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Major Depressive Disorder
The next slide shows the sources for this series of questions and answers.
As of 1 February 2014.
MDD - sources
Unless otherwise noted, the questions are from:
• DSM-IV-TR, pages 369-376• Practice Guideline for the Treatment of
Patients with Major Depressive Disorder, second edition, published as supplement to AJP, April 2000
• Guideline Watch on above Disorder, available at www.psych.org., 2005.
DSM-IV-TR
• Since the Boards will be based on DSM-IV-TR through 2014 [and maybe beyond], these screens use DSM-IV-TR, NOT YET DSM-5.
Dx criteria for MDD
Q. List the dx criteria for Major Depressive Disorder. Assume rule outs of other disorders, such as never had a manic episode, and just list the signs/symptoms of “depressive event.”
MDD criteria
Ans.Five or more of nine: 1. *Depressed mood [irritable mood is also an
option in children and adolescence]2. *Markedly diminished interest in activities.3. Weight loss of gain of 5%/month.4. Insomnia or hypersomnia*Has to have one of these two.[see next screen for other five]
MDD criteria
Continued:5. Psychomotor agitation or retardation6. Anergy7. Feelings of worthlessness or guilt8. Decreased ability to think or to decide9. Ideation of death or suicide.Except for #3 above, “every day” applies to
each of these signs
MDD criteria
Continued:5. Psychomotor agitation or retardation6. Anergy7. Feelings of worthlessness or guilt8. Decreased ability to think or to decide9. Ideation of death or suicide.Except for #3 above, “every day” applies to
each of these signs
Melancholic specifier
Ans. Meets both A and B infra.
A. Either or both:
1. loss of pleasure in virtually all activities
2. Feels dysphoric even when something good happens
B. See next screen
Melancholic specifier
ContinuedB. At least three:1. Dysphoric feeling is more profound than what
the pt experienced in the past as grief.2. Dysphoria worse in AM3. Awakes early in AM4. Psychomotor retardation or agitation5. Significant weight loss6. Inappropriate guilt
Atypical Specifier
Ans.
1.Reacts positively to good news/events.
2.Two or more of:
-- increase appetite or weight gain
-- hypersomnia
-- heavy/leaden feeling in arms/legs
-- very prone to disabling interpersonal rejection sensitivity
Melancholic studies
Q. What lab studies are more common in pts with melancholic specifier than other MDD pts?
Melancholic studies
Ans. More likely to have:
1. Nonsuppression of dexamethasone
2. Plasma, urine and saliva elevated cortisol levels
3. Abnormal tyramine challenge test
4. Abnormal asymmetry on dichotic listening tests.
Neurotransmitters - monoamine
Ans.-- serotonin-- norepinephrine-- dopamine
[Kandel ER et al: Principles of Neural Science. 1991]
Neurotransmitters – non-monoamine
Q. Two non-monoamine neurotransmitters system that are often disturbed are?
Neurotransmitters – non-monoamine
Ans.
-- Corticotropin-releasing factor [CRF]
-- Substance P
[Schecter LE et al: NeuroRx 2005;590-611.]
5-HT
Ans.
Low in CSF, blood platelets and postmortem brain tissue.
[Cheetham SC et al: Brain Res 1988;443:272-280]
Suicide prediction
Ans. “Poor.” It remains a clinical judgment. No rating scales are useful to facilitate clinical judgment, and no “scores” should be relied upon to be predictive.
MDD – death rate, >55 y/o
Q. What is death rate of people with MDD and > 55 y/o in comparison to those without MDD?
Dysthymia >> MDD
Q. What percentage of people with dysthymia, who have not yet had MDD, will go on to have MDD within one year of onset of dysthymia if not treated?
Prevalence
Q. About what percent of the population will have symptoms of MDD over a year from onset?
MDD – prevalence - gender
Ans. Life-time:
women: 10-25%men: 5-12%
Community sample at a given time:women: 5-9%men: 2-3%
{So, depending on how the question is asked, at least 2/3 are women.}
MDD – prevalence - generation
Q. Prevalence of MDD and more recent generations, e.g., born in 1930 in comparison to born in 1940.
MDD – prevalence - generation
Ans. More recent generations have a higher rate of MDD. Thus, people in their 60ies born in the 1940s will have a higher rate that people who were in their sixties who were born in the 1930s. Bottom line, the rate in the population is increasing.
MDD – second episode
Q. You are seeing a pt who is having her first episode of MDD. What are chances of a second?
MDD - third
Q. You are seeing a pt who is having his second episode of MDD. What are the chances of a 3rd?
MDD – 4th episode
Q. You are treating a pt in her third episode of MDD. What are her chances of having a 4th?
MDD >> Bipolar
Q. You are seeing a pt in her first episode of MDD. What are her chances of later having dx of bipolar, i.e., chances of having a manic episode?
MDD >> Bipolar
Ans. DSM’s answer is 5-10%.
{If the examiner’s question focuses on gender, keep in mind that women are more likely than men to have their first bipolar episode be depression whereas men are more likely to have a manic episode first. So, in theory, men should be dxed bipolar sooner than women.}
Suggest future bipolar
Q. What would increase your suspicion that your pt with MDD is going to go on to have bipolar disorder?
Suggest future bipolar
Ans.
- psychotic signs
- psychomotor retardation
- family hx of bipolar disorder
MDD – at one year
Q. Naturalistic studies, i.e., people not receiving treatment, of MDD people finds what percentage still meet DSM criteria for MDD at one year, only have some signs [“partial”] and have no signs?
Role of stressors
Q. Stressors, e.g., death of family member, are more likely to precipitate early episodes of MDD, later episodes or all episodes equally?
Role of stressors
Ans. More likely to precipitate the first or second. Later episodes are less likely to have a precipitant.
Hospitalization
Ans. 1. Danger to self or others.2. Severely disabled and lacks any social supports3. Has another medical condition [including psychiatric] that in combination with MDD requires hospitalization.4. Has failed to respond to outpt or partial treatment.
Medications - general
Q. Breaking down the medication choices depending on whether your pt’s MDD is:
mild,
moderate,
severe, or
severe with psychotic signs.
State place of meds with each of the four.
Medications - general
Ans.
mild: antidepressants meds if preferred by pt [as opposed to pt preferring psychotherapy]
moderate: antidepressants meds are preferred [unless ECT is planned]
severe: antidepressant meds are preferred [unless ECT is planned]
severe with psychotic signs: antidepressants AND antipsychotics [unless ECT is planned]
FDA as to citalopram - 2
• Recommending electrolyte and/or electrocardiographic monitoring in patients at risk for arrhythmia if citalopram therapy is considered
• A maximum daily dosage of 20 mg for all patients older than 60
• Discontinuing the drug if QTc measurements are consistently greater than 500 ms
FDA as to citalopram - 3
• The label will continue to state that citalopram should be "avoided, if possible," in patients with or at risk for prolonged QT interval, including those prone to low blood levels of potassium and magnesium. Also, per the FDA's order of last August, the maximum dose in patients 60 and younger should be 40 mg/day.
FDA as to citalopram - 4
• QT interval prolongation can result in the fatal arrhythmia known as torsade de pointes.
• Patients with low potassium or magnesium levels should receive supplements to normalize them before starting on citalopram, the agency said.
FDA as to citalopram - 5
Max dose for those > 60 y/o: 20 mg/d
Discontinue if QTc measurements are > 500 ms.
FDA as to citalopram - 6
• If the pt has congenital long QT syndrome, citalopram is not recommended in these patients but it is recognized that there may be some patients with this condition who could benefit from a low dose of citalopram and who lack viable alternatives.
Psychotherapy
Q. List 7 factors that would lead one to tilt toward providing psychotherapy for your pt with MDD.
Psychotherapy
Ans.
1] MDD is mild or moderate level of severity
2] Pt preference
3] Pregnant, lactating or wish to become pregnant
4] Co-morbid personality disorder
5] Presence of substantial stressors
6] Substantial interpersonal difficulties
7] Substantial intrapsychic conflict
Psychotherapy - evidence
Q. Two psychotherapies with the most “research-documented efficacy” in MDD?
Psychotherapy - reappraisal
Q. After how many weeks of psychotherapy should one reappraise if the psychotherapy is the correct choice?
Combination
Ans. Same 7 as to psychotherapy with the following 3 addictions:
-- Can also consider with severe level of the disorder, not just mild or moderate.
-- Poor response to just meds or just psychotherapy
-- Poor compliance with just meds or just psychotherapy
Combination - reappraisal
Q. Pt has not shown even moderate improvement after combination of SSRIs and CBT after 8 weeks. Next you switch to venlafaxine, gradually go to max dose and continues CBT, and still no improvement after another 8 weeks. What to do?
ECT - 1
Ans.
1] Pt’s preference
2] Prior good results with ECT
3] Pt has medical conditions that preclude use meds and conditions too severe for psychotherapy. Medical conditions would include pregnancy.
4] see next slide
ECT - 2
4] Catatonic
5] Urgent need for response, e.g. very suicidal or not eating.
6] Very high level of severity of the MDD
Initial choice of a med
Q. Practice guideline list one whole class, two tricyclics, one dopamine-norepinephrine reuptake inhibitor, two serotonin-norepinephrine reuptake inhibitor, and one norepinephrine-serotonin modulator as “likely to be effective for most patients” as an initial med choice for MDD. Name the class, then name the two tricyclics, then the other three meds.
Initial choice of med
Ans.
Class: SSRIs
Tricyclics: desipramine and nortriptyline
Dopamine-norepinephrine reuptake inhibitor:
bupropion
Serotonin-norepinephrine reuptake inhibitor: venlafaxine or duloxetine
Norepinephrine-serotonin modulator: mirtazapine
Partial response
Q. Your pt has partially responded to an SSRI in 6 weeks, dose pushed to max, and still not improved further at 12 weeks, what to do?
Partial response
Ans. Augment with:-- a non-MAOI antidepressant -- Li-- thyroid hormone-- anticonvulsant mood stabilizer-- psychostimulantAlso acceptable: add or increase frequency
of psychotherapy
TCAs - problems
Q. Tricyclics are especially problematic in pts with what two medical conditions [not including suicidal]?
MAOIs - action
Ans. Form bond with MAO enzyme that in turn decreases the degradation of nor-epinephrine and serotonin, thus increasing synaptic concentration of those two amines. Two weeks.
[Bodkin JA: Curr Psychiatry 2006;5:79-83]
MAOIs - used
Ans.
-- phenelzine
-- selegiline transdermal system
-- tranylcypromine
-- isocarboxazid is rarely used today
MAOI & venlafaxine
Q. Pt is on venlafaxine and is to be switched to tranylcypromine. How long a wash out?
MAOI & venlafaxine
Ans. 2 weeks.
[This “2 weeks” answer will work for most of the other antidepressants.]
Atypical - bupropion
Ans. Yes, works as well as SSRIs.
[I’m unaware of any studies of bupropion v. MAOIs.]
[Thase ME et al: J Clin Psychiatry 2005;66:974-981]
Atypical - CBT
Ans. Yes. CBT did as well as phenelzine in a ten week study.
[Remember in the exam, never bet against CBT.]
[Jarrett RB et al: Arch Gen Psychiatry 1999;56:431-437]
Treatment failure
Ans. 1]Non-compliance with treatment?
2]Reconsider dx.
a] General medical condition?
b] Substance-related disorder?
Continuation phase
Q. Pt did not respond to escitalopram, 20 mg/d, and was switched to venlafaxine ER at the 7th week and gradually increased to 225 mg/d of venlafaxine ER and symptoms remitted at the 13th week. What now as to medicating?
Discontinuation of medications
Q. If pt has done well for 12 months while on an antidepressant, if med is to be discontinued, what to do?