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p. 1812

Depression is a common and often chronic disorder that may manifest at

any time in one’s life. Diagnostic criteria for major depression include a

minimum of five symptoms persisting for at least 2 weeks. One of these

symptoms must be either depressed mood or anhedonia. Suicidal

ideation should be assessed in all patients.

Case 86-1 (Question 1),

Table 86-4

A variety of treatment modalities are available for the management of

depression. These include prescription medications, psychotherapy, and

somatic treatments. Prescription medications and/or psychotherapy are

indicated for depressive symptoms that are moderate to severe in

nature, whereas somatic treatments are for severe refractory cases.

Case 86-1 (Question 2),

Case 86-2 (Questions 1, 2),

Case 86-3 (Question 2)

All of the prescription medications that are currently available are

equally effective and possess the same delayed onset of therapeutic

effects. Selection of an antidepressant is based on many factors,

including previous response to medication, age, reproduction status, and

both medical and psychiatric comorbidities.

Case 86-1 (Questions 2, 4),

Case 86-2 (Question 2)

Case 86-4 (Question 1),

Table 86-6

SSRIs are regarded as the initial treatment of choice for most depressed

patients. They are inexpensive and effective for comorbid anxiety

conditions, and possess a lower side effect burden than other

antidepressants overall. Side effects are generally mild and transient.

Case 86-1 (Question 2),

Case 86-2 (Question 1)

Educating the patient regarding side effects, how to monitor for efficacy,

and the duration of treatment is important action for successful

treatment.

Case 86-1 (Question 3),

Case 86-3 (Question 3),

Table 86-10

The goal of antidepressant treatment is remission of symptoms. Once

remission is achieved, the general recommendation is to continue the

effective antidepressant regimen for a minimum of 6 months.

Case 86-1 (Question 3),

Table 86-10

Because only half of depressed patients will achieve remission with the

first antidepressant selected, clinicians should have a comprehensive

understanding of the role many antidepressants may have in optimizing

outcomes. Clinicians should be familiar with switching antidepressants in

patients with an incomplete response, and the merits of augmentation

strategies.

Case 86-2 (Questions 1–3)

Untreated depression in children under 18 has a significant risk of Case 86-3 (Questions 1, 2)

suicide. Treatment consists of talking therapy and specific

antidepressants, which is different than the broad options available to

adults.

Depression and chronic pain are commonly comorbid, and

pharmacologic treatment that addresses both is recommended. This

makes the SNRI class of antidepressants preferred.

Case 86-4 (Question 1)

p. 1813

p. 1814

INTRODUCTION

In general, depressive disorders are enormous health concerns that are often

misdiagnosed or undertreated. The physical and social dysfunction associated with

depression is profound and is believed to outweigh many other chronic medical

conditions, including hypertension, diabetes, and arthritis.

1 The Medical Outcomes

Study determined that the degree of impairment in depressed individuals is

comparable to that seen in patients with chronic heart disease.

2 The financial

ramifications of depression are tremendous and place an overwhelming burden on

our society. In 2000, the estimated cost of depression in the United States was $83.1

billion annually, with most of these costs ($51.5 billion) attributed to lost

productivity and absenteeism in the workplace.

1,3

Epidemiology

Since World War II, the lifetime incidence of depression has been rising steadily in

studied populations. The annual incidence of all mood disorders is approximately

10% in the adult population, and 1 in 15 adults (6.7%) will suffer from an episode of

major depression during any 12-month period.

4 Various studies from Europe and the

United States have estimated the 1 year and lifetime prevalence to be 4.1% and

6.7%, respectively.

5 Although the incidence of depression is remarkably similar

across various races and ethnic groups, the illness may be slightly more common in

lower socioeconomic classes and women having double the incidence than men.

1,5

The onset of depression occurs most commonly in the late 20s, but there is a wide

range, and the first episode may actually present at any age. Genetic factors appear to

play a major role in the cause of depression. The offspring of depressed individuals

are 2.7 times more likely to have depression if one parent is afflicted, and 3.0 times

more likely if both parents suffer from depression.

6 Concordance rates for

monozygotic (identical) twins range from 54% to 65%, whereas the corresponding

rates in dizygotic (fraternal) twins range from 14% to 24%.

7 Genetic factors may also

1.

2.

3.

4.

5.

6.

7.

8.

predispose individuals to an earlier onset of depression (younger than 30 years of

age).

8 Additionally, there is clear evidence that depression may occur as a result of

stressful events (i.e., environmental factors) in one’s life. These factors include a

difficult childhood, physical or verbal abuse, pervasive low self-esteem, death of a

loved one, loss of a job, and the end of a serious relationship. Acute depressive

episodes are often attributed to a combination of environmental and genetic factors.

For instance, individuals carrying a genetic predisposition to mood disorders may

undergo a stressful experience that ultimately triggers the manifestation of depressive

symptomatology. Depression may also occur spontaneously among people who

appear to lack any obvious genetic or environmental predisposition.

Diagnosis and Classification

When assessing a person for depression, it is important to recognize the level of

impairment due to the symptoms. Just as with all biologic systems, the body can

function well within a particular range (e.g., serum potassium or BP). Mood is not

different; as long as the depressive symptoms are not prolonged or impairing, there

would be no reason to aggressively treat. Once the depression is severe enough to

impact functioning or induce harm, it requires treatment.

Major depressive disorder (MDD) may manifest as a single episode, but it is more

commonly a series of recurrent events. Thus, in most patients, depression is a chronic

illness.

5 The frequency of recurrent episodes is highly variable, with some people

experiencing discrete episodes separated by many years of relatively normal mood

(euthymia), and others experiencing residual symptoms between episodes that may

never completely remit. The risk of future episodes appears to increase

disproportionately with the chronicity of the illness. For instance, after the first

episode there is a 50% likelihood of a second episode. After the second, there is a

70% chance of a third, and with the third episode comes nearly a 90% incidence of a

fourth.

Table 86-1