Major Depressive Disorder

Major Depressive Disorder

A clinical course characterized by one or more major depressive episodes without a history of manic or hypomanic episodes

Major Depressive Disorder

Spectrum of depression, compared to bipolar which is a spectrum for mania

Norepinephrine; Serotonin (5-HT); Dopamine

Neurotransmitters decreased in brain causing depression according to biogenic amine hypothesis (3)

Biogenic Amine Hypothesis

Refers to decreased brain levels of the neurotransmitters norepinephrine, serotonin (5-HT), and dopamine may cause depression

Post-synaptic changes in receptor sensitivity

Refer to the desensitization or downregulation of norepinephrine or 5-HT1A receptors may relate to onset of antidepressant effects

Norepinephrine; 5-Hydroxytryptamine 1A

Desensitixation or downregulation of receptors may relate to onset of antidepressant effects acording to post-synaptic changes in receptor sensitivity (2)

Dysregulation Hypothesis

Emphasizes a failure of homeostatic regulation of neurotransmitter systems, rather than absolute increase or decrease in their activities

Norepinephrine; 5-Hydroxytryptamine

Receptors suggested to be linked to be involved in antidepressant response according to 5-HT/NE link hypothesis (2)

Dysregulation Hypothesis

Imbalance of neurotransmitters in the brain

5-HT/Norepinephrine link hypothesis

This theory suggests that 5-HT and norepinephrine activities are linked, and that both the serotonergic and noradrenergic systems are involved in antidepressant response

Role of dopamine

Studies suggest that dopamine transmission is decreased in depression and that increased dopamine activity in the mesolimbic pathway contributes to antidepressant activity

Mesolimbic pathway

Pathway with dopamine activity that contributes to antidepressant activity

Dopamine

Transmission of this neurotransmitter is decreased in depression

Parkinson’s Disease

The other disorder patients with depression may also experience

Hippocampus

The part of the brain where disruption of brain-derived neurotrophic factor expression happens

Brain-derived neurotrophic factor expression

Disruption of this in the hippocampus may be associated with depression

Decrease

Occurs to the hippocampus in people with depression

Biogenic amine hypothesis; Post-synaptic changes in receptor sensitivity; Dysregulation hypothesis; 5-HT/Norepinephrine link hypothesis; Role of dopamine

Pathophysiology of depression (5)

Diminished ability to experience pleasure; Loss of interest in usual activities; Sadness; Pessimism; Crying; Hopelessness; Anxiety; Guilt; Psychotic feautures

Emotional symptoms of depression (9)

Pessimism

Characterized by frequent thoughts about negative things

Fatigue; Pain (especially headache); Sleep disturbance; Increased/Decreased appetite; Loss of sexual interest; Gastrointestinal and cardiovascular complaints (especially palpitations)

Physical symptoms of depression (6)

Headache

Form of pain common in depression

Palpitations

Form of GI and cardiovascular complaints common in depression

Decreased or increased appetite

Physical symptom of depression as a form of compensation of the body

Decreased ability to concentrate; Poor memory of recent events; Confusion; Indecisiveness

Intellectual/Cognitive symptoms of depression (4)

Slowed physical movements and thought processes; Speech/Psychomotor agitation

Psychomotor disturbances of depression characterized by psychomotor retardation (2)

Psychomotor retardation

Characterized by slowed physical movements, thought processes, and speech or psychomotor agitation

Major depressive disorder

Characterized by one or more major depressive episodes as defined by DSM 5

Diagnostic and Statistical Manual of Mental Disorders

(DSM-5) Reference and manual for mental disorders

5 or more

Amount of symptoms that must be present to diagnose depression

2-week period

Period of time for symptoms of depression to be present for diagnosis

FALSE

True/False: A person taking substances or medications that have a depressant effect (like alcohol) can be diagnosed with major depressive disorder

TRUE

True/False: A patient with no history of maniclike or hypomanic-like episodes can be diagnosed for major depressive disorder

FALSE

A patient with history of maniclike or hypomanic-like eposides induced by a substance or medical condition CANNOT be diagnosed with major depressive disorder

Medication review; Physical examination; Mental status examination; Complete blood count with differential; Thyroid function test; Electrolyte determination

Diagnosis required in depression (6)

Stroke; Parkinson’s Disease; Traumatic brain injury; Hypothyroidism

Chronic illnesses associated with depression (4)

Antihypertensives; Oral contraceptives; Isotretinoin; Interferon-B1a

Medications associated with depression (4)

Isotretinoin

Drug used for acne vulgaris linked to increase of suicidal hydration

Resolution of current symptoms; Prevention of further episodes of depression

Goals of treatment of depression (2)

Remission

Refers to resolution of current symptoms, meaning there will be no more symptoms of depression

Relapse; Recurrence

Refers to further episodes of depression (2)

Psychotherapy

May be first-line therapy for mild to moderately severe major depressive episode

Additive

The efficacy of psychotherapy and antidepressants is considered to be ___

Psychotherapy alone

Not recommended for acute treatment of severe and/or psychotic MDD

Combined treatment

May provide no unique advantage for uncomplicated, nonchronic MDD

Acute treatment of severe and/or psychotic major depressive disorder

Psychotherapy alone is not recommended for this

Uncomplicated, nonchronic major depressive disorder

Combined treat of this condition may provide no unique advantage

Electroconvulsive therapy

May be considered when a rapid response is needed, risk of other treatment outweigh potential benefits, there is history of poor response to drugs, and the patient prefers it

10-14 days

Days until ECT reports therapeutic response

6-week trial

Trial of antidepressant at maximum dosage considered an adequate trial of medication

Acute phase

The goal of this treatment phase is remission

6-12 weeks

The time the acute phase of treatment lasts

Continuation phase

Seeks to eliminate residual symptoms or prevent relapse

4-9 months

Time the continuation phase lasts for

Maintenance phase

Seeks to prevent recurrence of a new episode of depression

12-36 months or more

The time the maintenance phase lasts for

6-12 weeks

The length of time of treatment required for elderly to achieve the desired antidepressant response

Lifelong therapy

Recommended by some clinicians for persons younger than 40 years with two or more prior episodes and for all persons with three or more prior episodes

Selective serotonin reuptake inhibitor

Inhibit the reuptake of 5-HT into the presynaptic neuron

Selective serotonin reuptake inhibitors

Generally chosen as first-line antidepressants because of their relative safety in overdose and improved tolerabiliity compared with earlier agents

Escitalopram; Sertraline

SSRIs suggested to have the best efficacy/side effect profile compared to other newer-generation antidepressants (2)

Selective serotonin reuptake inhibitor

Pharmacologic category of Escitalopram and Sertraline

Norepinephrine; 5-Hydroxytryptamine

Receptors inhibited by tricyclic antidepressants

Tricyclic antidepressant

Use of this has diminished because of the availability of equally effective therapies that are safer on overdose and better tolerated

Tricyclic antidepressant

Inhibit the reuptake of norepinephrine and 5-HT and have affinity for adrenergic, cholinergic, and histaminergic receptors

Monoamine oxidase inhibitors

Increase the concentrations of norepinephrine, 5-HT, and dopamine within the neuronal synapse through inhibition of monoamine oxidase

Phenelzine; Tranylcypromine

MAOIs used for depression (2)

Monoamine oxidase inhibitor

Pharmacologic category of Phenelzine and Tranylcypromine (2)

Monoamine oxidase inhibitor-A; Monoamine oxidase inhibitor-B

Nonselectively inhibited by MAOIs (2)

Hypertensive crisis

Conditions caused by eating foods that should be avoided when taking MAOIs

Vetsin

Brand name of Monosodium glutamate

Monosodium glutamate

Generic name of Vetsin

Licorine

Food that is related to increase blood pressure

Symphatomimetic agents; Depressants; Centrally-acting agents

Class of medication to avoid with MAOIs (3)

Triazolopyridines

Antagonize the 5-HT2 receptor and inhibit the reuptake of 5-HT

Triazolopyridines

Class of medication that can also enhance 5-HT1A neurotransmission

Trazodone; Nefazodone

Drugs that fall under the category of Triazolopyridines (2)

Triazolopyridine

Pharmacologic class of Trazodone and Nefazodone

Trazodone

Blocks a1-adrenergic and histaminergic receptors increasing dizziness and sedation

Vilazodone

May be particularly useful for depressed patients with anxiety

Vortioxetine

May be helpful for depressed patients with cognitive difficulties

Mirtazapine

Enhances central noradrenergic and serotonergic activity by antagonizing central presynaptic a2-adrenergic autoreceptors and heteroreceptors

Mirtazapine

This drug antagonized 5-HT2 and 5-HT3 receptors and blocks histamine receptors

Mirtazapine

It may be an option for patients who experience sexual dysfunction taking other antidepressants

St. John’s Wort

A herb containing hypericum, which may be effective for mild to moderate depression

St. John’s wort

This drug is associated with several drug-drug interactions

QT-interval prolongation

ADR of Citalopram

Citalopram

Causes an ADR of QT-interval prolongation

Anorexia

ADR of Fluoxetine

Fluoxetine

This SSRI causes anorexia as an ADR

Somnolence

ADR caused by Fluvoxamine

Fluvoxamine

This drug has an ADR of somnolence

Anticholinergic effects

ADR caused by Paroxetine

Paroxetine

This drug has an ADR of anticholinergic effects

Dry mouth; Constipation; Urinary retention; Mental status changes

Symptoms of anticholinergic effects (4)

Citalopram; Fluoxetine; Fluvoxamine; Paroxetine

Drugs under the category of Selective serotonin reuptake inhibitor (4)

Desvenlafaxine

This SNRI has an ADR on dose-related hyperlipidemia

Dose-related hyperlipidemia

The ADR caused by Desvenlafaxine

Duloxetine

This SNRI has an ADR of orthostatic hypotension

Orthostatic hypotension

This ADR is caused by Duloxetine