MAJOR depressive DISORDER By: Farrukh Hashmi MD Board certified in psychiatry and NEUROLOGY Lourdes Counseling Center Reliance medical center

Major depressive disorder Diagnosis Criteria According to DSM-V Diagnostic Code (F32.X and F33.X) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure ( Anhedonia).

Major depressive disorder Depressed mood most of the day Markedly diminished interest or pleasure in all/almost all activities Significant weight change not due to other medical condition Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death, SI w/ past attempt or specific plan

Major depressive disorder In addition, the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning The episode is not attributable to the physiological effects of a substance or to another medical condition

Differential diagnosis of clinical depression Major Depressive Disorder (MDD) Bipolar Disorder Seasonal Affective Disorder (SAD) Psychotic Depression Peripartum (Postpartum) Depression Premenstrual Dysphoric Disorder (PMDD) “Situational” Depression—Significant Life Changes Dysthymia

Comorbidities of Depression Depressive and anxiety disorders commonly occur together in patients presenting in the primary care setting The presence of depressive/anxiety comorbidity substantially increases medical utilization Is associated with greater chronicity, slower recovery, increased rates of recurrence, and greater psychosocial disability Long-term treatment is indicated SSRI (Selective Serotonin Reuptake Inhibitor) is preferred

Route to treatment Appearance of Symptoms but Lack of Insight Life is not great but it goes on Recognition of Changes in Mood It’s caused by stress from work and family Self-Medication Alcohol, marijuana, and other illegal street drugs to enhance my mood Visit to My PCP Referral to a Specialist Gaining insight and judgement toward my illness Most patients resist of seeing a specialist unless it is strongly recommended by their PCPs

Route to Treatment It is estimated that about 70% of visits to PCPs are psychosocial related issues Different patients presents themselves differently. Gender/ Race Only less than a quarter of those issues will be referred to a specialist PCPs are often the final stop for most patients with mild to moderate psychiatric conditions

If things aren’t bad enough already… Often time, there is also the issue of substance abuse The National Bureau of Economic Research reports that people who have been diagnosed with a mental illness at some point in life consume 69 percent of the nation’s alcohol and 84 percent of the national’s cocaine People who abuse substances are more likely to suffer from depression (substance induced depression) People who are depressed may drink or abuse drugs to lift their mood(self medicated)

If things aren’t bad enough already… Some diseases are also known to cause depression, including but not limited to: Diabetes Heart disease Arthritis Kidney disease HIV/AIDS Autoimmune such as Lupus and multiple sclerosis (MS) Hypothyroidism Fibromyalgia

Treatment for Depression First, rule out other medical conditions that may cause depression Medications Therapy sessions (CBT is the most common type, but also not limited to psychoanalysis, psychodynamic, interpersonal, etc.) Brain Stimulation Techniques—ECT and TMS

Medication for Depression SSRI—Selective Serotonin Reuptake Inhibitor SNRI—Serotonin and Norepinephrine Reuptake Inhibitor TCA—Tricyclic Antidepressant MAOI—Monoamine Oxidase Inhibitor Others—stimulant

SSRI Citalopram Escitalopram Paroxetine Fluoxetine Sertraline Vilazodone Vortioxetine

SSRI general Side Effects Drowsiness Nausea Dry mouth Insomnia Diarrhea Nervousness, agitation or restlessness/ suicidal ideas Dizziness Sexual problems Blurred vision Headache / weight gain

SNRI Venlafaxine Desvenlafaxine Duloxetine Levomilnacipran

SNRI general Side Effects Upset stomach Insomnia Sexual problems Anxiety Dizziness Fatigue Weight gain

TCA Amitriptyline Desipramine Doxepin Imipramine Nortriptyline Protriptyline Trimipramine

TCA General Side Effects Stomach upset Dizziness Dry mouth Changes in blood pressure, in blood sugar levels Nausea Weight gain Sexual side effects

MAOI Phenelzine Tranylcypromine Isocarboxazid

MAOI Not very commonly prescribed due to severe interaction with other medications and food Foods that can negatively react with the MAOIs include aged cheese, aged meats , Alcohol.

Others Bupropion Mirtazapine Trazodone Stimulants D-amphetamine Methylphenidate

ECT Electroconvulsive therapy Gold standard for treating MDD when standard treatments have failed Major side effects include transient memory loss, along with nausea, headache, jaw pain or muscle ache Refer to a specialist if your patient is interested in trying out ECT

TMS Transcranial Magnetic Stimulation Therapy Less invasive than ECT, less side effects Suitable for patients who are planning to become pregnant Suitable for patients who are unable to tolerate side effects of most oral medications Refer to a specialist if your patients express interest in this kind of treatment

Common Augmentation Medications Lithium Thyroid hormones

Suicide evaluation -Vague suicidal ideas. -Actively thinking about committing suicide. -Making plans, giving away prized possessions, writing note, good bye letter. -Attempting suicide. -Committing suicide.

Suicide Risk evaluation ( cont) Who attempts more ? Who completes more and why? Suicide gesture vs Lethality of attempt. Most risky patient in your clinic or ER.

reference DSM5 Diagnostic Criteria Major Depressive Disorder - Pearson Clinical Substance Abuse and Depression - Kathleen Smith LPC, PhD