Major Depressive Disorder

MDD lifetime prevalence
monoamine hypothesis
reduction in concentration and/or dysfunction of receptors of NE, 5HT, DA
MDD dx requirements
5+ symptoms must present for at least 2 weeks (suicidal ideation, diminished interest, guilt, loss of energy, low concentration, appetite changes, psychomotor agitation or retardation, sleep changes)
fraction of patients who recover fully from MDD
acute phase of treatment of MDD
6-12 weeks, goal: remission
continuation phase of treatment of MDD
4-9 months, goal: eliminate residual symptoms, prevent relapse
maintenance phase of treatment of MDD
>1 year, lifelong, goal: precent recurrence
first line therapy for MDD
SSRIs, SNRIs, buproprion, mirtazapine (if one doesn't work, try another 1st line)
second line therapy for MDD
augmentation and combination therapies, TCAs
third line therapy for MDD
insomnia, activation/anxiety, GI upset, headache, sexual dysfunction
SSRI ADR + elevated BP
bupropion ADR
insomnia, decreased appetite, anxiety, may reduce seizure threshold, minimal to no sexual dysfunction
mirtazapine ADR
sedation, weighty gain, elevated triglycerides, may HELP with GI upset
trazodone ADR
sedation, orthostasis, priapism (rare)
anticholinergic, antihistaminic, antiadrenergic, cardiac conduction abnormalities, sexual dysfunction, can be fatal in OD
orthostasis, weight gain, sexual dysfunction, hypertensive crisis (stroke, death)
MAOI diet/drug restrictions
aged cheeses, cured meat, tap beer, sauerkraut, pseudoephedrine, dxm, stimulants
serotonin syndrome
overstimulation of 5HT1A receptors, occurs within 24 hours after OD or beginning of tx, can be fatal, DC TX
serotonin syndrome triad of symptoms
mental: altered consciousness, elevated mood
autonomic: diaphoresis, hyperthermia, tachycardia
neurological: tremors, chills, rigidity, hyperreflexia
Black box warning on antidepressants
increased risk of suicide
augmentation agents
lithium, buspirone, triiodothyronine, antipsychotics (aripiprazole, quetiaprine, olanzapine/fluoxetine)
first week of treatment
improvements in physical symptoms
several weeks after treatment initiation
improvements in depressed mood, anhedonia
time when remission is reached
up to 12 weeks
major counseling point
avoid alcohol and recreational drugs