Depression

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Contents

More Specific Terms

Introduction

  • A mental state marked by feelings of despair, discouragement, & sadness.

Etiology

  • medical illness may be a severe form of stress
  • job stress
  • marital discord
  • death
  • divorce
  • job loss
  • religion or spirituality may confer protective effect [20]
  • pharmacologic causes:

Epidemiology

  • 10-15% of general medical outpatients [17]
  • female/male ratio is about 2-3/1
  • lifetime incidence of major depression is 10-25% in women & about 1/2 as much in men
  • more common among blacks & Hispanics than whites
  • more common among middle-aged adults than among younger & older adults
  • individuals without health insurance more likely to be depressed than those with coverage [17]

Pathology

  • pretreatment telomerase activity is directly correlated with depression ratings
  • lower pretreatment telomerase activity with relatively greater increase in telomerase activty during treatement correlates with better treatment response [23]
  • comment: difficult to envision a mechanism

Genetics

History

Clinical-manifestations

Laboratory

Diagnostic-procedures

  • * changes in sleep also seen with aging; effects may be additive

Radiology

Complications

Differential-diagnosis

  • depression associated with medical illness

Management

  • ensure the safety of the suicidal depressed patient
  • assess suicide risk in all patients
  • refer to a psychiatrist those patients with a plan
  • hospitalize if patient is a imminent risk to themselves or others (place hold on patient if necessary)
  • aggressively treat contributing medical problems
  • psychotherapy [13,15]
  • be alert for increased risk of suicide associated with initiation of drug therapy for depression [3]
  • antidepressants can trigger a manic attack in patients with bipolar-affective disorder [3]
  • selective serotonin reuptake inhibitors (1st line agents)
  • start 25 mg QD
  • increase after 4-7 days (minimal adverse reaction)
  • effective dose: 50-200 mg QD
  • alternative agents
  • therapeutic monitoring may be indicated
  • duration of therapy with 1st recurrence of depression: 18-36 months
  • lifetime therapy for patients with > 2 episodes of major depression [5]; including reccurence within 1 year of treatment & suicide attempt
  • patients > 50 years of age: > 3 years
  • 1/3 of patients don't fully respond to standard antidepressant therapy [7]
  • for partial responders, maximize dose, then add a second agent
  • for non-responders, change to a different agent [3]
  • combination therapy for partial-responders
  • may fall below accepted criteria for clinical significance [14]
  • ineffective in demented patients [25]
  • recommended for adults when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, & follow-up, otherwise not recommended ( USPSTF)
  • 1 of 11 patients identified by screening respond to treatment [6]
  • at a prevalence of 10% in the general adult population, 110 patients need to be screened for 1 to benefit [6]
  • screening not recommended for children [6]
  • within 1 week of initial presentations
  • weekly or biweekly for 6 weeks
  • 3 times within 3 months, one face to face
  • monthly or bimonthly if patient improving
  • at least quarterly while patient still on anti-depressant medications

More General Terms

Additional Terms

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1110-1113
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
  4. Prescriber's Letter 7(11):65 2000
  5. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  6. Journal Watch 22(13):105, 2002 US Preventive Services Task Force, Screening for Depression, Ann Intern Med 136:760, 2002 PMID: [1] Pignone MP et al, Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 136:765, 2002 PMID: [2]
  7. Treatment-Resistant Depression Prescriber's Letter 9(7):38 2002 Detail-Document#: [3] (subscription needed) [4]
  8. Journal Watch 25(9):75, 2005 Szegedi A, Kohnen R, Dienel A, Kieser M. Acute treatment of moderate to severe depression with hypericum extract WS 5570 (St John's wort): randomised controlled double blind non-inferiority trial versus paroxetine. BMJ. 2005 Mar 5;330(7490):503. Epub 2005 Feb 11. Erratum in: BMJ. 2005 Apr 2;330(7494):759. dosage error in text. <PubMed> PMID: [5] <Internet> [6]
  9. Antonioli C and Reveley MA Randomised controlled trial of animal facilitated therapy with dolphins in the treatment of depression BMJ 2005; 331:1231 PMID: [7]
  10. Hariri AR, Brown SM. Serotonin. Am J Psychiatry. 2006 Jan;163(1):12. No abstract available. PMID: [8]
    - Parsey RV, Hastings RS, Oquendo MA, Huang YY, Simpson N, Arcement J, Huang Y, Ogden RT, Van Heertum RL, Arango V, Mann JJ. Lower serotonin transporter binding potential in the human brain during major depressive episodes. Am J Psychiatry. 2006 Jan;163(1):52-8. PMID: [9]
    - Parsey RV, Hastings RS, Oquendo MA, Hu X, Goldman D, Huang YY, Simpson N, Arcement J, Huang Y, Ogden RT, Van Heertum RL, Arango V, Mann JJ. Effect of a triallelic functional polymorphism of the serotonin-transporter-linked promoter region on expression of serotonin transporter in the human brain. Am J Psychiatry. 2006 Jan;163(1):48-51. PMID: [10]
    - Sibille E, Lewis DA. SERT-ainly Involved in Depression, But When? Am J Psychiatry. 2006 Jan;163(1):8-11. No abstract available. PMID: [11]
  11. Prescriber's Letter 13(5): 2006 Pharmacotherpy of resistant depression: an update Detail-Document#: [12] (subscription needed) [13]
  12. McMahon FJ, Buervenich S, Charney D, Lipsky R, Rush AJ, Wilson AF, Sorant AJ, Papanicolaou GJ, Laje G, Fava M, Trivedi MH, Wisniewski SR, Manji H. Variation in the gene encoding the serotonin 2A receptor is associated with outcome of antidepressant treatment. Am J Hum Genet. 2006 May;78(5):804-14. Epub 2006 Mar 20. PMID: [14]
  13. Brent D, Emslie G, Clarke G, Wagner KD et al Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008 Feb 27;299(8):901-13. PMID: [15]
  14. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008 Feb;5(2):e45. PMID: [16]
  15. US Preventive Services Task Force Screening and Treatment for Major Depressive Disorder in Children and Adolescents: US Preventive Services Task Force Recommendation Statement PEDIATRICS 2009 123:1223-1228 (doi:10.1542/peds.2008-2381) [17]
    - Williams SB et al Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventive Services Task Force PEDIATRICS 2009, 123:e716-e735 (doi:10.1542/peds.2008-2415) [18]
  16. Segal ZV et al. Antidepressant monotherapy vs sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Arch Gen Psychiatry 2010 Dec; 67:1256 PMID: [19]
  17. Depression in children and young people National Institute of Health and Clinical Excellence (NICE) [20]
    - NIH Institute and Center Resources [21]
  18. Centers for Disease Control and Prevention (CDC). Current Depression Among Adults - United States, 2006 and 2008 Morbidity and Mortality Weekly Report (MMWR) October 1, 2010 / 59(38);1229-1235 <PubMed> PMID: [22] <Internet> [23]
  19. Pan A et al Depression and Incident Stroke in Women Stroke August 11, 2011 <PubMed> PMID: [24] <Internet> [25]
    - Pan A et al Depression and Risk of Stroke Morbidity and Mortality: A Meta-analysis and Systematic Review JAMA. 2011 Sep 21;306(11):1241-9. <PubMed> PMID: [26] <Internet> [27]
  20. Miller L et al. Religiosity and major depression in adults at high risk: A ten-year prospective study. Am J Psychiatry 2011 Aug 24; <PubMed> PMID: [28] <Internet> [29]
  21. Prescriber's Letter 18(10): 2011 Folate for Depression Detail-Document#: [30] (subscription needed) [31]
  22. Barber JP et al. Short-term dynamic psychotherapy versus pharmacotherapy for major depressive disorder: A randomized, placebo-controlled trial. J Clin Psychiatry 2012 Jan; 73:66. PMID: [32]
    - Kocsis JH. Questions raised by the failure of a trial for short-term psychodynamic therapy versus pharmacotherapy for major depressive disorder. J Clin Psychiatry 2012 Jan; 73:64. PMID: [33]
  23. Wolkowitz OM et al. Resting leukocyte telomerase activity is elevated in major depression and predicts treatment response. Mol Psychiatry 2012 Feb; 17:164. PMID: [34]
  24. Journal Watch March 13, 2012, Massachusetts Medical Society Gibbons RD et al. Benefits from antidepressants: Synthesis of 6-week patient- level outcomes from double-blind placebo-controlled randomized trials of fluoxetine and venlafaxine. Arch Gen Psychiatry 2012 March 5; PMID: [35]
  25. Banerjee S et al Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo- controlled trial The Lancet, Early Online Publication, 18 July 2011 <PubMed> PMID: [36] <Internet> [37]
  26. National Guideline Clearinghouse
    - Depression (University of Michigan Health System) ngc-guideline: [38]
    - Primary care diagnosis and management of adults with depression. (University of Michigan Health System) ngc-guideline: [39]
    - Adult primary care depression guidelines. (Kaiser Permanente) ngc-guideline: [40]
    - Pharmacotherapy companion to the depression. American Medical Directors Association ngc-guideline: [41]
    - Depression: management of depression in primary and secondary care. (National Collaborating Centre for Mental Health) ngc-guideline: [42]
    - Detecting depression in older adults with dementia. University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core ngc-guideline: [43]
    - Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. ngc-guideline: [44]
    - Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. ngc-guideline: [45]
    - Identification of common mental disorders and management of depression in primary care. New Zealand Guidelines Group. ngc-guideline: [46]
    - Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians. ngc-guideline: [47]
    - Screening for depression in adults. U.S. Preventive Services Task Force ngc-guideline: [48]
    - Depression in adults with a chronic physical health problem. Treatment and management. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [49]
    - Depression. The treatment and management of depression in adults National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [50]
    - Non-pharmaceutical management of depression in adults. A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN) ngc-guideline: [51]
    - Gaynes BN et al Primary Care Depression Guidelines and Treatment Resistant Depression: Variations on an Important but Understudied Theme National Guideline Clearinghouse, May 7, 2012 [52]

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