• A 70 year old woman was recently admitted after her son informed the doctor that she had been doing very poorly. The patient reports a 30 pound weight loss, decreased concentration, feelings of helplessness and hopelessness, decreased energy, depressed mood, and decreased sleep.

Presenting Symptoms

• Depressed mood most of the day• Anhedonia during most of the day• Significant weight loss or weight gain• Insomnia or Hypersomnia• Psychomotor agitation or retardation• Fatigue or loss of energy nearly every day• Feelings of worthlessness and guilt• Diminished ability to concentrate• Recurrent thoughts about death

Physical Exam

DSM-IV Criteria for Major Depressive Episode and Major Depressive Disorder

Specific Components of Psychiatric Management

• Performing a diagnostic evaluation• Evaluating safety of the patient and others• Evaluating the level of functional impairments • Determining a treatment setting• Establishing and maintaining a therapeutic alliance• Monitoring the patient’s psychiatric status and safety • Providing education to patients and families, enhancing

treatment adherence• Working with patients to address early signs of relapse

Components of an Evaluation for Suicide Risk

• • Presence of suicidal or homicidal ideation, intent, or plans

• • Access to means for suicide and the lethality of those means

• • Presence of psychotic symptoms, command hallucinations,

• or severe anxiety• • Presence of alcohol or substance use• • History and seriousness of previous attempts• • Family history of or recent exposure to suicide

Factors to Consider in Choosing a First-Line Antidepressant Medication

• • Anticipated side effects and their safety or tolerability• • History of prior response in patient or family member• • Patient preference• • Cost• • Quantity and quality of clinical trial data• • MAOIs: generally reserve for patients who do not

respond to other treatments• • SSRIs or MAOIs: consider for patients with atypical

symptoms

Acute Phase

• Pharmacotherapy• Psychotherapy• Combination of medications plus

psychotherapy• ECT

Choice of specific pharmacologic treatment

Treatment

• SSRI• TCA• MAOI

Commonly Used Antidepressant Medications

Generic Name Starting Dose(mg/day)

Usual Dose

Tricyclics and tetracyclics

Tertiary amine tricyclicsAmitriptylineClomipramineDoxepinImipramineTrimipramine

25–502525–5025–5025–50

100–300100–250100–300100–300100–300

Commonly Used Antidepressant Medications

Generic Name Starting Dose(mg/day)

Usual Dose

Secondary amine tricyclicsDesipraminebNortriptylinebProtriptyline

25–502510

100–30050–20015–60

TetracyclicsAmoxapineMaprotiline

5050

100–400100–225

Commonly Used Antidepressant Medications

Generic Name Starting Dose(mg/day)

Usual Dose

SSRIsbCitalopramFluoxetineFluvoxamineParoxetineSertraline

2020502050

20–60c20–60c50–300c20–60c50–200c

Commonly Used Antidepressant Medications

Generic Name Starting Dose(mg/day)

Usual Dose

Dopamine-norepinephrine reuptake inhibitorsBupropionbBupropion, sustained releaseb

150150

300300

Serotonin-norepinephrine reuptake inhibitorsVenlafaxinebVenlafaxine, extended releaseb

37.537.5

75–22575–225

Commonly Used Antidepressant Medications

Generic Name Starting Dose(mg/day)

Usual Dose

Serotonin modulatorsNefazodoneTrazodone

5050

150–30075–300

Norepinephrine-serotonin modulatorMirtazapine 15 15–45

Commonly Used Antidepressant Medications

Generic Name Starting Dose(mg/day)

Usual Dose

Commonly Used Antidepressant Medications

Generic Name Starting Dose(mg/day)

Usual Dose

MAOIsIrreversible, nonselectivePhenelzineTranylcypromineReversible MAOI-AMoclobemide

1510

150

15–9030–60

300–600

Selective noradrenaline reuptake inhibitorReboxetine —d —d

Risk Factors for Recurrence of Major Depressive Disorder

• • Prior history of multiple episodes of major depressive disorder

• • Persistence of dysthymic symptoms after recovery from an episode

• of major depressive disorder• • Presence of an additional nonaffective

psychiatric diagnosis• • Presence of a chronic general medical disorder