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Key Features

Essentials of Diagnosis

  • In most depressions

    • Mood varies from mild sadness to intense guilt, worthlessness, and hopelessness

    • Difficulty in thinking and concentration, with rumination and indecision

    • Loss of interest, with diminished involvement in activities

    • Somatic complaints

    • Disrupted, reduced, or excessive sleep

    • Loss of energy, appetite, and sex drive

  • In some severe depressions

    • Psychomotor disturbance: retardation or agitation

    • Delusions of a somatic or persecutory nature

    • Withdrawal from activities

    • Suicidal ideation

General Considerations

  • Sadness and grief are normal responses to loss; depression is not

  • Unlike grief, depression is marked by a disturbance of self-esteem, with a sense of guilt and worthlessness

  • Dysthymia is a chronic depressive disturbance with symptoms generally milder than in a major depressive episode

Demographics

  • Up to 30% of primary care patients have depressive symptoms

Clinical Findings

Symptoms and Signs

  • Anhedonia

  • Withdrawal from activities

  • Feelings of guilt

  • Poor concentration and cognitive dysfunction

  • Anxiety

  • Chronic fatigue and somatic complaints

  • Diurnal variation with improvement as the day progresses

  • Vegetative signs

    • Insomnia

    • Anorexia

    • Constipation

  • Occasionally, severe agitation and psychotic ideation

  • Atypical features

    • Hypersomnia

    • Overeating

    • Lethargy

    • Mood reactivity

Differential Diagnosis

  • Bipolar disorder or cyclothymia

  • Adjustment disorder with depressed mood

  • Dysthymia

  • Premenstrual dysphoric disorder

  • Major depression with postpartum onset: usually 2 weeks to 6 months postpartum

  • Seasonal affective disorder

    • Carbohydrate craving

    • Lethargy

    • Hyperphagia

    • Hypersomnia

Diagnosis

Laboratory Tests

  • Complete blood count

  • Thyroid-stimulating hormone

  • Folate

  • Toxicology screen may be indicated

  • Blood tests to diagnose depression and predict antidepressant response are being developed

Treatment

Medications

  • See Table 25–7 and Figure 25–2

  • Selective serotonin reuptake inhibitors (SSRIs) and atypical antidepressants

    • Generally lack anticholinergic or cardiovascular side effects

    • Most are activating and should be given in the morning

    • Some patients may experience sedation with paroxetine, fluvoxamine, and mirtazapine

    • Clinical response varies from 2 to 6 weeks

    • Common side effects are headache, nausea, tinnitus, insomnia, nervousness

    • Sexual side effects (eg, erectile dysfunction) are very common and may respond to sildenafil

    • "Serotonin syndrome" may occur when SSRIs are taken in conjunction with monoamine oxidase inhibitors or selegiline

    • With the exception of paroxetine, SSRIs should be tapered over weeks to months to avoid a withdrawal syndrome

    • Fluoxetine, fluvoxamine, sertraline, and venlafaxine appear to be safe in pregnancy; paroxetine carries a black box warning for possible teratogenecity

      • Their use should be weighed against the risks of an untreated depression in the mother

    • Vortioxetine

      • Blocks serotonin reuptake, is a partial agonist of the 5-HT1A receptor, and affects a variety of other serotonin receptor sites

      • Has demonstrated efficacy in improving cognitive symptoms of depression and has received regulatory approval for this indication in Europe

      • Typical dose: 10 mg/day orally and may be increased to 20 mg/day

      • Side ...

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