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Depression
Suma P. Chand; Hasan Arif.
Objectives:
Outline the evaluation and management of depression and the role of interprofessional
team members in collaborating to provide well-coordinated care and enhance patient
outcomes.
Introduction
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest.[1]
[2] The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) classifies the depressive disorders into:
The common features of all the depressive disorders are sadness, emptiness, or irritable mood,
accompanied by somatic and cognitive changes that significantly affect the individual’s capacity
to function.[3]
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Because of false perceptions, nearly 60% of people with depression do not seek medical help.
Many feel that the stigma of a mental health disorder is not acceptable in society and may hinder
both personal and professional life. There is good evidence indicating that most antidepressants
do work but the individual response to treatment may vary.
Etiology
The etiology of major depressive disorder is multifactorial with both genetic and environmental
factors playing a role. First-degree relatives of depressed individuals are about 3 times as likely
to develop depression as the general population; however, depression can occur in people
without family histories of depression.[4][5]
Some evidence suggests that genetic factors play a lesser role in late-onset depression than in
early-onset depression. There are potential biological risk factors that have been identified for
depression in the elderly. Neurodegenerative diseases (especially Alzheimer disease and
Parkinson disease), stroke, multiple sclerosis, seizure disorders, cancer, macular degeneration,
and chronic pain have been associated with higher rates of depression. Life events and hassles
operate as triggers for the development of depression. Traumatic events such as the death or loss
of a loved one, lack or reduced social support, caregiver burden, financial problems,
interpersonal difficulties, and conflicts are examples of stressors that can trigger depression.
Epidemiology
Twelve-month prevalence of major depressive disorder is approximately 7%, with marked
differences by age group. The prevalence in 18- to 29-year-old individuals is threefold higher
than the prevalence in individuals aged 60 years or older. Females experience 1.5- to 3-fold
higher rates than males beginning in early adolescence. In the US, depression affects nearly 17
million adults but these numbers are gross underestimates as many have not even come to
medical attention.
Pathophysiology
The underlying pathophysiology of major depressive disorder has not been clearly defined.
Current evidence points to a complex interaction between neurotransmitter availability and
receptor regulation and sensitivity underlying the affective symptoms.
Clinical and preclinical trials suggest a disturbance in central nervous system serotonin (5-HT)
activity as an important factor. Other neurotransmitters implicated include norepinephrine (NE),
dopamine (DA), glutamate, and brain-derived neurotrophic factor (BDNF).
The role of CNS 5-HT activity in the pathophysiology of major depressive disorder is suggested
by the therapeutic efficacy of selective serotonin reuptake inhibitors (SSRIs). Research findings
imply a role for neuronal receptor regulation, intracellular signaling, and gene expression over
time, in addition to enhanced neurotransmitter availability.
Seasonal affective disorder is a form of major depressive disorder that typically arises during the
fall and winter and resolves during the spring and summer. Studies suggest that seasonal
affective disorder is also mediated by alterations in CNS levels of 5-HT and appears to be
triggered by alterations in circadian rhythm and sunlight exposure.
Vascular lesions may contribute to depression by disrupting the neural networks involved in
emotion regulation—in particular, frontostriatal pathways that link the dorsolateral prefrontal
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cortex, orbitofrontal cortex, anterior cingulate, and dorsal cingulate. Other components of limbic
circuitry, in particular, the hippocampus and amygdala, have been implicated in depression.
1. Sleep disturbance
2. Interest/pleasure reduction
4. Energy changes/fatigue
5. Concentration/attention impairment
6. Appetite/weight changes
7. Psychomotor disturbances
8. Suicidal thoughts
9. Depressed mood
All patients with depression should be evaluated for suicidal risk. Any suicide risk must be given
prompt attention which could include hospitalization or close and frequent monitoring.
1. Past medical history and family medical history, and current medications
2. Social history with a focus on stressors and the use of drugs and alcohol
3. History and physical examination to rule out organic causes of depression. Depressive
symptoms and their severity are also evaluated with the help of questionnaires such as the
Beck's Depression Inventory (BDI), Hamilton Depression Scale (Ham-D), and Zung Self
Rating Depression Scale
Evaluation
The diagnosis of depression is based on history and physical findings. No diagnostic laboratory
tests are available to diagnose major depressive disorder. Laboratory studies are, however, useful
to exclude medical illnesses that may present as major depressive disorder. [6][7][8]These
laboratory studies might include the following:
Vitamin B-12
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HIV test
Computed tomography (CT) scanning or magnetic resonance imaging (MRI) of the brain
should be considered if organic brain syndrome or hypopituitarism is included in the
differential diagnosis
Treatment / Management
Medication alone and brief psychotherapy (cognitive-behavioral therapy, interpersonal therapy)
alone can relieve depressive symptoms. Combination therapy has also been associated with
significantly higher rates of improvement in depressive symptoms; increased quality of life; and
better treatment compliance. There is also empirical support for the ability of CBT to prevent
relapse.[9][10]
Electroconvulsive therapy is useful for patients who are not responding well to medications or
are suicidal.[11][1]
Medications
3. Atypical antidepressants
7. Selective serotonin reuptake inhibitors (SSRIs): SSRIs have the advantage of ease of
dosing and low toxicity in overdose. They are also the first-line medications for late-onset
depression.
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particularly in patients with significant fatigue or pain syndromes associated with the
episode of depression. SNRIs also have an important role as second-line agents in patients
who have not responded to SSRIs.
ECT is a highly effective treatment for depression. Onset of action may be more rapid than that
of drug treatments, with benefit often seen within 1 week of commencing treatment. A course of
ECT (usually up to 12 sessions) is the treatment of choice for patients who do not respond to
drug therapy, are psychotic, or are suicidal or dangerous to themselves. Thus, the indications for
the use of ECT include the following:
Although advances in brief anesthesia and neuromuscular paralysis have improved the safety and
tolerability of ECT, this modality poses numerous risks, including those associated with general
anesthesia, postictal confusion, and, more rarely, short-term memory difficulties.
Psychotherapy
Cognitive Behavior Therapy and Interpersonal Therapy are evidence-based psychotherapies that
have been found to be effective in the treatment of depression.
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CBT is a structured, and didactic form of therapy that focuses on helping individuals identify and
modify maladaptive thinking and behavior patterns (16 to 20 sessions). It is based on the premise
that patients who are depressed exhibit the “cognitive triad” of depression, which includes a
negative view of themselves, the world, and the future. Patients with depression also exhibit
cognitive distortions that help to maintain their negative beliefs. CBT for depression typically
includes behavioral strategies (i.e., activity scheduling), as well as cognitive restructuring to
change negative automatic thoughts and addressing maladaptive schemas.
There is evidence supporting the use of CBT with individuals of all ages. It is also considered
being efficacious for the prevention of relapse. It is particularly valuable for elderly patients, who
may be more prone to problems or side effects with medications.
Differential Diagnosis
Adjustment disorders
Anaemia
Dissociative disorders
Hypoglycemia
Hypopituitarism
Schizoaffective disorders
Schizophrenia
Prognosis
Major depression has very high morbidity and mortality contributing to high rates of suicide.
Even though effective drug treatment is available, nearly 50% may not initially respond.
Complete remission is not common but at least 40% achieve partial remission in 12 months.
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However, relapses are common and many patients require a variety of treatments to control the
symptoms. The quality of life of most patients with depression is poor.
Depression accounts for nearly 40,000 cases of suicide each year in the US. The highest rate of
suicides is in older men.
Education plays an important role in the successful treatment of major depressive disorder. This
would include the education of the family and the patient. Lack of accurate information and
misperceptions of the illness as a personal weakness or failings leads to painful stigmatization
and avoidance of the diagnosis by many of those affected. Patients should know the rationale
behind the choice of treatment, potential adverse effects, and expected results.
The involvement of the pharmacist in the treatment plan can enhance medication compliance and
referral for psychotherapy. The pharmacist can also check that dosing is appropriate, that there
are no significant interactions, and counsel on adverse effects. Engaging family members can be
a critical component of a treatment plan. Family members are helpful informants, can ensure
medication compliance, be a big source of social support and can encourage patients to change
behaviors that perpetuate depression (e.g., inactivity).
Patients with moderate to severe depression should also be seen by a social worker or case
management nurse to ensure that they have a support system and finances for treatment. If there
is a concern, the person managing the case should present the issues to the interprofessional team
so that a plan can be developed to get the patient the care they need. Overall, depression is
managed by an interprofessional team dedicated to the management of mental health disorders.
Open communication between all the members of the interprofessional team is the key to
lowering the morbidity of the disorder. [Leve 5]
Outcomes
The outcomes for patients with depression are guarded. There is no cure and the condition has
frequent relapses and remissions, leading to a poor quality of life.[3][12][13]
Review Questions
References
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2.
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Jun 21, 2022. Provider Burnout. [PubMed: 30855914]
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Lancet Psychiatry. 2019 Jun;6(6):538-546. [PubMed: 30850328]
10. Knappe S, Einsle F, Rummel-Kluge C, Heinz I, Wieder G, Venz J, Schouler-Ocak M,
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30829159]
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[PubMed: 30797709]
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Disclosure: Suma Chand declares no relevant financial relationships with ineligible companies.
Disclosure: Hasan Arif declares no relevant financial relationships with ineligible companies.
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