Ali S, Fleck K, et al. Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial. JAMA Psychiatry. 2022;79(2):101-108. [PMID:34878526]
- Folstein MF, Romanoski AJ, Nestadt G, et al. Brief report on the clinical reappraisal of the Diagnostic Interview Schedule carried out at the Johns Hopkins site of the Epidemiological Catchment Area Program of the NIMH. Psychol Med. 1985;15(4):809-14. [PMID:4080884]
- Mondimore FJ, Depression: The Mood Disease, 4th Edition, Johns Hopkins Press, 2013
- O'Connor EA, Whitlock EP, Beil TL, et al. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med. 2009;151(11):793-803. [PMID:19949145]
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Last updated: May 8, 2022