Professional Documents
Culture Documents
Depression
O P L
OX F O RD P S YC HIATRY LIB RARY
Depression
THIRD EDITION
Raymond W. Lam
Professor and BC Leadership Chair in Depression Research
Department of Psychiatry, University of British Columbia
Vancouver, British Columbia, Canada
1
1
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Preface to the Third Edition
Despite some initial controversy, DSM-5 (Diagnostic and Statistical Manual of
Mental Disorders, 5th edn) has been accepted and adopted by most clinicians as
an incremental advance for the field. This new edition now incorporates DSM-5
as well as recent revisions in treatment guidelines for depression. The CANMAT
206 Clinical Guidelines for the Management of Adults with Major Depressive
Disorder were published as a theme issue in the Canadian Journal of Psychiatry,
and are available for free download at http://www.canmat.org, accessed
October 207. The CANMAT guidelines provide much of the reference material
used to summarize new evidence and recommendations for the dizzying array
of available treatments for depression, ranging from mindfulness-based psycho-
therapies to novel antidepressant medications, to neurostimulation and exercise.
All the key references in this edition have been updated to reflect the latest evi-
dence. I want to thank, again, my CANMAT colleagues (nearly 50 strong) for their
dedicated leadership in producing these internationally used guidelines, especially
my guidelines’ co-lead, Dr Sidney Kennedy. Their efforts contribute to making this
book clinically useful.
Progress usually advances incrementally, but medicine is at the tipping point
for the next great revolution—a digital personalized one. The emergence of
data science with ‘big data’ artificial intelligence and machine learning algorithms
heralds a real promise of precision medicine. Biomarker studies have given way
to biosignature research incorporating panels of integrated clinical, neuroimag-
ing, and molecular markers. Predicting individual response to treatment using
crowdsourced EEG (electroencephalographic) and clinical information; personal-
ized alerts for relapse with apps that analyze voice modulation, text messages,
and geographic location patterns; reprogramming neural circuits with individual-
ized brain games; adapting the lighting at home to optimize sleep and circadian
rhythms—these possibilities are no longer science fiction even if, for now, they
are not yet ready for prime-time clinical use. I have no doubt that this innova-
tive research will soon transform the diagnosis, management, and treatment of
depression. I look forward to incorporating these discoveries in a major rewrite
for the next edition of this book.
. Introduction 1
2. Epidemiology and burden 3
3. Pathogenesis 11
4. Clinical features and diagnosis 23
5. Associated clinical features 35
6. Clinical management 45
7. Psychological treatments 53
8. Pharmacological treatments 63
9. Somatic treatments 85
0. Special populations 95
xii • abbreviations
SAM-e S-adenosylmethionine
SCID Structured Clinical Interview for DSM-IV-TR
SERT serotonin transporter
SGA second-generation antipsychotic
SIGMA structured interview guide for the Montgomery–Åsberg Depression
Rating Scale
SNRI serotonin and noradrenaline reuptake inhibitor
SRI serotonin reuptake inhibitor
SSRI selective serotonin reuptake inhibitor
STAR*D Sequenced Treatment Alternatives to Relieve Depression (study)
SWA slow-wave activity
SWS slow-wave sleep
TADS Treatment for Adolescents with Depression Study
TCA tricyclic antidepressant
TRD treatment-resistant depression
TSD total sleep deprivation
VNS vagus nerve stimulation
WHO World Health Organization
Chapter 1
Introduction
Key points
• Depression is a common and disabling psychiatric condition that must be
recognized by all physicians and health professionals.
• The principles of care for major depressive disorder include: thorough
assessment and diagnosis, selection of appropriate and evidence-based
treatments, and careful follow up using measurement-based care.
A 36 year old janitor who has insomnia and is fatigued all the time. A 24 year old
with diabetes who has stopped taking her insulin. A 40 year old homemaker who
cries and cannot cope at home. A 69 year old seen in the emergency room with
his second heart attack within 3 months. A 32 year old executive who is procras-
tinating about making decisions at work. A 7 year old high-school student who
cannot stop thinking about ending her life. What do all these various people have
in common? They are all suffering from depression, one of the most common of
all medical conditions, yet one of the most difficult to recognize.
Depression is ubiquitous, but the number and range of physical and cognitive
symptoms associated with major depressive disorder (MDD) means that many
people do not present with emotional symptoms. Although one in seven people
will suffer psychosocial impairment from MDD, many will not be diagnosed des-
pite repeated healthcare visits. And, it is not only family physicians, psychiatrists
and mental health clinicians that need to diagnose depression. The high preva-
lence of MDD with other medical illnesses means that other health profession-
als and physicians, whether internists or oncologists or surgeons or cardiologists
or neurologists or any other specialist, must also recognize and manage clinical
depression in their patients. After all, as some authors have noted, there is ‘no
health without mental health’.
Governments and healthcare payers are now finally appreciating the hidden
socioeconomic burden that results from MDD. Depression is a huge drain on
the economy, with exceedingly high rates of disability and reduced productivity.
The World Health Organization announced in 207 that depression had become
the leading medical cause of functional disability worldwide. The concentration,
memory, and decision-making problems associated with depression are particu-
larly damaging to workforces in knowledge-based industries, a major issue for
many countries trying to convert from resource-based economies.
chapter 1
2 • introduction
But, recognizing depression is not enough. The good news is that there are very
effective treatments for depression. Evidence-based psychotherapies abound,
there are many effective antidepressant medications, and several non-invasive
somatic treatments also are available. With appropriate treatment, most patients
are able to promptly recover from a depressive episode and return to their usual
functioning. And, there is an explosion of new research and new methodolo-
gies to expand our understanding of the pathophysiology of depression, with the
promise of new, more effective, and better tolerated treatments to come.
The bad news, however, is that many patients with depression are still not able
to access these treatments, whether psychotherapy or new medications or new
technologies. Even when available, the current systems of health care often do
not achieve best practices for treating MDD, so that the ‘usual care’ of depression
is not good enough. For those patients whose depression can be regarded as a
chronic or persistent condition, collaborative disease management programmes
that include a focus on self-management and functional improvement, instead of
symptom resolution, will further engage patients and clinicians to optimize care.
Mobile and internet technologies also herald promise in terms of access to both
educational information and evidence-based treatments. And, we are getting
closer to identifying clinically useful biomarkers to personalize treatment recom-
mendations for patients with MDD.
This book seeks to succinctly address the diagnostic and treatment issues
that clinicians will encounter when dealing with patients with MDD. The princi-
ples of care for depression can be quite simple. Attention to early recognition,
careful assessment, selection of appropriate evidence-based treatments, and
measurement-based follow up will help our patients get the best care possible.
Further Reading
Lam RW, Kennedy SH, Parikh SV, et al. (206) Canadian Network for Mood and Anxiety
Treatments (CANMAT) 206 Clinical Guidelines for the Management of Adults with
Major Depressive Disorder: Introduction and methods. Can J Psychiatry 61: 506–9.
Prince M, Patel V, Saxena S, et al. (2007) No health without mental health. Lancet
370: 859–77.
Summergrad P (206) Investing in global mental health: the time for action is now. Lancet
Psychiatry 3: 390–.
World Health Organization (207) Depression and Other Common Mental Disorders.
Geneva: WHO Document Production Services.
chapter 1
Chapter 2
2.1 Prevalence
2.. Current trends
Depressive disorders are very common conditions as the lifetime risk for expe-
riencing major depressive disorder (MDD) is approximately 5% (Table 2.).
Depression also contributes significantly to disability, with estimates that depres-
sion accounts for .3–4.4% of all disability and premature deaths worldwide. Two
major epidemiological trends are occurring with respect to depressive disorders.
First, the lifetime risk of developing depression in those born after the Second
World War is increasing, although some studies suggest this increase began as far
back as 925. Second, in both women and men, the age of onset for depression
is becoming increasingly younger, which corresponds to the rise in psychiatric
hospitalizations amongst adolescents.
2..2 Sex
The lifetime prevalence of MDD is .6–3. times more common in women than
men, with a greater disparity found in the USA and Western Europe. The dispar-
ity begins at the age of puberty and it is common to find worsening of depressive
symptoms in women coinciding with the onset of menses. Other hypothesized
causes of increased depressive episodes in women include hormonal differences,
psychosocial stressors, and childbirth. The disparity between the sexes appears
to be narrowing in studies involving younger cohorts, and the gap also decreases
after the age of 50–55 years as women enter menopause.
chapter 2
4 • epidemiology and burden
2..3 Age
In worldwide population samples aged 8–64 years, the average age for the
onset of depression varies from 24 to 35 years, with a mean age of 27 years.
There is currently a trend of an increasingly younger age of depression onset. For
example, 40% of depressed individuals have their first depressive episode prior
to the age of 20, 50% have their first episode between the ages of 20–50, and the
remaining 0% after 50 years of age.
Depressive symptoms also vary with age. Childhood depression tends to involve
more somatic complaints combined with irritability and social withdrawal, and ado-
lescents experience more ‘atypical’ features of depression (e.g. overeating, hyper-
somnia), while elderly depressed patients are most likely to have depressive features
of melancholia (e.g. loss of interest or pleasure, lack of reactivity, insomnia).
chapter 2
epidemiology and burden • 5
symptoms, which can be present for weeks to years prior to diagnosis, include
anxiety and other mild depressive symptoms. The length of an untreated depres-
sive episode varies from 4 to 30 weeks for a mild–moderate depression, while
severe episodes have an average length of 6–8 months. Nearly 25% of individuals
with severe depressive episodes will endure symptoms for more than 2 months.
Treated depressive episodes last on average 3 months; however, stopping anti-
depressants prior to 3 full months of use almost always results in the return of
symptoms.
2.2.2 Prognosis
For many patients, MDD can be a chronic, relapsing illness. Relapse within the
first 6 months of recovery occurs in 25% of patients, 58% will relapse within the
first 5 years, and 85% will relapse within 5 years of initial recovery. Moreover,
those individuals that have had two previous depressive episodes have a 70%
probability of a third, and having three previous depressive episodes incurs a 90%
likelihood of relapse. As the disease progresses, the interval between depressive
episodes becomes shorter and the severity of each episode becomes greater.
Over a 20-year span, depressive recurrences occur on average five to six times.
A significant proportion of depressed individuals remain chronically ill with
varying levels of symptoms. About two-thirds of patients with a major depressive
episode will fully recover, while one-third of depressed patients will either only
partially recover or remain chronically ill. In a study of patients at year post-
MDD diagnosis, 40% had recovered with no symptoms of depression, 20% con-
tinued to have residual symptoms but did not meet the criteria for MDD, while
40% remained in a major depressive episode. Those individuals that continue to
have residual depressive symptoms are at a high risk of relapse, suicide, poor
psychosocial functioning, and higher mortality from other medical conditions.
In addition to depression, 5–0% of individuals who have experienced a major
depressive episode will subsequently have a manic or mixed episode indicative
of bipolar disorder.
Numerous studies have focused on prognostic indicators which have a pre-
dictive value in terms of the recovery rate and relapse probability in depressed
individuals (Box 2.).
chapter 2
6 • epidemiology and burden
Similarly, depressed patients have almost two times greater overall mortality risk
than the general population owing to direct causes (e.g. suicide) and indirect causes
(e.g. medical illness). The risk of death by suicide increases 26-fold in depressed
individuals. However, the lifetime prevalence of suicide for depressed individuals
is 2.2% and suicide represents only % of reported deaths related to depression.
Depressed patients are at a .8 times greater risk of developing a medical
illness year post-diagnosis. In particular, hospitalized depressed patients with
comorbid cardiovascular disease are at a significantly increased risk for myocar-
dial infarct and death for 0 years post-hospitalization. For example, depressed
patients with unstable angina are at a three times greater risk of death than non-
depressed individuals. The increased risk of cardiovascular death likely is due to
both direct physiological effects (e.g. reduced heart rate variability, increased
platelet aggregation) and indirect effects (e.g. poor compliance with medications,
drug and alcohol abuse, etc.) of depression (see Chapter 0).
chapter 2
epidemiology and burden • 7
Major
depression
Iron deficiency
anaemia
Neck pain
Hearing loss
0 20 40 60 80
Mean years lived with disability (x1,000,000)
Figure 2. The Global Burden of Disease Study. In 203, depression ranked second
in total health-related disability worldwide.
treating depression. Studies have also found that employers, on the whole, have
negative beliefs about mental illness and are less likely to hire depressed individu-
als based on expectations of sub-standard work performance. In fact, depressed
individuals have a perceived increase in self-rated productivity when they experi-
ence fewer and less severe depressive symptoms, suggesting that early treatment
of depression would economically benefit employers.
The astounding economic costs of depression are due to a combination of dir-
ect treatment of depression, premature mortality (e.g. by suicide), and reduced
productivity and absenteeism. The total annual costs of depression in the United
States are estimated at US$44 billion: US$2.4 billion in direct costs of treat-
ment (hospitals, medications, doctors’ fees), US$8 billion in premature death,
and US$24 billion in absenteeism and reduced productivity in the workplace. In
Canada, the indirect costs of depression (premature mortality and reduced prod-
uctivity) are estimated at C$5 billion, and represent 58% of the overall economic
cost of depression. These approximations, however, underestimate the overall
cost of depression because they do not include out-of-pocket family expenses,
and costs of minor and untreated depression, excessive hospitalization, general
medical services, and diagnostic tests.
chapter 2
8 • epidemiology and burden
suicide more often than MDD-diagnosed patients. In a U.S. study, patients diag-
nosed with depression recovering from surgery stay on average 0 days longer in
hospital than non-depressed patients. However, those individuals with untreated
depressive symptoms stayed 26 days longer than non-depressed patients. In fact,
individuals with untreated depression account for the majority of ‘high utilizers’
of general medical services. Thus, diagnosing and treating these individuals should
lessen the burden on the medical system.
100
Perceived need for treatment Received any treatment Received adequate treatment
90
80
70
% of people with MDD
60
50
40
30
20
10
0
USA France Germany Spain Brazil* Mexico Bulgaria Iraq China* Columbia Peru
6.7% 5.6% 3.1% 3.8% 10.1% 3.7% 3.0% 3.9% 2.0% 5.3% 2.7%
* Data from individual city surveys for Brazil (Sao Pâulo) and China (Beijing/Shanghai).
Percentages below country label indicate the 12-month prevalence rate of MDD.
Figure 2.2 Proportion of people with MDD who perceived a need for treatment,
received any treatment, and received adequate treatment in the WHO World
Mental Health Survey.
Source data from The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of
Mental Disorders, Kessler R.C and Ustun T.B (eds.), 2008.
chapter 2
epidemiology and burden • 9
scaling up treatment services for depression are considerable, with a global study
estimating a US$5 return on investment for every US$ spent.
Further Reading
Bromet E, Andrade LH, Hwang I, et al. (20) Cross-national epidemiology of DSM-IV
major depressive episode. BMC Medicine 9: 90.
Chesney E, Goodwin GM, Fazel S (204) Risks of all-cause and suicide mortality in mental
disorders: a meta-review. World Psychiatry Rep 13: 53–60.
Chisolm D, Sweeny K, Sheehan P, et al (206) Scaling-up treatment of depression and
anxiety: a global return on investment analysis. Lancet Psychiatry 3: 45–24.
Coventry PA, Hudson JL, Kontopantelis E, et al. (204) Characteristics of effective
collaborative care for treatment of depression: a systematic review and meta-regression
of 74 randomised controlled trials. PLoS One 9: e084.
Donohue JM, Pincus HA (2007) Reducing the societal burden of depression: a review of
economic costs, quality of care and effects of treatment. Pharmacoeconomics 25: 7–24.
Global Burden of Disease Study 203 Collaborators (205) Global, regional, and national
incidence, prevalence, and years lived with disability for 30 acute and chronic diseases
and injuries in 88 countries, 990–203: a systematic analysis for the Global Burden of
Disease Study 203. Lancet 386: 743–800.
Kessler RC (202) The costs of depression. Psychiatr Clin North Am 35: –4.
Lam RW, McIntosh D, Wang JL, et al. (206) Canadian Network for Mood and Anxiety
Treatments (CANMAT) 206 Clinical Guidelines for the Management of Adults with
Major Depressive Disorder: Section . Disease burden and principles of care. Can J
Psychiatry 61: 50–23.
Thornicroft G, Chatterji S, Evans-Lacko S, et al. (207) Undertreatment of people with
major depressive disorder in 2 countries. Br J Psychiatry 210: 9–24.
World Health Organization (207) Depression and Other Common Mental Disorders.
Geneva: WHO Document Production Services.
chapter 2
Chapter 3
Pathogenesis
Key points
• There are likely multiple processes to explain the aetiology and pathophysiology
of depression, with involvement of biological, psychological, and social factors.
• Circadian rhythmicity, stressful life events, and stress reactivity can modify
genetic and biological processes (gene–environment interactions) to contribute
to depression.
• Endophenotypes, or genetic expressions of neural systems involved in
depression, are important in the study of the pathogenesis of depression and
the development of novel treatments.
3.1 Introduction
The exact pathophysiology of major depressive disorder (MDD) remains
unknown, but the aetiology has always been presumed to be heterogeneous
since the diagnosis of MDD is only descriptive and likely consists of a number
of syndromes with related symptoms. Biological, psychological, and social factors
all influence MDD, and each has reciprocal relationships with the others (Figure
3.). New research in genetics, neuroimaging, and molecular biology has clarified
some of the relationships between these broad forces, particularly in the modu-
lation of stress and life events on genetic and neurobiological processes. There is
increasing emphasis on endophenotypes, defined as endogenous phenotypes that
are not evident to the unaided eye that fill the gap between genes and a complex
disease, to advance our classification of depressive disorders and to guide treat-
ment selection (Figures 3.2 and 3.3). This chapter will highlight some of these
recent advances.
3.2 Genetics
3.2. Family, twin, and adoption studies
Family studies indicate at least two or three times increased relative risk (5–25%)
for MDD in first-degree relatives of MDD probands, with early age of onset
and recurrent depression conferring greater risk. Adoption studies, most from
Scandinavia, found that biological relatives of depressed adoptees were much
more likely to have depression than the adoptive relatives. Twin studies, by
comparing monozygotic to dizygotic twins, allow the dissection of genetic from
chapter 3
12 • pathogenesis
Relationships,
Genetics Personality
Work/Leisure
Circadian
Rhythms
Neurohormones,
Neurochemicals,
Person
with depression
Neuroinflammation
Figure 3. Relationships between biological, psychological, and social factors in the
pathophysiology of depression.
chapter 3
pathogenesis • 13
Major depression
Increased stress
Depressed mood sensitivity (Gender
(Mood bias toward specific)
negative emotions)
Anhedonia
Impaired learning
(Impaired reward
and memory
Stress function)
Stress
Increased amygdala
activity/decreased Reduced Reduced Decreased
amygdala volume hippocampal ACC subgenual PFC
volume volume activity
CREB
events, suggesting that this transporter gene modifies stress reactivity rather
than causing MDD, per se. Other candidate genes being investigated in MDD
include tryptophan hydroxylase-2, brain-derived neurotrophic factor (BDNF),
cAMP-responsive element-binding protein (CREB)-, and genes involved in the
circadian clock.
3.3 Neurobiology
3.3. Monoamines
The monoamine hypothesis has been the foundation of neurobiological theories
for depression for the past half century. Initially based upon observations of the
mechanism of action of antidepressants, this hypothesis postulates that depres-
sion results from deficits in key brain areas in serotonin (5-HT) or noradrenaline
synaptic neurotransmission. Antidepressants were thought to act by blocking the
chapter 3
14 • pathogenesis
chapter 3
pathogenesis • 15
chapter 3
16 • pathogenesis
Figure 3.5 Mechanisms for cellular plasticity and neurogenesis and therapeutic effects
of standard and novel antidepressants. Abbreviations: α2AR, α2 adrenergic recep-
tor; 5-HT, serotonin; AC, adenyl cyclase; AMPAR, α-amino-3-hydroxy-5-methyl-4-
isoxazole propionic acid (AMPA) receptor; Bcl-2, B-cell lymphoma 2 protein; BDNF,
brain-derived neurotrophic factor; cAMP, cyclic adenosine monophosphate; CREB,
cAMP response element binding; CRH, corticotropin-releasing hormone; GC, gluco-
corticoids; Glu, glutamate; GR, glucocorticoid receptor; HPA, hypothalamic pituit-
ary adrenal; MAPK, mitogen-activated protein kinase; NE, norepinephrine; NMDAR,
N-methyl-D-aspartate (NMDA) receptor; PKA, protein kinase A; TrkB, receptor
tyrosine kinase B.
This figure depicts the multiple targets by which neuroplasticity and cellular resilience can be increased in
mood disorders. (a) Phosphodiesterase inhibitors increase the levels of pCREB; (b) MAP kinase modula-
tors increase the expression of the major neurotrophic protein Bcl-2; (c) mGluR II/III agonists modu-
late the release of excessive levels of glutamate; (d) drugs such as lamotrigine and riluzole act on Na+
channels to attenuate glutamate release; (e) AMPA potentiators upregulate the expression of BDNF;
(f ) NMDA antagonists like ketamine and memantine enhance plasticity and cell survival; (g) novel drugs
to enhance glial release of trophic factors and clear excessive glutamate may have utility for the treatment
of depressive disorders; (h) CRF antagonists and (i) glucocorticoid antagonists attenuate the deleterious
effects of hypercortisolemia, and CRF antagonists may exert other beneficial effects in the treatment of
depression via non-HPA mechanisms; (j) agents which upregulate Bcl-2 (e.g., pramipexole, shown to be
effective in bipolar depression). These distinct pathways have convergent effects on cellular processes
such as bioenergetics (energy metabolism), neuroplasticity, neurogenesis, resilience, and survival.
Adapted from: Mathew SJ, Manji HK, Charney DS. Novel drugs and therapeutic targets for severe mood
disorders. Neuropsychopharmacology 2008; 33:2080–2092.
chapter 3
pathogenesis • 17
Other molecular biology studies have shifted attention from immediate pre-or
postsynaptic events to delayed post-receptor signalling pathways in the mech-
anism of action of antidepressants. The activation of postsynaptic receptors
initiates a cascade of biochemical effects mediating signal transduction, involv-
ing G-protein-coupled stimulation of cAMP (cyclic adenosine monophosphate)
or Ca2+ cascades. Activation of CREB results in increased expression of BDNF,
which acts to promote neurogenesis and cellular plasticity, and which may account
for the therapeutic effects of antidepressants. These neuroplasticity and cellular
resilience pathways provide novel targets for antidepressant drug development
(Figure 3.5).
chapter 3
18 • pathogenesis
3.4 Neuropsychology
3.4. Cognition and memory
Patients with depression demonstrate a number of cognitive and memory defi-
cits, especially in selective attention and explicit (working) memory. In addition,
chapter 3
pathogenesis • 19
Behaviour Environment Biology Disorder
Photic Sleep
zeitgebers functioning
Rhythmic Depressive
social symptoms
behavior
Non-photic Circadian
zeitgebers functioning
Predisposition/
genetics
chapter 3
20 • pathogenesis
DL PFC
Dorsal ACC
Figure 3.7 Limbic- cortical dysregulation model. Regions in light shading indi-
cate overactivity and regions in dark shading indicate underactivity. Abbreviations:
ACC, anterior cingulate cortex; DL, dorsolaeral; N, nucleus; OM, orbitomedial;
PFC, prefrontal cortex; SCC (Cg25), subcallosal (subgenual) cingulate cortex; VM,
ventromedial.
chapter 3
pathogenesis • 21
can affect biological systems of interest in depression. For example, animal stud-
ies have shown that early maternal deprivation leads to hypersensitivity of the
HPA axis in adulthood, with decreased hippocampal cell proliferation similar to
the reduced hippocampal volumes found in neuroimaging studies of patients with
depression and childhood trauma. This may have implications for treatment, as
studies have shown that patients with MDD and a history of early childhood
maltreatment have poorer outcomes in general, and better responses to psycho-
therapy than to antidepressant monotherapy.
Twin studies have shown an interaction between genetic risk and life events for
developing depression. However, not all stressful life events precipitate depres-
sion, and certain depressive episodes are not associated with stressors. A gene-
by-environment (G×E) interaction hypothesis, in which genetic vulnerability
influences the likelihood that exposure to stress will result in psychopathology,
may explain this discrepancy (Figure 3.8). Stressful life events have been shown
Normal
Level of Functioning
Impaired
Low High
Environmental stress
chapter 3
22 • pathogenesis
to have no effect on risk of developing a depression in women with the lowest
genetic vulnerability, but life events had increasing effects on depression risk in
those with increasing genetic loading for depression. These findings suggest that
environmental events, even those that happened in the past, can alter neurobio-
logical function for a long time.
The biological effects of early childhood adversity and life stressors may also
be mediated via epigenetic mechanisms, which involve functional modifications of
the genome that are influenced by environmental factors. MicroRNAs, small units
of non-coding RNA that help regulate gene function by influencing the translation
of target mRNAs, are also emerging targets for antidepressant drug discovery.
Further Reading
Abdallah CG, Sanacora G, Duman RS, et al. (205) Ketamine and rapid-acting
antidepressants: a window into a new neurobiology for mood disorder therapeutics.
Annu Rev Med 66: 505–23.
Cai S, Huang S, Hao W (205) New hypothesis and treatment targets of depression: an
integrated view of key findings. Neurosci Bull 31: 6–74.
Goldstein BL, Klein DN (204) A review of selected candidate endophenotypes for
depression. Clin Psychol Rev 34: 47–27.
Gudayol-Ferré E, Peró-Cebollero M, González-Garrido AA, et al. (205) Changes in
brain connectivity related to the treatment of depression measured through fMRI: a
systematic review. Front Hum Neurosci 9: 582.
Harvey AG (20) Sleep and circadian functioning: critical mechanisms in the mood
disorders? Annu Rev Clin Psychol 7: 297–39.
Hasler G, Drevets WC, Manji HK, et al. (2004) Discovering endophenotypes for
depression. Neuropsychopharmacology 29: 765–8.
Hasler G, Northoff G (20) Discovering imaging endophenotypes for major depression.
Mol Psychiatry 16: 604–9.
Kupfer DJ, Frank E, Phillips ML (202) Major depressive disorder: new clinical,
neurobiological and treatment perspectives. Lancet 379: 045–55.
Nugent NR, Tyrka AR, Carpenter LL, et al. (20) Gene–environment interactions: early
life stress and risk for depressive and anxiety disorders. Psychopharmacology
214: 75–96.
Rosenblat C, McIntyre RS, Alves GS, et al. (205) Beyond monoamines–novel targets
for treatment-resistant depression: A comprehensive review. Curr Neuropharmacol
13: 636–55.
Taylor C, Fricker AD, Devi LA, et al. (2005) Mechanisms of action of
antidepressants: from neurotransmitter systems to signaling pathways. Cell Sig
17: 549–57.
Wohleb ES, Franklin T, Iwata M, et al. (206) Integrating neuroimmune systems in the
neurobiology of depression. Nat Rev Neurosci 17: 497–5.
chapter 3
Chapter 4
4..2 Symptoms
Low mood: While depressed people describe feelings of low mood, the emo-
tional misery experienced during a depression is qualitatively different from nor-
mal periods of sadness or grief that everyone experiences. Some have crying
spells, or feel like crying, while others describe a complete lack of emotional
response.
Interest/Pleasure: Loss of interest and pleasure (anhedonia) in activities or
social interactions which previously were pleasurable is another cardinal feature
of depression. Anhedonia also may show as indifference or boredom, and can be
present even when the person does not endorse low mood. Loss of sexual inter-
est, desire, or functioning is also common, which can lead to difficulty in intimate
relationships and marital conflict.
Sleep: Most depressed patients experience sleeping difficulties. The classic
presentation is waking from sleep early in the morning and being unable to fall
asleep again (terminal insomnia), but restless sleep and frequent waking during
the night (middle insomnia) are also common. Difficulty falling asleep at the begin-
ning of the night (early insomnia) is usually seen when anxiety also is present.
chapter 4
24 • clinical features and diagnosis
chapter 4
clinical features and diagnosis • 25
Psychomotor activity: Psychomotor changes, which are subjective changes
in motor function without objective abnormalities on testing, are commonly seen
in depression. Psychomotor retardation consists of slowing (slowed body move-
ments, lack of facial expression, long latency of speech response) which, at its
extreme, can manifest as mute or catatonic presentations. Anxiety can also present
as psychomotor agitation (talking quickly, pacing, restlessness, inability to sit still).
Racing thoughts may be a symptom of mania, but is also a descriptor for anxiety.
Suicide: Some type of suicidal ideation, ranging from fleeting thoughts of wishing
everything would end to elaborate plans for suicide, is present in nearly two-thirds
of people with depression. Even when suicidal thoughts are serious, depressed
patients often lack the energy and motivation to attempt suicide. However, suicide
remains a significant issue as 0–5% of hospitalized depressed individuals eventu-
ally die by suicide. A period of high risk for suicide is during initial treatment, when
energy and motivation may improve before the cognitive symptoms (e.g. hope-
lessness), making it possible for suicidal patients to act on their thoughts and plans.
Other symptoms: Although not formally indicated as criteria for the diagno-
sis, a number of other symptoms and signs, including anxiety, irritability, cognitive
dysfunction, and pain, are associated with depression. These are discussed fur-
ther in Chapter 5.
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26 • clinical features and diagnosis
MDD is identified as either single episode or recurrent, with the latter consist-
ing of two or more major depressive episodes with a remission interval of at
least 2 months. MDD can also be ‘sub-typed’ according to several specifiers and
by severity; these sub-types can be used to differentiate presentations of depres-
sion that have implications for recognition (distinctive symptoms or pattern),
prognosis, or treatment selection.
chapter 4
clinical features and diagnosis • 27
Source data from American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition DSM-5, 203, American Psychiatric Association
4.3.2 Severity
Both the DSM-5 and the ICD-0 categorize three separate levels of sever-
ity for MDD: mild, moderate, and severe (Table 4.3). The DSM-5 distinguishes
the severity based on the number and severity of symptoms and the extent of
chapter 4
28 • clinical features and diagnosis
Source data from American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition DSM-5, 203, American Psychiatric Association
chapter 4
clinical features and diagnosis • 29
chapter 4
30 • clinical features and diagnosis
chapter 4
clinical features and diagnosis • 31
such as loss of a job. Instead, the severity and duration of symptoms and their
impact on psychosocial functioning can help distinguish between grief and MDD
(Table 4.4).
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32 • clinical features and diagnosis
carefully rule out bipolarity when diagnosing MDD. In fact, 5–0% of individuals
that experience a major depressive episode will have a manic or hypomanic epi-
sode in their lifetime. Depressive symptoms that suggest bipolarity include racing
thoughts, psychotic symptoms, atypical features (hypersomnia, overeating), early
chapter 4
clinical features and diagnosis • 33
Further Reading
American Psychiatric Association (203) Diagnostic and Statistical Manual of Mental
Disorders, 5th edn. Washington, DC: American Psychiatric Press.
Cuthbert BN (204) The RDoC framework: facilitating transition from ICD/DSM to
dimensional approaches that integrate neuroscience and psychopathology. World
Psychiatry 13: 28–35.
Hirschfeld RM, Williams JB, Spitzer RL, et al. (2000) Development and validation of a
screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire.
Am J Psychiatry 157: 873–5.
Lam RW, McIntosh D, Wang JL, et al. (206) Canadian Network for Mood and Anxiety
Treatments (CANMAT) 206 Clinical Guidelines for the Management of Adults with
Major Depressive Disorder: Section . Disease burden and principles of care. Can J
Psychiatry 61: 50–23.
Rackley S, Bostwick JM (202) Depression in medically ill patients. Psychiatr Clin North Am
35: 23–47.
Weber AN, Michail M, Thompson A, et al. (207) Psychiatric emergencies: Assessing and
managing suicidal ideation. Med Clin North Am 10: 553–7.
chapter 4
34 • clinical features and diagnosis
World Health Organization (2005) International Statistical Classification of Diseases
and Health Related Problems (The) ICD-0 Second Edition. Geneva: World Health
Organization.
Yatham LN, Kennedy SH, Parikh SV, et al. (203) Canadian Network for Mood and
Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD)
collaborative update of CANMAT guidelines for the management of patients with
bipolar disorder: update 203. Bipolar Disord 15: –44.
Zigmond AS, Snaith RP (983) The Hospital Anxiety and Depression Scale. Acta Psychiatr
Scand 67: 36–70.
chapter 4
Chapter 5
5.2 Anxiety
5.2. Anxiety and depression
Anxiety is a ubiquitous symptom in psychiatric disorders, but there is a very close
relationship between depression and anxiety. Indeed, 60–90% of patients with
MDD experience prominent symptoms of anxiety (e.g. excessive worry, tension,
and somatic symptoms) during a depressive episode, and DSM-5 (Diagnostic and
Statistical Manual of Mental Disorders, 5th edn) now includes the episode specifier
‘with anxious distress’ to recognize the importance of assessing anxiety. Many
studies have shown that the presence of significant anxiety is associated with
increased severity of depression, greater functional and psychosocial impairment,
higher suicide risk, and poorer responses to treatment.
Anxiety has both emotional and somatic components. Descriptors of anxiety
include: nervous, stressed, worried, tense, apprehensive, edgy, restless, jittery, on
chapter 5
36 • associated clinical features
edge, jumpy, uneasy, fearful, and panicky. Somatic features can involve multiple
systems, including cardiovascular (chest pain, rapid heartbeat, palpitations, heart
pounding), respiratory (shortness of breath, gasping, hyperventilating), gastro-
intestinal (dry mouth, heartburn, gas, diarrhoea, constipation), musculoskeletal
(stiffness, cramps, twitching), and central nervous system (headaches, tremor, diz-
ziness). Generalized forms of anxiety should be distinguished from phobic anxiety
and panic attacks.
In addition to anxiety as a symptom, anxiety disorders (especially generalized
anxiety disorder, panic disorder, and social anxiety disorder) are also frequently
comorbid with depression. The symptom and functional outcomes are poorer,
and suicide and relapse rates higher, for people with comorbid depressive and
anxiety disorders.
chapter 5
associated clinical features • 37
chapter 5
38 • associated clinical features
and pressured thinking and speech. In borderline personality disorder, anger is a
chronic, lifelong symptom, not limited to distinct episodes.
In the management of depressed patients with irritability and anger, assess-
ment must include an evaluation of potential aggression and violence against
self and others. Effective treatments for depression appear to also treat irrit-
ability and anger. As with anxiety, when irritability is a prominent symptom, it
is important to monitor for increased agitation and suicidality with initiation of
antidepressants.
chapter 5
associated clinical features • 39
Objective cognitive dysfunction, however, may not be well correlated with sub-
jective complaints, which can be confounded by the negative cognitive bias seen in
depression. Cognitive deficits in depression appear to be less prevalent and less
severe, whether in acute phase or in remission phase, than in schizophrenia or bipo-
lar disorder. People with depression can have severe global cognitive problems,
focal deficits in specific cognitive domains, or no cognitive dysfunction. Cognitive
deficits in one or more domains can be identified in 20–60% of depressed patients,
depending on the population studied and the definition of deficit. Cognitive dys-
function can be demonstrated in first-episode depression, but certain subsets of
depressed patients have higher risk of cognitive deficits, including those with psych-
otic features, those with chronic or severe depression, and those of older age.
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40 • associated clinical features
Deficits in cognition and memory would be expected to play a major role
in functional impairment, whether at work or at home. In particular, executive
dysfunction has great impact on quality of life and functionality since executive
functions control many aspects of our daily lives, such as problem-solving and
decision-making. Cognitive deficits would also affect the ability to cope, make it
more difficult to adhere to treatment, and increase the risk of relapse.
chapter 5
associated clinical features • 41
5.5 Pain
5.5. Pain and depression
Pain commonly accompanies depression. Depression can magnify painful
symptoms, including headaches, muscle aches, and back pain. Chronic pain
conditions may also precipitate and exacerbate depression, and some pain
conditions (e.g. fibromyalgia) are commonly associated with depressive
disorders.
There is much evidence for cognitive and neural modulation of pain, and
several specific brain structures that are implicated in the pathophysiology
of depression are also involved in pain. For example, the anterior cingulate
cortex, insular cortex, thalamus, nucleus accumbens, and hippocampus are all
involved in pain processing, especially the affective response to pain. In add-
ition, depression and pain share a common dysfunction of neurotransmitter
systems involving both serotonergic and noradrenergic mechanisms, with sig-
nificant cross-talk between systems. Hence, it is not surprising that pathological
changes in neurotransmitters and neurocircuitry in one condition would affect
another.
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42 • associated clinical features
Further Reading
Beblo T, Sinnamon G, Baune BT (20) Specifying the neuropsychology of affective
disorders: Clinical, demographic and neurobiological factors. Neuropsychol Rev
21: 337–59.
Fava M, Ball S, Nelson JC, et al. (204) Clinical relevance of fatigue as a residual symptom
in major depressive disorder. Depress Anxiety 31: 250–7.
Jaracz J, Gattner K, Jaracz K, et al. (206) Unexplained painful physical symptoms in
patients with major depressive disorder: Prevalence, pathophysiology and management.
CNS Drugs 30: 293–304.
Lam RW, McIntosh D, Wang JL, et al. (206) Canadian Network for Mood and Anxiety
Treatments (CANMAT) 206 Clinical Guidelines for the Management of Adults with
Major Depressive Disorder: Section . Disease burden and principles of care. Can J
Psychiatry 61: 50–23.
McIntyre RS, Xiao HX, Syeda K, et al. (205) The prevalence, measurement, and
treatment of the cognitive dimension/domain in major depressive disorder. CNS Drugs
29: 577–89.
Painuly N, Sharan P, Mattoo SK (2005) Relationship of anger and anger attacks with
depression: A brief review. Eur Arch Psychiatry Clin Neurosci 255: 25–22.
chapter 5
associated clinical features • 43
Robinson MJ, Edwards SE, Iyengar S, et al. (2009) Depression and pain. Front Biosci
14: 503–5.
Roiser JP, Elliot R, Sahakian BJ (202) Cognitive mechanisms of treatment in depression.
Neuropsychopharmacology 37: 7–36.
Schaffer A, McIntosh D, Goldstein BI, et al. (202) The CANMAT task force
recommendations for the management of patients with mood disorders and comorbid
anxiety disorders. Ann Clin Psychiatry 24: 6–22.
chapter 5
Chapter 6
Clinical management
Key points
• Clinical management of depression includes screening, assessment, developing
a therapeutic alliance, selecting treatment(s), monitoring, and follow up.
• The treatment of depression has two phases: the acute phase to achieve full
remission of symptoms, and the maintenance phase to prevent relapse and
recurrence.
• Self-management is an important component of disease management
programmes for depression.
6.1 Introduction
Clinical management for patients with depression involves following general
principles of care: careful assessment, developing a therapeutic alliance, select-
ing evidence-based treatments, monitoring outcomes, and following up appro-
priately. Understanding that treatment of depression has two phases, acute and
maintenance, will ensure that patients not only get well, but stay well. For many
patients, depression can be considered a recurrent and/or chronic illness, so fol-
lowing principles of chronic disease management (CDM) will also help improve
outcomes. CDM, which is widely used for medical conditions such as diabetes
and arthritis, includes elements of screening, self- management, monitoring,
collaborative care, and rehabilitation. CDM also incorporates the concept of
‘stepped care’, progressing first from lower intensity and lower cost treatments
in milder, less complicated cases, to more intensive and expensive treatments in
more severe and/or refractory cases.
6.2 Assessment
6.2. Screening
Depression is not easily diagnosed, especially in primary care settings, because
often the presenting complaint is physical (e.g. body aches, fatigue, insomnia).
Some depressed individuals are unaware of sad mood, or are feeling lack of emo-
tion. In these cases, asking about loss of interest or pleasure can be diagnostic.
People with high-risk factors should be screened for a depressive illness (Box 6.).
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46 • clinical management
Box 6. Patients with the following factors are at high risk for major
depressive disorder and should be screened
• Chronic pain
• Chronic physical illness (diabetes, heart disease, etc.)
• Unexplained somatic symptoms
• Frequent visits to primary care setting
• Postpartum state
• Recent psychosocial stressors
If these risk factors are present, a two-question ‘quick screening tool’ can be
used. An answer of ‘Yes’ to either question indicates that a more detailed assess-
ment is required.
) In the last month, have you been bothered by little interest or pleasure in
doing things?
2) In the last month, have you been feeling down, depressed, or hopeless?
chapter 6
clinical management • 47
chapter 6
48 • clinical management
self-rated ((QIDS-SR), used in the STAR*D (Sequenced Treatment Alternatives
to Relieve Depression) study; see Chapter 0). Some of these rating scales are
described in the Appendix.
Clinical response is often defined as a 50% or greater reduction from base-
line in depression rating scale scores, which indicates substantial and meaningful
improvement. However, despite this clinical improvement, patients may be left
with residual symptoms of depression. Many studies have shown that residual
symptoms are associated with poorer outcomes, including higher risks of relapse,
chronicity, suicide, and poor social and occupational functioning. Therefore, the
target for treatment should be remission of symptoms, which is defined as a rat-
ing scale score within the normal, not depressed, range (e.g. MADRS score ≤0,
HAM-D score ≤7, QIDS-SR ≤5).
While attention to symptoms is essential, more important to patients are out-
comes such as quality of life and functionality. Interestingly, there is only a moder-
ate correspondence between symptoms and functioning, so separate assessment
of social and occupational functioning should be conducted alongside symptom
assessment. Simple patient-rated scales such as the Sheehan Disability Scale and
the Lam Employment Absence and Productivity Scale (LEAPS) can be helpful in
clinical settings (see Appendix).
Empowering patients to participate in measurement-based care can also help
with self-efficacy and strengthen the therapeutic alliance. This can be done via
websites such as http://www.MoodFx.ca, accessed October 207, which
allows patients free access to screen, assess, and track their moods and other out-
comes (e.g. quality of life and side-effect burden) using brief, validated self-rated
questionnaires (e.g. PHQ-9, LEAPS). Patients can print their results to show their
clinician and can subscribe to weekly self-management tips for their depression.
chapter 6
clinical management • 49
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50 • clinical management
6.4.4 Follow up
Health service studies show that, in primary care settings, an average of three
office visits take place in the first 6 months after a diagnosis of depression is
made. This is not considered adequate follow up for depression management,
and may be a factor in less than optimal outcomes associated with depression
treatment in ‘usual care’. It is especially important to monitor more frequently in
the first weeks of treatment, as this is a period with higher suicide risk, challenges
to adherence, and potential clinical worsening. Follow-up visits may be brief (or
even conducted via telephone or videoconference), but the recommended min
imum frequency is weekly for the first 4 weeks, then monthly for 6 months, then
every 3 months, as needed.
chapter 6
clinical management • 51
Mobile health (mHealth) via smartphones and tablet devices is also gaining
traction, with many mobile applications (apps) now available to screen and track
symptoms and to deliver information and psychological treatments (e.g. self-
management). At this time, most apps have not been rigorously evaluated, and
given the rapid changes in this field, recommendations are not listed.
Further Reading
Archer J, Bower P, Gilbody S, et al. (202) Collaborative care for depression and anxiety
problems. Cochrane Database Syst Rev 10: CD006525.
Cozine EW, Wilkinson JM (206) Depression screening, diagnosis, and treatment across
the lifespan. Prim Care 43: 229–43.
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52 • clinical management
Guo T, Xiang YT, Xiao L, et al. (205) Measurement-based care versus standard care
for major depression: A randomized controlled trial with blind raters. Am J Psychiatry
172: 004–3.
IsHak WW, Greenberg JM, Balayan K, et al. (20) Quality of life: The ultimate outcome
measure of interventions in major depressive disorder. Harv Rev Psychiatry 19: 229–39.
Kupfer DJ, Frank E, Phillips ML (202) Major depressive disorder: New clinical,
neurobiological and treatment perspectives. Lancet 379: 045–55.
Lam RW, Filteau MJ, Milev R (20) Clinical effectiveness: The importance of psychosocial
functioning outcomes. J Affect Disord 132(Suppl ): S9–S3.
Lam RW, McIntosh D, Wang JL, et al. (206) Canadian Network for Mood and Anxiety
Treatments (CANMAT) 206 Clinical Guidelines for the Management of Adults with
Major Depressive Disorder: Section . Disease burden and principles of care. Can J
Psychiatry 61: 50–23.
Lam RW, Michalak EE, Swinson RP (2005) Assessment Scales in Depression, Mania and
Anxiety. London: Taylor and Francis.
Trivedi MH (203) Evaluating and monitoring treatment response in depression using
measurement-based assessment and rating scales. J Clin Psychiatry 74: e4.
Van Ameringen M, Turna J, Khalesi Z, et al. (207) There is an app for that! The current
state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder,
posttraumatic stress disorder, anxiety and mood disorders. Depress Anxiety 34: 526–39.
chapter 6
Chapter 7
Psychological treatments
Key points
• Evidenced-based psychological treatments for depression include problem-
solving therapy, behavioural activation, cognitive–behavioural therapy,
interpersonal psychotherapy, and the cognitive behavioural-analysis system of
psychotherapy.
• For mild-to-moderate severity of depression, evidence-based psychological
treatments are first-line treatments and are as effective as pharmacotherapy.
• For more severe, chronic, or comorbid depressions, combined treatment with
psychotherapy and pharmacotherapy is indicated.
• Mindfulness-based cognitive therapy, developed as a maintenance treatment,
also has benefit in acute depressive episodes.
7.1 Introduction
7.. Efficacy
Evidenced-based psychological treatments are those which have shown empirical
evidence of efficacy in randomized controlled trials (RCTs) in defined populations
of patients with major depressive disorder (MDD). Table 7. lists the evidence-
based psychotherapies and their key features. Although these psychotherapies
have different principles, areas of focus, and techniques, they also share many
common elements, including their short-term nature, active participation by both
therapist and patient, and use of pragmatic strategies. Other psychotherapies
(e.g. long-term or brief psychodynamic psychotherapy) may also be effective but
have been less systematically studied in MDD, and so are considered second-or
third-line recommendations.
Many therapists in the community use an assortment of techniques from dif-
ferent types of psychotherapy in what is sometimes termed ‘eclectic psychother-
apy’. However, some evidence suggests that the more experienced the therapist,
and the greater the integrity of the therapist to the structure of a particular psy-
chotherapy, the better is the outcome. Access to evidence-based psychothera-
pies remains a major problem for patients, as the availability of qualified therapists
is limited, and psychotherapy is often not funded by public health systems.
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54 • psychological treatments
chapter 7
psychological treatments • 55
equally well in MDD. There is also little information about clinical factors
that might predict better outcomes with a specific psychotherapy. In one of
the few large trials comparing cognitive therapy (CT) and IPT, the predictive
factors found for response were counter-intuitive––namely, that patients did
better with CT when they had fewer negative cognitions, while patients did
better with IPT when they had less social impairment. Several studies have
shown that investigator allegiance to a particular psychotherapy also influ-
ences outcomes.
chapter 7
56 • psychological treatments
chapter 7
psychological treatments • 57
vulnerability to further depression, while medications appear to provide only
symptomatic relief. It is unclear whether this is due to compensatory mechanisms
(e.g. learning new ways to adapt to depressive symptomatology) or whether
there is a fundamental change in the processes that are causal for depression (e.g.
changing negative cognitive schemas).
chapter 7
58 • psychological treatments
chapter 7
psychological treatments • 59
remission rates compared to less than 50% for the monotherapies). Therefore,
patients are encouraged to use pharmacotherapy as they undergo CBASP.
chapter 7
60 • psychological treatments
many patients, although again the effect sizes may be somewhat smaller than with
in-person psychotherapy. While they may not help everyone with depression, the
use of these technologies will no doubt make psychotherapy accessible to many
more people and will help to stream those who need more intensive treatment
to the appropriate services.
chapter 7
psychological treatments • 61
Further Reading
Barth J, Munder T, Gerger H, et al. (203) Comparative efficacy of seven
psychotherapeutic interventions for patients with depression: A network meta-analysis.
PLoS Med 10: e00454.
Beck AT, Rush AJ, Shaw BF, et al. (979) Cognitive Therapy of Depression.
New York: Guilford Press.
Chiesa A, Serretti A (20) Mindfulness based cognitive therapy for psychiatric
disorders: A systematic review and meta-analysis. Psychiatry Res 187: 44–53.
Ekers D, Webster L, Van Straten A, et al. (204) Behavioural activation for depression; an
update of meta-analysis of effectiveness and sub group analysis. PLoS One 9: e0000.
Gratzer D, Khalid-Khan F (206) Internet-delivered cognitive behavioural therapy in the
treatment of psychiatric illness. CMAJ 188: 263–72.
McCullough JP (2000) Treatment for Chronic Depression: Cognitive behavioral analysis system
of psychotherapy (CBASP). New York: Guilford Press.
Parikh SV, Quilty L, Ravitz P, et al. (206) Canadian Network for Mood and Anxiety
Treatments (CANMAT) 206 guidelines for the management of major depressive
disorder in adults. Section 2. Psychological treatments. Can J Psychiatry 61: 524–39.
Segal ZV, Walsh KM (206) Mindfulness-based cognitive therapy for residual depressive
symptoms and relapse prophylaxis. Curr Opin Psychiatry 29: 7–2.
Weissman MM, Markowitz JC, Klerman GL (2000) A Comprehensive Guide to Interpersonal
Psychotherapy. New York: Basic Books.
chapter 7
Chapter 8
Pharmacological treatments
Key points
• The newer antidepressants (SSRIs, SNRIs, other agents) are first-line
medications owing to improved safety and tolerability over first-generation
medications (TCAs, MAOIs).
• Selection of an antidepressant must be personalized to an individual patient and
must take into account efficacy, side-effect profile, safety, specific symptoms,
comorbid conditions, concurrent medications, simplicity of use, and cost.
• Switching antidepressants must take into account side effects, discontinuation
effects, potential drug interactions, and rapidity of switch.
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64 • pharmacological treatments
chapter 8
pharmacological treatments • 65
clinically relevant, differences between two active drugs than to find the larger
differences between drug and placebo. Statistical calculations show that a rand-
omized controlled trial (RCT) requires over 400 patients in each group to dem-
onstrate a 0% difference in efficacy between two active drugs; there are no
antidepressant studies with those sample sizes. Consequently, there is increas-
ing use of meta-analysis, a statistical technique to combine results from studies
involving smaller samples, to investigate comparative efficacy. There are several
limitations to this approach. For example, establishing equivalent doses among
the different medications is difficult. Some of these meta-analyses group together
classes of medications (e.g. SSRIs), but this may not be appropriate since it is not
clear whether all these medications, even within the SSRI class, have the same
efficacy profile (e.g. non-response to one SSRI does not predict non-response to
another, and vice versa).
With these limitations in mind, there is reasonable evidence from meta-analyses
that venlafaxine, particularly at higher doses, has a greater likelihood of producing
remission than SSRIs. Meta-analyses have consistently shown 7–0% superiority
in remission rates for venlafaxine compared to those for SSRIs (primarily fluoxet-
ine), leading to a ‘number needed to treat’ (NNT) of 0–2 (i.e. need to treat ten
patients with venlafaxine to achieve one more remission than treating with an SSRI;
or, for every 00 patients treated with venlafaxine, ten more will go into remission
than with SSRIs). The superiority of venlafaxine has not been shown against other
agents such as bupropion, duloxetine, escitalopram, or mirtazapine. Meta-analyses
also show that escitalopram is consistently superior to citalopram and other SSRIs,
with an effect size and NNT similar to those of venlafaxine/SSRI comparisons
(i.e. for every 00 patients treated with escitalopram, more will go into remis-
sion than with citalopram). Other antidepressants with some evidence to support
superior efficacy include agomelatine, duloxetine, mirtazapine, and sertraline.
In the subpopulation of patients with more severe illness (and its proxy, hos-
pitalized patient samples), the TCA clomipramine was found to be superior to
SSRIs and moclobemide. Meta-analyses show that the clomipramine results do
not extend to other TCAs such as amitriptyline and imipramine. In prospective
head-to-head RCTs, escitalopram also shows superiority to citalopram and par-
oxetine in severe depression.
8.3 Safety
The newer antidepressants have superseded TCAs and MAOIs in clinical use
because of their superior tolerability and safety profile. The absence of cardio-
vascular side effects makes SSRIs and other new agents much safer in both over-
dose and in potential drug interactions. However, there has been increasing public
and professional attention regarding the possibility that antidepressants, particu-
larly SSRIs and other second-generation agents, may worsen suicidal ideation and
behaviours. While this issue was first raised in the paediatric trials (see Chapter 0),
suicidality with antidepressants has also been queried in adult populations.
chapter 8
66 • pharmacological treatments
Reviews of meta-analyses and large-sample naturalistic database studies, how-
ever, do not show evidence of any excess suicidality associated with specific anti-
depressants in adult populations. In fact, analysis of suicide items on depression
rating scales shows marked improvement in suicidal ideas with antidepressant
treatment, especially in older age samples. Pharmacoepidemiology studies also
have shown decreasing suicide rates associated with increasing rates of anti-
depressant prescriptions. However, overdose with venlafaxine carries a greater
risk for death than overdose with SSRIs, but not as great a risk as with TCAs.
In summary, unlike the youth age group (see Chapter 0), in adults there is no
evidence that antidepressants cause an increase in suicidality overall, and in older
age groups these medications show protective effects on suicidality. Regardless,
it is certainly possible that antidepressants can worsen suicidality in a small subset
of patients, perhaps by worsening anxiety and agitation. Therefore, it is import-
ant to carefully monitor clinical status, including suicidality, when initiating treat-
ment. This is a period of high risk because patients are at high symptom severity,
may not yet be feeling better from treatment, and instead may be experiencing
troublesome side effects that contribute to suicidality.
chapter 8
Table 8.2 SSRIs
Mechanism of action Common side effects (bold Drugs, usual daily doses Comments
indicates >30%)
• Selective inhibition • GI (distress, nausea, • Citalopram, 20–40 mg • Mild side-effect profile; low potential for drug
of serotonin vomiting, diarrhoea) interactions
reuptake • CNS (headache, agitation, • Doses of 60 mg and above are associated with
sleep disturbance, tremor) prolonged QTc—caution with use of other drugs that
• Drowsiness, sedation, affect QTc
dry mouth
• Fluoxetine, 20–60 mg • Longer half-life; markedly inhibits CYP 2D6; fewer
• Sexual side effects
discontinuation symptoms
• Fluvoxamine, 00–300 mg • More GI effects (GI distress, nausea) and sedation;
markedly inhibits CYP A9
• Paroxetine, 20–50 mg • More weight gain with long-term use; markedly inhibits
CYP 2D6; more discontinuation symptoms (less so with
CR formulation)
• Sertraline, 50–200 mg • More diarrhoea; medium potential for drug
interactions
• Inhibition of • Similar to SSRIs • Escitalopram, 0–20 mg • More effective than SSRIs, especially for more severely
serotonin reuptake ill, mild side effects; low potential for drug interactions
• Allosteric binding • Also known as an allosteric serotonin reuptake inhibitor
to transporter • Not associated with QT prolongation to doses of 30
protein mg (unlike citalopram)
• Inhibition of • Similar to SSRIs. • Vilazodone, 40 mg • Metabolized by CYP 3A4; should be taken with food;
serotonin reuptake should titrate to therapeutic dose
• 5-HTA agonism
68 • pharmacological treatments
and other SSRIs. The side-effect profile, however, is no different from that of
citalopram.
Citalopram has an additional caution for its dose-dependent increase in QTc
interval, with most regulatory agencies revising down the therapeutic dose to
20–40 mg/day in adults. However, there is no indication that this is a clinically
relevant effect because rates of arrhythmia are no different for citalopram than
for other antidepressants, and other known cardiac risk factors are usually pre-
sent in reports of citalopram-associated arrhythmias. Similarly, there appear to
be no clinically important QTc issues with escitalopram, and no dose adjustments
are required.
chapter 8
Table 8.3 SNRIs
Mechanism of action Common side effects Drugs, usual Comments
(bold indicates >30%) daily doses
• Inhibition of serotonin • GI (distress, nausea, • Desvenlafaxine, • Active metabolite of venlafaxine; low rate of sexual side effects;
reuptake vomiting, diarrhoea) 50–00 mg low potential for drug interactions
• Inhibition of • CNS (headache, agitation,
• Duloxetine, • Effective in neuropathic pain and fibromyalgia
noradrenaline sleep disturbance)
60–90 mg
reuptake • Sweating
• Sexual side effects • Levomilnacipran, • Titrate to therapeutic dose; small increases in blood pressure—
(some SNRIs) 40–20 mg not recommended for certain cardiovascular conditions
chapter 8
pharmacological treatments • 73
chapter 8
Table 8.7 TCAs
Mechanism of action Common side effects Drugs, usual daily doses Comments
(bold indicates >30%)
• Inhibition of • Side effects vary with drug— Secondary amines • Fewest anticholinergic/cardiovascular
serotonin reuptake secondary amine TCAs have fewer • Nortriptyline, 75–50 mg effects
• Inhibition of side effects than tertiary amine TCAs • Therapeutic window for plasma level
noradrenaline • Anticholinergic (blurred vision,
• Desipramine, 75–225 mg • More activating
reuptake dry mouth, constipation, urinary
• Minimum therapeutic plasma level
• Affects many retention, sweating, confusion)
other receptors • Antihistaminic (drowsiness, • Dosulepin, 75–300 mg • Similar to desipramine
(e.g. histamine, sedation, weight gain) • Most sedating; used in low doses as
Tertiary amines
acetylcholine, • Cardiovascular (dizziness, postural
• Amitriptyline, 75–200 mg hypnotic; used for pain
α2-adrenergic) hypotension, antiarrhythmic effects, • Minimum therapeutic plasma level
QRS prolongation)
• GI (nausea, vomiting) • Imipramine, 00–300 mg • Very sedating
• CNS (tremor, headaches, seizures, • Minimum therapeutic plasma level
insomnia) • Clomipramine, 00–250 mg • More effective in severe depression,
• Sexual dysfunction
used for OCD, very sedating
• Minimum therapeutic plasma level
Heterocyclics • Lowers seizure threshold
• Maprotiline, 00–225 mg
• Amoxapine, 200–400 mg • Dopaminergic; may be useful in
psychotic depression, but also more
likely to cause extrapyramidal symptoms
• Lofepramine, 40–20 mg • Although it is metabolized to
desipramine, it has a safe cardiovascular
profile, even in overdose
Table 8.8 MAOIs and related agents
Mechanism of Common side effects Drugs, usual daily doses Comments
action (bold indicates >30%)
• Irreversible • Hypertensive crises • Phenelzine, 45–90 mg • Phenelzine more sedating; tranylcypromine more
inhibition of • Drowsiness, agitation, • Tranylcypromine 20–60 mg activating
MAO (A and B) hyperreflexia, headache, (in the UK, close supervision • MAOIs require tyramine-free diet
sweating, GI distress, weight gain, is recommended for doses • Caution for drug interactions (see Table 7.7)
sleep disturbance, orthostatic above 30 mg) • Requires 2-week washout before switching to
hypotension, oedema another drug
• Isocarboxazid, 20–60 mg • Milder side effects compared to other MAOIs
• Reversible • Insomnia, agitation, headache, • Moclobemide, 300–600 mg • Mild side-effect profile; dietary restrictions
inhibition of sedation, dry mouth, not needed
MAO-A constipation, nausea, dizziness • Same cautions for drug interactions as for MAOIs
• Selective • Application site reactions, • Selegiline transdermal patch, • At higher doses and in overdosage, selegiline also
irreversible insomnia, headache, dry mouth, 6–2 mg inhibits MAO-A, thereby acting as a MAOI
inhibition of diarrhoea • Dietary restrictions not needed for 6 mg dose,
MAO-B but tyramine-free diet recommended for 9–2
mg dose
• Same cautions for drug interactions as for MAOIs
76 • pharmacological treatments
chapter 8
Table 8.9 Clinically significant interactions of antidepressants with common drugs*
Drug Mechanism Interacts with Comments
Agomelatine • Substrate for • cimetidine • Reduce dose when used with CYP A2 inhibitors
CYP A2 • ciprofloxacin
• fluvoxamine
Bupropion • Moderate • TCAs • Usually not a clinically relevant effect, but caution with
inhibition of CYP • beta blockers (metoprolol, propranolol) higher doses
2D6 • codeine and other opioids (reduces
effect)
Duloxetine • Moderate • TCAs • Usually not a clinically relevant effect, but caution with
inhibition of • beta blockers (metoprolol, propranolol) higher doses
CYP 2D6 • codeine and other opioids (reduces • Reduce dose when used with CYP 3A4 inhibitors
• Substrate for effect)
CYP 3A4
Fluoxetine • Marked • TCAs • Can potentially increase serum TCA levels to
inhibition of CYP • beta blockers (metoprolol, propranolol) cardiotoxic levels
2D6 • codeine and other opioids (reduces • Long half-life of fluoxetine means that inhibition of CYP
effect) 2D6 can occur for up to 5 weeks after discontinuation
Fluvoxamine • Marked • buspirone • Increased statin levels can cause rhabdomyolysis
inhibition of • clozapine • Monitor INR carefully when warfarin used
CYP A2 • diazepam
• Moderate • quinidine
inhibition of • warfarin
CYP 3A4 • statin drugs
• Moderate • sildenafil
inhibition of CYP • vardenafil
2C9 • phenytoin
• cyclosporine (cyclosporin A)
(continued)
Table 8.9 Continued
Drug Mechanism Interacts with: Comments
MAOIs • Inhibits MAO • high tyramine-containing foods • Potentially fatal reactions with sympathomimetics or
(isocarboxazid, metabolism of • sympathomimetic agents (e.g. tyramine due to hypertensive crises
phenelzine, noradrenaline, pseudoephedrine) • Delirium, confusion, seizures, coma, death reported after
tranylcypromine) serotonin, and • meperidine ingestion of meperidine or other narcotics (including
dopamine • dextromorphan dextromorphan), and with serotonergic agents
• other antidepressants • Avoid disulfiram (Antabuse) with isocarboxazid
• other serotonergic agents
Moclobemide • Inhibits MAO • same as for MAOIs (except dietary • Theoretical risk of serotonin syndrome when combined
metabolism of interactions) with other antidepressants
noradrenaline,
serotonin, and
dopamine
Paroxetine • Marked • TCAs • Can potentially increase serum TCA levels to cardiotoxic
inhibition of CYP • beta blockers (metoprolol, propranolol) levels
2D6 • codeine and other opioids (reduces
effect)
Quetiapine-XR • Substrate for CYP • ketoconazole • Reduce dose when used with CYP 3A4 inhibitors
3A4 • erythromycin
Selegiline • Inhibits MAO • same as for MAOIs (except dietary • Theoretical risk of serotonin syndrome when combined
metabolism of interactions at lower doses) with other antidepressants
noradrenaline,
serotonin, and
dopamine
TCAs • Substrate for CYP • fluoxetine • Can potentially increase serum TCA levels to cardiotoxic
2D6 • paroxetine levels
• bupropion (less likely)
• duloxetine (less likely)
Vilazodone • Substrate for CYP • ketoconazole • Reduce dose when used with CYP 3A4 inhibitors
3A4 • erythromycin
Vortioxetine • Substrate for CYP • fluoxetine • Reduce dose when used with CYP 2D6 inhibitors
2D6 • paroxetine
Marked = >50% increase in blood levels; moderate = 50–50% increase in blood levels.
*
Not a comprehensive list of interactions; only a selection of commonly used drugs.
80 • pharmacological treatments
V Approach X Approach
Dose
Time
8.9 Discontinuation
Some patients will experience transient discontinuation symptoms, usually of mild
severity, when antidepressants are abruptly stopped (Box 8.2). Sensory distur-
bances can include tingling or ‘electric shock’-like sensations. Paroxetine, venlafax-
ine, and TCAs are most likely to be associated with discontinuation symptoms (but
less so with the controlled and extended-release preparations), while fluoxetine
is the least likely, in part owing to its long half-life. Other drugs with low propen-
sity for discontinuation symptoms include agomelatine, bupropion, citalopram,
chapter 8
Table 8.0 Washout periods required for switching between antidepressants
Switching to: SSRIs, SNRIs, and Multimodal and other TCAs/SGAs MAOIs Moclobemide
other reuptake receptor agents Selegiline
inhibitors
Switching from:
SSRIs, SNRIs, and None (watch for None (watch for None (watch for week (5 weeks for week (5 weeks for
other reuptake additive serotonergic/ additive serotonergic/ additive serotonergic/ fluoxetine) fluoxetine)
inhibitors noradrenergic effects) noradrenergic effects) noradrenergic effects)
Multimodal and other None (watch for None (watch for None (watch for week (3 weeks for week (3 weeks for
receptor agents additive serotonergic/ additive serotonergic/ additive serotonergic/ vortioxetine) vortioxetine)
noradrenergic effects) noradrenergic effects) noradrenergic effects)
TCAs/SGAs None (watch for None (watch for None (watch for week week
additive serotonergic/ additive serotonergic/ additive serotonergic/
noradrenergic effects) noradrenergic effects) noradrenergic effects)
MAOIs 2 weeks 2 weeks 2 weeks 2 weeks 2 weeks
Moclobemide week week week week week
Selegiline
82 • pharmacological treatments
chapter 8
pharmacological treatments • 83
Box 8.3 Caveats and consideration for the use of complementary and
alternative treatments
• There is little RCT evidence for many CAM treatments.
• Many of the conducted RCTs have significant methodological limitations,
including small sample size; lack of placebo controls; inadequate allocation
concealment and blinding; variability in diagnostic and inclusion/exclusion cri-
teria; lack of standardization of doses, potency, and concentration of treat-
ments; and few systematic evaluations of side effects.
• Most of the studies have included patients with mild-to-moderate depressive
severity.
• Few long-term and maintenance studies have been conducted.
• Few comparative studies with standard antidepressants or treatments have
been conducted.
• Although CAM treatments may be widely available (e.g. sold at health food
and grocery stores), manufacturing standards and regulations vary.
• There is little information about interactions with standard medications.
Further Reading
Bauer M, Pfennig A, Severus E, et al. (203) World Federation of Societies of Biological
Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders,
part : Update 203 on the acute and continuation treatment of unipolar depressive
disorders. World J Biol Psychiatry 14: 334–85.
chapter 8
84 • pharmacological treatments
Cleare A, Pariante CM, Young AH, et al. (205) Evidence-based guidelines for treating
depressive disorders with antidepressants: A revision of the 2008 British Association for
Psychopharmacology guidelines. J Psychopharmacol 29: 459–525.
Procyshyn RM, Bezchlibnyk-Butler KZ, Jeffries JJ (207) Clinical Handbook of Psychotropic
Drugs, 22nd edn. Toronto: Hogrefe and Huber.
Cipriani A, Furukawa TA, Salanti G, et al. (2009) Comparative efficacy and acceptability
of 2 new-generation antidepressants: A multiple-treatments meta-analysis. Lancet
373: 746–58.
Kennedy SH, Lam RW, McIntyre RS, et al. (206) Canadian Network for Mood and
Anxiety Treatments (CANMAT) 206 guidelines for the management of major
depressive disorder in adults. Section 3. Pharmacological treatments. Can J Psychiatry
61: 540–60.
Ravindran AV, Balneaves L, Faulkner G, et al. (206) Canadian Network for Mood
and Anxiety Treatments (CANMAT) 206 guidelines for the management of major
depressive disorder in adults. Section 5. Complementary and alternative medicine
treatments. Can J Psychiatry 61: 576–87.
Stahl SM (203) Stahl’s Essential Psychopharmacology, 4th edn. Cambridge: Cambridge
University Press.
chapter 8
Chapter 9
Somatic treatments
Key points
• Wake therapy, exercise, and light therapy are non-invasive and clinically useful
treatments.
• Electroconvulsive therapy remains an effective, safe, and well-tolerated
treatment for patients with severe, psychotic, or medication-resistant
depression.
• Repetitive transcranial magnetic stimulation now has good evidence for acute
efficacy, but with limited data about long-term management.
• Surgical treatments with novel neuromodulation techniques may become
clinically useful for some patients with difficult-to-treat depression.
9.1 Introduction
Psychiatry has a long history of using physical or somatic treatments that purport
to address the biological pathogenesis of depression. One of the earliest and best
known of these somatic treatments is electroconvulsive therapy (ECT), which,
despite the negative popularized depictions of its use, remains one of the saf-
est and most effective treatments for severe and treatment-resistant depression
(TRD; see Chapter 0). Others, such as insulin shock, are no longer used because
the risks of treatment outweighed any proven benefits. Somatic treatments, how-
ever, vary from non-invasive (wake therapy, exercise, light therapy) to more inva-
sive methods (transcranial magnetic stimulation) and to the most invasive (those
that involve surgery such as vagus nerve stimulation, limbic neurosurgery).
A major problem for evaluating somatic treatments is that, since a physical
treatment is used, designing a suitable placebo control condition for randomized
controlled trials (RCTs) is challenging, and blinding of conditions is often very dif-
ficult to achieve. Hence, the evidence base for these somatic treatments is not as
robust as for medication treatments (Table 9.).
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86 • somatic treatments
daytime fatigue, keeping them awake all night can result in a clear improvement
in mood that continues through the next day. Total sleep deprivation (TSD, now
known as wake therapy to better describe the active intervention) can result
in dramatic changes in mood, with many patients feeling a return to baseline.
Although it is difficult to design placebo-controlled studies, the fact that wake
therapy is so counterintuitive to patients (most of whom think they will feel better
if only they had more sleep) makes a placebo response less likely.
Unfortunately, the mood improvement after TSD is not long lived. The majority
of patients relapse after a recovery sleep the next day after TSD. Several reviews of
sleep deprivation studies found the clinical response rate to TSD averaged about
60%, but 80–85% of patients relapsed the the day after the recovery sleep. Relapse
can occur even after brief naps. However, it is intriguing that up to 5% of patients
appear to have sustained responses to TSD even after a recovery sleep. Newer
techniques have suggested that wake therapy, in combination with medications
such as lithium or antidepressants, or with bright light therapy, can help sustain
response in a good proportion of patients. The main problem with wake therapy is
adherence, since many patients do not have the motivation to stay awake all night.
A regimen in which an all-night sleep deprivation is alternated with nights of regular
sleep may make it easier to perform as an outpatient. Alternatively, partial sleep
deprivation, in which patients are allowed to sleep from 0 p.m. to 2 a.m., may
also be effective and may make it easier for patients to comply with wake therapy.
Clinical summary: Given the non-invasive, easily conducted nature of wake
therapy, it can be considered as adjunctive treatment for patients with MDD,
especially those who require rapid response and can be monitored (e.g. hospital-
ized patients, acutely suicidal patients).
chapter 9
somatic treatments • 87
9.3 Exercise
Exercise has been shown to improve mood and reduce depressive symptoms in
various populations, with now many RCTs conducted in MDD. Several system-
atic reviews and meta-analyses have shown that exercise is effective and well-
tolerated compared to control conditions in mild-to-moderate MDD, with effect
sizes similar to antidepressants and psychotherapy. Both aerobic (cardiovascular)
and anaerobic (resistance) exercise are effective, without clear evidence to sup-
port superiority of either. The recommended regimen for MDD is similar to the
general public health recommendations: at least 30 minutes of moderate intensity
(an activity level in which you can still talk) at least three times weekly for at least
9 weeks. This regimen should be tailored to the physical status of the patient, and
supervised exercise has more benefit than unsupervised.
Clinical summary: Although there remain some methodological limitations
to the RCT evidence, given the lack of side effects and the other medical benefits,
supervised exercise can be recommended as monotherapy for mild-to-moderate
MDD and as adjunctive treatment for more severe MDD.
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88 • somatic treatments
Figure 9. Example of fluorescent light box used for light therapy.
Source: Image provided by Compass Health Brands.
light with dimmer blue light. Several systematic reviews of RCTs have shown that
bright light is effective in the treatment of seasonal depression, with some trials
showing the effects of light to be comparable to those with SSRI antidepressants.
There is emerging evidence for efficacy of light therapy in other conditions, includ-
ing non-seasonal depression. For non-seasonal MDD, the combination of light and
SSRI antidepressant appears to be more efficacious than either monotherapy alone.
Adverse effects reported for light therapy are generally mild, but include head-
ache, nausea, eye strain, agitation, and insomnia. There are also case reports of
manic induction with bright light so that patients with bipolar disorder should use
the same cautions as with other antidepressants. Relative contraindications to
using bright light include pre-existing retinal disease, macular degeneration, and
use of retinal photosensitizing drugs (e.g. thioridazine, lithium, melatonin).
Clinical summary: Light therapy is a first-line treatment for seasonal affect-
ive disorder. Although the evidence base for efficacy in non-seasonal depression
is limited, given the non-invasive nature, tolerability, and low cost of light therapy
it can be considered as a first-line treatment for patients with mild-to-moderate
depression severity when standard treatments are not tolerated, or as adjunctive
treatment with antidepressants.
chapter 9
somatic treatments • 89
9.5 Transcranial magnetic stimulation
Repetitive transcranial magnetic stimulation (rTMS) is a technique in which a brief,
high-intensity magnetic field is generated and used to stimulate cortical neurons.
The advantage of rTMS is that it is a non-invasive treatment which can be applied
while patients are awake, and in which adverse effects are minimal. Compared
to ECT, there are no cognitive side effects and no anaesthesia is required. In the
mid-990s, rTMS, in which a ‘train’ of sequential pulses is applied in one session,
began to be evaluated as a treatment for MDD and other neuropsychiatric condi-
tions. Since then, dozens of RCTs, systematic reviews, and meta-analyses have
found statistically and clinically significant effects of active rTMS over sham con-
trol conditions. In ‘real-world’ studies, the response rate for rTMS in depressed
patients is about 50%, while the remission rate is about 30%. A consistent pre-
dictor for rTMS response is the degree of treatment resistance—the more failed
trials of medications, the lower the response to rTMS. Also consistent with this
finding is that ECT is superior to rTMS in direct comparisons.
High-frequency stimulation is considered excitatory in neuronal regions, while
low-frequency stimulation is inhibitory. Studies of rTMS parameters have shown
efficacy for high-frequency stimulation over the left dorsolateral prefrontal cortex
(DLPFC), low-frequency stimulation over the right DLPFC, and bilateral rTMS
using both. Other rTMS parameters are being studied, including deep rTMS and
both intermittent and continuous theta-burst stimulation. The usual course for
rTMS consists of daily treatments (five times per week) for 4–6 weeks. Each
treatment takes 5–45 minutes, depending on the stimulation protocol, although
theta-burst stimulation protocols only take –3 minutes per session. Side effects
can include mild scalp pain during stimulation and transient headache.
The major limitation of the evidence for rTMS is the lack of long-term follow-
up and maintenance data. The studies of rTMS have been short—generally 2–4
weeks in duration—and the durability of response is variable—between 2 and
2 months. As with ECT, most patients relapse within 6 months after response
to an acute course. Studies using different maintenance rTMS schedules are being
conducted, but there remains insufficient evidence to make recommendations.
Clinical summary: rTMS is a non-invasive treatment with few side effects,
and efficacy is demonstrated in short-term studies. Overall, rTMS can be recom-
mended as a first-line acute treatment for patients who have failed at least one
antidepressant trial. It should be considered earlier in the treatment algorithm
than ECT, as rTMS is not a substitute for ECT. The limiting clinical factors include
lack of availability, the inconvenience of daily visits to the clinic for 4–6 weeks, and
limited information on longer term outcomes and maintenance strategies.
chapter 9
90 • somatic treatments
parameters while reducing cognitive side effects. ECT also appears to work faster
than antidepressants, especially for elderly patients and/or those with psychotic
depression. Systematic reviews have highlighted the strong evidence for efficacy
compared to sham treatments, and recent RCTs have also shown clear acute
benefits of ECT. Unfortunately, there remain only a few comparisons of ECT with
second-generation antidepressants and combinations.
Indications for ECT are shown in Box 9.. High-dose (three to eight times the
dose needed for seizure threshold) unilateral electrode placement has similar effi-
cacy to bilateral placement with fewer cognitive side effects. In addition, some
evidence exists that bifrontal electrode placement, which requires lower electrical
dose to achieve seizures, also has similar efficacy to the traditional bitemporal
placement, with fewer cognitive side effects. Ultrabrief pulse stimulation appears
to have less severe short-term cognitive side effects than brief pulse stimulation,
but at the cost of slightly less efficacy. Seizure duration is commonly monitored
using EEG analysis or the blood pressure cuff method (for seizure-induced motor
activity), but there is no good definition of an ‘adequate’ seizure. The usual course
of treatment consists of six to 2 sessions administered three times weekly, but
less frequent sessions are associated with fewer cognitive side effects.
ECT is a safe treatment. With careful pre-anaesthesia examination, the mortality
rate approximates that of general anaesthesia. There is no evidence for any long-
term neural damage due to ECT; indeed, there are animal studies suggesting that
electroconvulsive shock can lead to enhanced neurogenesis.
The common side effects of ECT relate to recovery from the general anaes-
thetic and the brief seizure, including nausea, headache, and muscle aches. These
resolve spontaneously or with symptomatic treatment. Less common are mus-
culoskeletal and dental injuries, persistent myalgia, and cardiovascular events.
The cognitive side effects of ECT include a post-ECT confusional state (due to
post-ictal and post-anaesthetic effects) that resolves quickly, and a short-term
retrograde memory loss that resolves more slowly. Although there are anecdotal
reports of severe and permanent memory loss, neuropsychological studies show
no sustained cognitive deficits upon testing 6 months after ECT. In fact, one meta-
analysis showed recovery or improvement in neuropsychological tests 3–5 days
chapter 9
somatic treatments • 91
after a course of ECT. Some loss of memory for events surrounding the time
of ECT may linger, but longer term cognitive effects seem to be selective for
impersonal autobiographical memories (such as public events) that do not affect
functioning. In addition, the majority of patients show improvement in cognitive
functioning because their depression-related memory problems improve.
Most guidelines have recommended stopping ineffective pre-ECT antidepres-
sants before or during a course of ECT, as they will not likely be effective for
maintenance treatment and their continued use may have additive side effects.
One RCT showed that concurrent use of nortriptyline with ECT was associated
with better response and fewer cognitive side effects than use of either placebo
or venlafaxine. Therefore, commencement of a new agent can be considered
either before or during the ECT course.
Without maintenance treatment, the relapse rate following successful ECT is
high, ranging from 50% to 80% within 6 months. Greater severity and degree of
medication resistance is associated with a higher rate of relapse. Limited data on
maintenance options exist, but the combination of lithium and nortriptyline has
been found to be superior to nortriptyline alone, and the combination of lithium
and venlafaxine was as effective as lithium and nortriptyline in preventing relapse.
In addition, continuation ECT (starting at twice a month and then tapering to once
a month) was as effective as the lithium–nortriptyline combination.
Clinical summary: ECT is a safe and effective treatment that should be con-
sidered in the treatment algorithm for TRD and psychotic depression. ECT can
also be a first-line recommended treatment for severely compromised patients—
for example, those with extreme suicidality, severe dysfunction, and physical
deterioration. The transient memory disturbance associated with ECT can be
minimized using high-dose unilateral or lower-dose bifrontal electrode placement,
or ultrabrief pulse stimulation. Maintenance strategies, including antidepressants,
combination lithium–nortriptyline, and continuation ECT, are important to pre-
vent relapse following ECT.
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92 • somatic treatments
continued to improve over a -to 2-year naturalistic follow up, and outcomes
were better than with a matched cohort of patients with TRD that received usual
care without VNS. Based on these results, VNS is currently approved for TRD in
the United States and Canada.
The therapeutic mechanism(s) of VNS is not known, but the vagus nerve is
a major afferent pathway to the brain. Neuroimaging studies suggest that VNS
results in changes in neural circuitry similar to those seen with antidepressants
and ECT. Side effects of VNS include mild voice changes (due to proximity to the
larynx and laryngeal nerve) and infections.
chapter 9
somatic treatments • 93
Clinical summary: Given the invasive nature of surgical interventions, VNS
can be recommended for patients who have not responded to standard treat-
ments, including pharmacotherapy, psychotherapy, and ECT, and/or for those
who refuse—or are intolerant to—ECT. However, the lack of robust efficacy
data must be factored into this decision. Limbic surgery is reserved for the most
chronic and refractory patients, while DBS remains an experimental treatment.
Further Reading
Andrade C, Arumugham SS, Thirthalli J (206) Adverse effects of electroconvulsive
therapy. Psychiatr Clin North Am 39: 53–30.
Bewernick B, Schlaepfer TE (205) Update on neuromodulation for treatment-resistant
depression. F000Res 4: pii: F000 Faculty Rev-389.
Brown ED, Lee H, Scott D, et al. (204) Efficacy of continuation/maintenance
electroconvulsive therapy for the prevention of recurrence of a major depressive
episode in adults with unipolar depression: A systematic review. J ECT 30: 95–202.
Brunoni AR, Chaimani A, Moffa AH, et al. (207) Repetitive transcranial magnetic
stimulation for the acute treatment of major depressive episodes: A systematic review
with network meta-analysis. JAMA Psychiatry 74: 43–52.
Lam RW, Levitt AJ, Levitan RD, et al. (206) Efficacy of bright light treatment, fluoxetine,
and the combination in patients with nonseasonal major depressive disorder: A
randomized clinical trial. JAMA Psychiatry 73: 56–63.
Lam RW, Tam EM (2009) A Clinician’s Guide to Using Light Therapy. Cambridge: Cambridge
University Press.
McClintock SM, Reti IM, Carpenter LL, et al. (207) Consensus recommendations for
the clinical application of repetitive transcranial magnetic stimulation (rTMS) in the
treatment of depression. J Clin Psychiatry 207 May 23. doi: 0.4088/JCP.6cs0905
Milev RV, Giacobbe P, Kennedy SH, et al. (206) Canadian Network for Mood and
Anxiety Treatments (CANMAT) 206 guidelines for the management of major
depressive disorder in adults. Section 4. Neurostimulation treatments. Can J Psychiatry
61: 56–75.
Nyström MB, Neely G, Hassmén P, et al. (205) Treating major depression with physical
activity: A systematic overview with recommendations. Cogn Behav Ther 44: 34–52.
Tor PC, Bautovich A, Wang MJ, et al. (205) A systematic review and meta-analysis of
brief versus ultrabrief right unilateral electroconvulsive therapy for depression. J Clin
Psychiatry 76: e092–8.
Wirz-Justice A, Benedetti F, Berger M, et al. (2005) Chronotherapeutics (light and wake
therapy) in affective disorders. Psychol Med 35: 939–44.
chapter 9
Chapter 10
Special populations
Key points
• The keys to optimal management of treatment-resistant depression and
depression in special populations include careful assessment, and selection
of evidence-based treatments tailored to the individual, along with ongoing
monitoring of response and outcome.
• Given the still limited evidence base, use and selection of antidepressants
depend on an individual risk–benefit assessment in elderly patients, those with
other medical illnesses, pregnant and breastfeeding women, and children and
adolescents.
chapter 10
96 • special populations
Box 0. Evaluation for patients with depression that are not responding
to treatment
• Reassess adherence to treatment (side effects, taking medication
properly, etc.)
• Reassess the diagnosis (especially hypomania, psychotic or seasonal depres-
sion, persistent depression)
• Reassess for comorbidity (especially anxiety disorder, substance abuse, per-
sonality disorder, attention deficit hyperactivity disorder, physical conditions)
• Reassess medication profile (any drug–drug interactions?)
• Determine degree of response/non-response (using a rating scale)
• Consider psychological treatment options
• Consider pharmacological treatment options
• Consider transcranial magnetic stimulation, electroconvulsive therapy, and
other somatic treatments.
targets for intervention may also be beneficial at this stage. Because there is lim-
ited information on approaches to the patient who has not responded to psycho-
therapy, the remainder of this section will focus on pharmacotherapy strategies
for TRD.
chapter 10
special populations • 97
chapter 10
98 • special populations
lisdexamfetamine) have not generally shown overall efficacy as add-on agents, but
may be more useful in targeting fatigue and/or cognitive symptoms. However, the
wake-promoting agent, modafinil, has Level 2 evidence to support its use as an
adjunctive agent.
Another advantage of adjunctive treatment is that it may be possible to target
specific symptoms or side effects with the second agent. For example, mirtazap-
ine/mianserin/quetiapine-XR may be particularly beneficial for residual symp-
toms of anxiety and/or insomnia, triiodothyronine/modafinil/psychostimulants
for fatigue and low energy, and bupropion for treating SSRI-induced sexual dys-
function. However, there is as yet little evidence to support any targeted adjunct-
ive treatment.
chapter 10
Select and initiate a
first-line
antidepressant
Yes 4
Switch to another
Add-on an
Switch to a 2nd or 3rd first-line antidepressant,
adjunctive
line antidepressant preferably with
medication
superior efficacy
Early
Continue Yes No
improvement
treatment for
after 2–4
6–8 weeks
weeks?
No 6 7
Symptom
remission?
Yes
Figure 0. CANMAT treatment algorithm for managing limited response to an ini-
tial antidepressant.
Reproduced from: Kennedy SH, Lam RW, McIntyre RS, et al. (206) Canadian Network for Mood and
Anxiety Treatments (CANMAT) 206 guidelines for the management of major depressive disorder in
adults. Section 3. Pharmacological treatments. Canadian Journal of Psychiatry 61: 540–60.
Notes for Figure 0..
() Monitor outcomes using measurement-based care. Early improvement (defined as ≥20% reduction
in symptom score) to a first-line antidepressant should be apparent within 2–4 weeks of achieving a
therapeutic dose.
(2) If there is not at least initial improvement and the drug is well tolerated, increase the dose. If there is
still limited improvement, reassess diagnosis (especially comorbidity), degree of improvement (such as
number and type of residual symptoms), adherence, and tolerability.
(3) At any step, especially with early treatment resistance, consider adding an evidence-based, non-
pharmacological treatment (e.g. cognitive–behavioural therapy, exercise, light therapy) or switching to
a neurostimulation treatment (such as transcranial magnetic stimulation or electroconvulsive therapy).
(4) Generally, consider second-line antidepressants only after trying two or more first-line agents.
(5) For more resistant depressions, consider a longer period to evaluate benefit.
(6) Depending on tolerability, increase to maximum dose.
(7) For more chronic and resistant depressions, consider a chronic disease management approach, with
less emphasis on reducing symptoms and more emphasis on improving functioning and quality of life.
100 • special populations
could select the sub-study for participation at each level, they were randomized
to treatments within the sub-study.
Table 0.3 summarizes the overall results. The remission rates were lower than
those seen in efficacy RCTs (randomized controlled trials), because the patient
population was more severe and challenging to treat. About two-thirds of patients
achieved full symptom remission after four treatment levels. Most of the treat-
ment options were indistinguishable from each other, but unfortunately, by Step
3 the sample sizes were too small to detect meaningful differences. Some differ-
ences in tolerability of treatments were observed. For example, citalopram com-
bined with bupropion was better tolerated than when combined with buspirone,
and citalopram combined with triiodothyronine was better tolerated than lithium
augmentation. The sub-study with cognitive therapy was smaller than expected,
but the remission rates were similar to those of medication options. Overall, this
study shows that remission is achievable for the majority of patients—even those
with challenging MDD—with increasing intensity of treatments. However, there
remain unresolved questions about the comparative efficacy of many of the treat-
ment options studied. Another major limitation of STAR*D is that the SGAs, now
the best-evidenced treatments for TRD, were not studied.
chapter 10
Table 0.3 Summary of STAR*D results
Level & sample size Sub-studies and intervention(s) Remission rate Cumulative remission2
Step • Citalopram 36.8% 36.8%
N = 3,67
Step 23 • SWITCH to: venlafaxine or bupropion or sertraline 30.6% 56.%
N = ,439 • COMBINE citalopram with: bupropion or buspirone
• SWITCH to or COMBINE with: cognitive therapy
Step 33 • SWITCH to: nortriptyline or mirtazapine 3.7% 62.%
N = 390 • AUGMENT with: lithium or triiodothyronine
Step 4 • SWITCH to: tranylcypromine or mirtazapine plus venlafaxine 3.0% 67.0%
N = 23
Combined remission rates from all sub-studies within treatment level.
2
By QIDS-SR criteria.
3
Patients could choose the sub-study for participation, but were randomized to treatments within the sub-study.
102 • special populations
the adjunctive strategies, few long-term data are available and the risk–benefit
ratio must continue to be considered for an individual patient.
chapter 10
special populations • 103
Numerous studies have also demonstrated that MDD is more common in
medically ill individuals than in the general population (Figure 0.2), but it is both
under-diagnosed and under-treated. A common barrier to diagnosis is the mis-
taken notion that ‘reactive depression’ is not pathological and that treatment is
unnecessary and/or ineffective. Reluctance to stigmatize patients with a psychi-
atric diagnosis may also play a role. Diagnosis is further complicated by the diffi-
culty in differentiating neurovegetative symptoms of depression (e.g. poor sleep,
loss of energy and appetite, fatigue) from physiological symptoms associated with
the medical condition. Certain screening tools such as the Hospital Anxiety and
Depression Scale have tried to simplify this by focusing on the cognitive symptoms
of depression.
Pain
Dementia
Obesity
Cancer
Cardiac
Diabetes
HIV/AIDS
Cerebrovascular
General Population
0 10 20 30 40 50 60
Prevalence Rates for Depression (%)
*Highest rates shown from reported data ranges.
chapter 10
104 • special populations
effective in these populations, but TCAs are usually avoided because of greater
side-effect burden due to anticholinergic, antihistaminic, and cardiovascular
effects. However, these patients may also have difficulty tolerating certain side
effects of the second- generation antidepressants— for example, the gastro-
intestinal side effects of SSRIs. SSRIs are also associated with hyponatremia in
some patients, which may be particularly problematic for the elderly, and with a
small increased risk of falls (not due to orthostatic hypotension) and gastrointes-
tinal bleeding (particularly with concurrent use of NSAIDs (non-steroidal anti-
inflammatory drugs), although the use of acid-suppressing drugs may mitigate this
risk). Overall, however, SSRIs are still considered first-line antidepressants for eld-
erly and medically ill patients.
Electroconvulsive therapy (ECT) can be the treatment of choice for some
medically ill and/or elderly patients because it is fast acting and bypasses the
problem of medication side effects and interactions. For example, the depressed
older person with inability or refusal to eat or drink may have physical deterior-
ation that requires rapid treatment with ECT (see Chapter 8).
chapter 10
special populations • 105
can decrease social isolation and help patients find meaning in life, despite their
illness.
Evidence-based psychotherapies such as cognitive–behavioural therapy (CBT)
and interpersonal psychotherapy (IPT) have been demonstrated to be benefi-
cial in many comorbid conditions, including cancer, HIV/AIDS, and cardiovascular
disease. In addition, CBT and self-management strategies are now widely used in
chronic disease management programmes as well as for adjunctive treatment of
many medical conditions (e.g. insomnia, cancer, diabetes, arthritis, fibromyalgia),
even when MDD is not comorbid.
chapter 10
106 • special populations
Several large clinical trials have been conducted in patients with cardiac dis-
ease and MDD, and two of these examined patients with MDD who were post-
MI. The SAD-HART (Sertraline AntiDepressant Heart Attack Randomized
Trial) study showed the efficacy of sertraline in improving depression symp-
toms compared to placebo, the ENRICHD (Enhancing Recovery in Coronary
Heart Disease) study found that CBT (augmented by sertraline when depres-
sion was severe or with non-response after 5 weeks) was modestly effect-
ive in reducing depression scores compared to usual care (which may have
included antidepressants), and the CREATE (Cardiac Randomized Evaluation
of Antidepressant and Psychotherapy Efficacy) trial examined citalopram,
IPT, and the combination of both in patients with coronary artery disease.
Citalopram was superior to placebo, but IPT alone was not, and the combin-
ation was not significantly more effective than citalopram. Note that citalo-
pram (but not other SSRIs) is associated with dose-dependent increase in QTc
prolongation, so doses higher than 20 mg/day should be avoided in patients
with cardiovascular disease. Finally, the Korean Depression in Acute Coronary
Syndrome (K-DEPACS) study found improved quality of life in patients treated
with escitalopram versus placebo.
These studies show that SSRIs such as citalopram, escitalopram, and sertra-
line are safe and effective for patients with cardiovascular disease, and that CBT
(but not IPT) also offers benefit. Unfortunately, while all were large sample trials
for depression studies, none had a sample that was sufficiently large to detect
changes in mortality or cardiac events. Further study is needed to determine
whether treatment of MDD in these patients has direct effects on cardiovascular
outcomes.
chapter 10
special populations • 107
0.3.2 Treatment approaches
There is evidence that non-pharmacological treatments such as IPT and CBT are
effective during pregnancy and post partum, so they should be considered as first-
line treatments for mild-to-moderate MDD. However, there remain significant
barriers to access for these evidence-based psychotherapies (see Chapter 7).
There is always concern about using medications during pregnancy and post
partum because of potential adverse effects on the fetus, and drug transmission
to the infant by breastfeeding. It must be remembered, however, that untreated
depression clearly results in poor outcomes for both mother and child, including
premature birth, low birth weight, increased neonatal distress, and relationship
problems. Discontinuing antidepressants during pregnancy is also not recom-
mended, since the risk of relapse may be as high as 70%.
chapter 10
108 • special populations
to detectable serum levels in infants; however, there have been no behavioural
effects noted in infants with low serum levels of antidepressants.
In summary, paroxetine has been associated with slightly more neonatal prob-
lems than other medications, but other SSRIs appear to be safe in pregnancy,
although neonates should be monitored for adaptation syndrome. Most antide-
pressants show low rates of transmission to infants via breast milk, but thera-
peutic drug monitoring in the infant may be reassuring to mothers since most will
have no detectable drug levels. Given the limited database, selection of medica-
tion for women in pregnancy and post partum is still based on an individualized
risk–benefit assessment.
chapter 10
special populations • 109
severity. In the one trial with a more severe and comorbid study sample, the
Treatment for Adolescents with Depression Study (TADS), CBT was no better
than pill placebo while fluoxetine was significantly superior to both. However,
there was indication that the best outcomes were achieved with combined fluox-
etine and CBT treatment.
chapter 10
110 • special populations
Further Reading
Hetrick SE, McKenzie JE, Cox GR, et al. (202) Newer generation antidepressants
for depressive disorders in children and adolescents. Cochrane Database Syst Rev
11: CD00485.
Huang AX, Delucchi K, Dunn LB, et al. (205) A systematic review and meta-analysis of
psychotherapy for late-life depression. Am J Geriatr Psychiatry 23: 26–73.
Isacsson G, Rich CL (204) Antidepressant drugs and the risk of suicide in children and
adolescents. Paediatr Drugs 16: 5–22.
Kennedy SH, Lam RW, McIntyre RS, et al. (206) Canadian Network for Mood and
Anxiety Treatments (CANMAT) 206 guidelines for the management of major
depressive disorder in adults. Section 3. Pharmacological treatments. Can J Psychiatry
61: 540–60.
McIntyre RS, Filteau MJ, Martin L, et al. (204) Treatment-resistant depression: Definitions,
review of the evidence, and algorithmic approach. J Affect Disord 156: –7.
MacQueen GM, Frey BN, Ismail Z, et al. (206) Canadian Network for Mood and Anxiety
Treatments (CANMAT) 206 guidelines for the management of major depressive
disorder in adults. Section 6. Special populations: Youth, women, and the elderly. Can J
Psychiatry 61: 588–603.
chapter 10
special populations • 111
March J, Silva S, Petrycki S, et al. (2004) Fluoxetine, cognitive-behavioral therapy, and
their combination for adolescents with depression: Treatment for Adolescents with
Depression Study (TADS) randomized controlled trial. JAMA 292: 807–20.
Mulsant BH, Blumberger DM, Ismail Z, et al. A systematic approach to pharmacotherapy
for geriatric major depression. Clin Geriatr Med 30: 57–34.
Nulman I, Koren G, Rovet J, et al. (202) Neurodevelopment of children following
prenatal exposure to venlafaxine, selective serotonin reuptake inhibitors, or untreated
maternal depression. Am J Psychiatry 169: 65–74.
Ramasubbu R, Taylor VH, Samaan Z, et al. (202) The Canadian Network for Mood and
Anxiety Treatments (CANMAT) task force recommendations for the management
of patients with mood disorders and select comorbid medical conditions. Ann Clin
Psychiatry 24: 9–09.
Rush AJ, Trivedi MH, Wisniewski SR, et al. (2006) Acute and longer-term outcomes in
depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J
Psychiatry 163: 905–7.
Seligman F, Nemeroff CB (205) The interface of depression and cardiovascular
disease: Therapeutic implications. Ann N Y Acad Sci 1345: 25–35.
Stewart DE, Vigod S (206) Postpartum depression. N Engl J Med 375: 277–86.
Thase ME (206) Adverse effects of second-generation antipsychotics as adjuncts to
antidepressants: Are the risks worth the benefits? Psychiatr Clin North Am 39: 477–86.
Vigod SN, Wilson CA, Howard LM (206) Depression in pregnancy. BMJ 352: i547.
chapter 10
APPENDIX
Sample rating scales
Sample rating scales 14
Hamilton Depression Rating Scale, 7-item version (HAM-D) 5
Montgomery–Åsberg Depression Rating Scale (MADRS) 8
Quick Inventory of Depressive Symptomatology (Self-Rated)
(QIDS-SR) 21
Patient Health Questionnaire (PHQ-9) 24
Perceived Deficits Questionnaire—Depression, 5 item (PDQ-D-5) 25
Lam Employment Absence and Productivity Scale (LEAPS) 26
Edinburgh Postnatal Depression Scale (EPDS) 28
Appendix
Sample rating scales
Sample rating scales are provided in Table A..
3. Genital symptoms
0 = Absent
= Mild
2 = Severe
4. Somatic symptoms—gastrointestinal
0 = None
= Loss of appetite but eating without staff encouragement; heavy feelings in
abdomen
2 = Difficulty eating without staff urging. Requests or requires laxatives or medi-
cation for bowels or medication for gastrointestinal symptoms
Appendix
116 • appendix: sample rating scales
5. Loss of weight
0 = No weight loss
= Probable weight loss associated with present illness
2 = Definite (according to patient) weight loss
6. Insomnia—early
0 = No difficulty falling asleep
= Complains of occasional difficulty in falling asleep—i.e. takes more than
half an hour
2 = Complains of nightly difficulty in falling asleep
7. Insomnia—middle
0 = No difficulty
= Patient complains of being restless and disturbed during the night
2 = Waking during the night—any getting out of bed rates 2 (except for pur-
poses of voiding)
8. Insomnia—late
0 = No difficulty
= Wakes in early hours of the morning but goes back to sleep
2 = Unable to fall asleep again if he/she gets out of bed
9. Somatic symptoms—general
0 = None
= Heaviness in limbs, back, or head; backaches, headache, muscle aches; loss
of energy and fatiguability
2 = Any clear-cut symptom rates 2
11. Suicide
0 = Absent
= Feels life is not worth living
Appendix
appendix: sample rating scales • 117
12. Anxiety—psychic
0 = No difficulty
= Subjective tension and irritability
2 = Worrying about minor matters
3 = Apprehensive attitude apparent in face or speech
4 = Fears expressed without questioning
13. Anxiety—somatic
0 = Absent
= Mild
2 = Moderate
3 = Severe
4 = Incapacitating
14. Hypochondriasis
0 = Not present
= Self-absorption (bodily)
2 = Preoccupation with health
3 = Frequent complaints, requests for help, etc.
4 = Hypochondriacal delusions
15. Insight
0 = Acknowledges being depressed and ill
= Acknowledges illness but attributes cause to bad food, climate, over-work,
virus, need for rest, etc.
2 = Denies being ill at all
17. Agitation
0 = None
= Fidgetiness
118 • appendix: sample rating scales
(continued)
Appendix
120 • appendix: sample rating scales
Appendix
Quick Inventory of Depressive Symptomatology
(Self-Report) (QIDS-SR)
See Figure A..
Appendix
appendix: sample rating scales • 123
Appendix
124 • appendix: sample rating scales
Appendix
appendix: sample rating scales • 125
Perceived Deficits Questionnaire—Depression, 5-item
(PDQ-D-5)
See Figure A.3.
Appendix
126 • appendix: sample rating scales
Appendix
appendix: sample rating scales • 127
Appendix
128 • appendix: sample rating scales
Appendix
appendix: sample rating scales • 129
Appendix
130 • appendix: sample rating scales
Key references
Cox J, Holden J, Sagovsky R (987) Detection of postnatal depression. Development of
the 0-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 150: 782–6.
Fehnel SE, Forsyth BH, DiBenedetti DB, et al. (206) Patient-centered assessment of
cognitive symptoms of depression. CNS Spectr 21: 43–52.
Hamilton M (967) Development of a rating scale for primary depressive illness. Br J Soc
Clin Psych 6: 278–96.
Kroenke K, Spitzer RL, Williams JB (200) The PHQ–9: Validity of a brief depression
severity measure. J Gen Intern Med 16: 606–3.
Lam RW, Michalak EE, Swinson RP (2005) Assessment Scales in Depression, Mania and
Anxiety. London: Taylor and Francis.
Lam RW, Michalak EE, Yatham, LN (2009) A new clinical rating scale for work absence and
productivity: Validation in patients with major depressive disorder. BMC Psychiatry 9: 78.
Leon AC, Olfson M, Portera L, et al. (997) Assessing psychiatric impairment in primary
care with the Sheehan Disability Scale. Int J Psychiatry Med 27: 93–05.
Montgomery SA, Asberg M (979) A new depression scale designed to be sensitive to
change. Br J Psychiatry 134: 382–9.
Trivedi MH, Rush AJ, Ibrahim HM, et al. (2004) The Inventory of Depressive
Symptomatology, Clinician Rating (IDS-C) and Self-Report (IDS-SR), and the Quick
Inventory of Depressive Symptomatology, Clinician Rating (QIDS-C) and Self-Report
(QIDS-SR) in public sector patients with mood disorders: A psychometric evaluation.
Psychol Med 34: 73–82.
Wilkinson MJ, Barczak P (988) Psychiatric screening in general practice: Comparison of
the general health questionnaire and the hospital anxiety depression scale. J R Coll Gen
Pract 38: 3–3.
Appendix
Index
NUMBERS levomilnacipran 63, 68, 69t
maintenance treatment 80, 82b
atomoxetine 68, 70
attention, patient descriptions
5-HTTLPR polymorphisms 2–3 mechanism of action 20 and neuropsychological
neurogenesis theory 9 tests 39t
A mianserin 7t
mirtazapine 70, 7t
atypical antipsychotics see
second-generation
acute phase of treatment 48, 49t monoamine oxidase antipsychotics
adherence, improvement of inhibitors 73 atypical depression 29t
49, 50b for pain 4 augmentation 96
adjunctive (‘add-on’) therapy reboxetine 68, 70t
96, 97–8 safety 65–6, 09
advantages and second-generation B
disadvantages 97t antipsychotics 72 BDNF (brain-derived
adjunctive agents 97–8 selection of 63–4t neurotrophic factor)
second-generation selective serotonin reuptake 6f, 7
antipsychotics 00, 02t inhibitors (SSRIs) 66–8, 67t Beacon 60t
adolescents selegiline 73, 75t, 78t, 80, 8t Beating the Blues 59
safety and efficacy of serotonin and noradrenaline Beck Depression Inventory 47
antidepressants 09 reuptake inhibitors behavioural activation (BA)
treatment controversies 08–9 (SNRIs) 68 54t, 57
treatment side effects 67t, 69t, 70t, 7t, bereavement 30–
recommendations 0b 73t, 74t, 75t, 76 differentiation from major
see also children in special populations 95 depressive episodes 3t
adoption studies children and adolescents 09 bibliotherapy 50, 5t
age of onset 3, 4 elderly patients 03–4 Big White Wall 60t
aggression 37t medically ill patients 03–4 biological factors 2f
agitation 37t pregnancy and bipolar disorder 3–3
agomelatine 5, 65, 70, 7t breastfeeding 07–8 irritability and anger 37
drug interactions 77t suicide risk 65–6, 08b borderline personality
amitriptyline 74t young people 09 disorder 38
drug interactions 4 switching agents 76, 80f Bounce Back Online 60t
see also tricyclic antidepressants washout periods 8t breastfeeding 07–8
amoxapine 74t in treatment-resistant brexpiprazole 00
see also tricyclic antidepressants depression 96–8 dosing recommendations 02t
AMPA receptor 6f advantages and broad-spectrum
d-amphetamine 97–8 disadvantages 97t antidepressants 64
anger 36–7t CANMAT guidelines 99f bupropion 68, 70t, 98
implications for diagnosis and STAR*D study 98, 00, 0t drug interactions 77t
management 37–8 tricyclics 72, 74t and fatigue 42
anger attacks 37t venlafaxine 64–9, 80, 9, 07 pregnancy 07
anhedonia 23 vilazodone 70, 7t, 72 burden of illness , 5–9
antidepressants vortioxetine 7t, 72 buspirone, STAR*D study 00
agomelatine 70, 7t anti-inflammatory agents 7
in anxiety disorders 36 anxiety disorders 35–6, 36
atomoxetine 68, 70 implications for diagnosis and C
bupropion 68, 70t management 36 cancer, prevalence of
citalopram 67t, 68, 06–7, 00, pharmacotherapy 64, 98 depression 03f
0t, 09, 0b anxious depression 29t candidate gene studies 2–3
CANMAT appetite changes 24 CANMAT antidepressant
recommendations 64t aripiprazole 00 recommendations 64t
and cognitive function 40 dosing recommendations 02t for limited response to initial
comparative efficacy 64–5 assessment antidepressant 99f
comparison with diagnostic tools 46 capsulotomy 92
psychotherapy 55, 58 monitoring outcomes 47–8 cardiac disease, prevalence of
concurrent use with ECT 9 screening 45–6b depression 03f
desvenlafaxine 69, 69t, 07 of suicidality 46–7 cardiovascular comorbidity
discontinuation 80, 82 associated clinical features 35 6, 05t–6
drug interactions 4, 76, 77t–9t anxiety 35–6 cardiovascular disease risk 6, 05t
duloxetine 65, 68, 69t, 77t, 07 cognitive dysfunction 38–40 catastrophizing 56t
escitalopram 64–8, 06, 07, fatigue and low energy 42 catatonic depression 29t
09, 0b irritability and anger 36–8 cellular resilience
and fatigue 42 pain 4 pathways 6f–7
indications for 49
132 • index
cerebrovascular disease, somatic treatments; delusional (psychotic)
prevalence of treatment-resistant depression 29t
depression 03f depression dementia 40
childhood trauma 20–, 22 clinical response 48, 95 differentiation from
children clomipramine 65, 74t depression 02
antidepressants, safety and see also tricyclic antidepressants prevalence of depression 03f
efficacy 09 codeine, drug interactions 4 deprenyl see selegiline
disruptive mood dysregulation cognitive behavioural analysis desipramine 74t
disorder 28b system of psychotherapy see also tricyclic antidepressants
irritability 37 (CBASP) 54t, 58–9 desvenlafaxine 68, 69t
persistent depressive cognitive–behavioural therapy pregnancy 07
disorder 28b (CBT) 20, 54t, 57 dexamethasone suppression
symptoms 4 in children and adolescents test 7
treatment controversies 08–9 08–9, 0b diabetes 3
treatment effect on cognitive function 40 painful neuropathy 4
recommendations 0b maintenance treatment 60 prevalence of depression 03f
choice of treatment 49 in medical illnesses 05 diagnosis
psychotherapies 54–5 coronary heart disease 06 elderly patients 02
chronic disease management in peripartum depression 07 medically ill patients 03
(CDM) 45 cognitive deficits 8–20, diagnostic tools 46
chronic illness 5 24, 38–40 dichotomous thinking 56t
chronic pain conditions 4 after ECT 90– differential diagnosis 26f, 30–3
cingulotomy 92 dementia 02 disability 5–6
circadian rhythm implications for diagnosis and discontinuation of
disturbance of 8, 9f management 40 pharmacotherapy 80, 82
effects of light 87 cognitive domains, patient discontinuation symptoms,
citalopram 67t, 68 descriptions and FINISH mnemonic 82b
breastfeeding 07 neuropsychological disruptive mood dysregulation
in children and adolescents tests 39t disorder 28b
09, 0b cognitive therapy (CT) 54t, 56–7 dosulepin 74t
CREATE trial 06 comparison with interpersonal see also tricyclic antidepressants
pregnancy 07 psychotherapy 55 double depressions 26
STAR*D study 00, 0t recurrence prevention 60 drug interactions 4, 76, 77t–9t
see also selective serotonin ‘cold’ cognition 20, 38 DSM-5 (Diagnostic and Statistical
reuptake inhibitors collaborative care 49–50 Manual of Mental
classification of depression 25–6 combination therapy 96 Disorders, 5th edn)
DSM-5 criteria for major comorbidities classification 25
depressive episodes 27b cardiovascular disease 05t–6 criteria for major depressive
severity 30t diagnosis of depression 03 episodes 27b
sub-types 27, 29t–30t pharmacotherapy 03–4 criteria for persistent
clinical features , 23–5, 35 see also medical illness depressive disorder 28b
anxiety 35–6 complementary and alternative other depressive disorders 28b
cognitive dysfunction 38–40 medicine (CAM) 82–3b severity criteria 30t
fatigue and low energy 42 computer-delivered duloxetine 65, 68, 69t
irritability and anger 36–8 psychotherapies 59–60t drug interactions 77t
pain 4 concentration problems 24 pregnancy 07
SIGECAPS mnemonic 24t corticotropin-releasing factor dysphoria 37t
variation with age 4 (CRP) 7 dysthymia (dysthymic
clinical management 45 costs disorder) 26
assessment 45–8 socioeconomic burden , 6–7f
children and adolescents of treatment 8–9
recommendations 0b of untreated depression 7–8 E
safety and efficacy of course of depression 4–5 eclectic psychotherapy 53
antidepressants 09 C-reactive protein 7 economic burden , 6–7f
treatment CREATE (Cardiac Randomized Edinburgh Postnatal Depression
controversies 08–9 Evaluation of Scale 06, 4t, 28–9
choice of treatment 49 Antidepressant and elderly patients
collaborative care 49–50 Psychotherapy Efficacy) diagnostic issues 02
follow up 50 study 06 electroconvulsive therapy 04
optimizing adherence 49, 50b CREB (cAMP response element pharmacotherapy 03–4
patient education and binding) 6f, 7 symptoms 4
self-management 50–t CYP isoenzymes 76 electroconvulsive therapy (ECT)
treatment phases 48–9t 85, 89–90
see also antidepressants; cognitive function 40
complementary and D efficacy 90
alternative medicine; deep brain stimulation in elderly patients 04
pharmacotherapy; (DBS) 20, 92 evidence levels for 86t
psychological treatments; evidence levels for 86t indications for 90b
index • 133
in medically ill patients 04
relapse rate and prevention 9
G K
safety and side effects 90– gene-by-environment ketamine 5
emotion-dependent processing (GxE) interaction Korean Depression in Acute
(‘hot’ cognition) 20, 38 hypothesis 2f–2 Coronary Syndrome
patient descriptions and genetics –3 (K-DEPACS) study 06
neuropsychological genome scanning 2
Global Burden of Disease
tests 39t
energy, lack of 24, 42 Study 7f L
pharmacotherapy 98 glucocorticoids 7 Lam Employment Absence and
ENRICHD (Enhancing Recovery glutamate 5, 6f Productivity Scale (LEAPS)
in Coronary Heart group psychotherapies 59 48, 4t, 26–7
Disease) study 06 medically ill patients 04–5 leaden paralysis 24
environmental factors 20–2 guilt 24 levomilnacipran 63, 68, 69t
epidemiology 3–4t life events 20–2
light therapy 87–8f
prevalence of MDD in other
medical conditions 03f H evidence levels for 86t
prevalence of peripartum Hamilton Depression Rating limbic–cortical dysregulation
depression 06 Scale (HAM-D) 47, model 9–20f
epigenetic mechanisms 22 4t, 5–8 limbic neurosurgery 92
episodic dyscontrol 37t hippocampus 9 evidence levels for 86t
escitalopram 66, 67t, 68 HIV/AIDS, prevalence of linkage analysis studies 2
broad-spectrum action 64 depression 03f lisdexamfetamine 98
in children and adolescents Hospital Anxiety and Depression lithium
09, 0b scale (HADS) 3, 47, 03 as an adjunctive agent 97
efficacy 65 hostility 37t STAR*D study 00
K-DEPACS study 06 ‘hot’ cognition 20, 38 use after ECT 9
pregnancy 07 patient descriptions and Living Life To The Full 60t
see also selective serotonin neuropsychological lofepramine 74t
reuptake inhibitors tests 39t see also tricyclic
evidence-based psychotherapies hypericum (St John’s wort) 83 antidepressants
53, 54t hypersomnia 24 low mood 23
evidence levels for somatic hypomania 33
treatments 86t hypothalamic-pituitary-adrenal-
executive function 38 immune axis 7 M
patient descriptions and maintenance treatment
neuropsychological 48–9t, 82b
tests 39t I after ECT 9
exercise 87 ICD (International Classification pharmacotherapy 80
evidence levels for 86t of Diseases)-0 25 psychotherapies 60
severity criteria 30t major depressive disorder
imipramine 74t (MDD) 25–6
F see also tricyclic antidepressants differentiation from
family studies immune function disturbances 7 bereavement 3t
family therapy 04 insomnia 23 DSM-5 criteria 27b
fatigue 24, 42 pharmacotherapy 98 severity 27, 30t
pharmacotherapy 98 insulin shock therapy 85 specifiers 27, 29t
fibromyalgia 4 interest, loss of 23 MAPK (mitogen-activated protein
FINISH mnemonic, internet, resources for kinase) 6f
discontinuation self-management 5t maprotiline 74t
symptoms 82b internet-delivered see also tricyclic antidepressants
fluoxetine 66, 67t psychotherapies 59–60t marital therapy 59
breastfeeding 07–8 interpersonal psychotherapy (IPT) maternal deprivation 2
in children and adolescents 54t, 58t maximizing 56t
09, 0b in children and adolescents measurement-based care 47–8
discontinuation 80 08–9, 0b medical illness
drug interactions 76, 77t comparison with cognitive cardiovascular disease 05t–6
pregnancy 07 therapy 55 chronic pain conditions 4
see also selective serotonin CREATE trial 06 depressive symptoms 3, 32t
reuptake inhibitors maintenance treatment 60 diagnosis of depression 03
fluvoxamine 67t in medical illness 05 electroconvulsive therapy 04
drug interactions 77t in peripartum depression 07 pharmacotherapy 03–4
pregnancy 07 irritability 36–7t prevalence of depression 03f
see also selective serotonin implications for diagnosis and psychotherapy issues 04–5
reuptake inhibitors management 37–8 risk of 6
follow up 50 isocarboxazid 75t medication-induced depressive
functionality assessment 48 see also monoamine oxidase disorder 3
functional polymorphisms 2 inhibitors melanopsin 87
134 • index
melancholic depression 29t see also selective serotonin see also monoamine oxidase
memory deficits 8–20, reuptake inhibitors inhibitors
24, 38–40 nortriptyline 74t pleasure, loss of 23
after ECT 90– breastfeeding 07 polysomnography 8
implications for diagnosis and use after ECT 9 postpartum depression
management 40 see also tricyclic antidepressants antidepressants 07–8
patient descriptions and prevalence 06
neuropsychological risk factors 06
tests 39t O treatment approaches 07
meta-analyses of obesity, prevalence of postsynaptic receptors and
antidepressants 65 depression 03f processes 5f
methylphenidate 97–8 olanzapine 00 pregnancy
mianserin 70, 7t, 98 dosing recommendations 02t antidepressants 07
microRNAs 22 omega-3 fatty acids 83 see also peripartum depression;
mild depression 30t outcome monitoring 47–8 postpartum depression
milnacipran 68, 69t overeating 24 premenstrual dysphoric
mindfulness-based cognitive over-generalizing 56t disorder 28b
therapy (MBCT) 54t, 57 over-personalization 56t presynaptic receptors and
recurrence prevention 60 processes 5f
minimizing 56t prevalence 3–4
minor depression 28b P in other medical
mirtazapine 65, 70, 7t, 98 pain 4 conditions 03f
pregnancy 07 pain conditions, prevalence of peripartum depression 06
mixed depressive episodes 29t depression 03f prevention of recurrence see
mobile health (mHealth) 5, 59 paroxetine 66, 67t recurrence prevention
moclobemide 73, 75t breastfeeding 07 problem-solving therapy (PST)
drug interactions 78t discontinuation 80 54t, 55
switching antidepressants 80 drug interactions 76, 78t prognosis 5
washout periods 8t see also selective serotonin prognostic indicators 6b
see also monoamine oxidase reuptake inhibitors proinflammatory cytokines 7
inhibitors pathogenesis psychological factors 2f
modafinil 98 biological, psychological, and psychological treatments
moderate depression 30t social factors 2f behavioural activation 57
monoamine hypothesis 3–5 genetics –3 choice of treatment 54–5
monoamine oxidase inhibitors neurobiology 3–8 cognitive behavioural
(MAOIs) 63–4, 73 neuropsychology 8–22 analysis system of
doses 75t patient education 50 psychotherapy 58–9
drug interactions 78t Patient Health Questionnaire cognitive–behavioural therapy 57
mechanism of action 75t (PHQ-9) 47, 4t, 24 cognitive therapy 56–7
side effects 75t Perceived Deficits Questionnaire– comparison with
washout periods 80, 8t Depression,5 item pharmacotherapy 55, 58
Montgomery–Åsberg Depression (PDQ-D-5)4t, 25 effect on cognitive function 40
Rating Scale (MADRS) 47, peripartum depression 29t efficacy 53
4t, 8–20 antidepressants 07–8 evidence-based
MoodGYM 60t prevalence 06 psychotherapies 54t
mortality risk 6 treatment approaches 07 group psychotherapies 59
see also suicide risk persistent depressive disorder 26 indications for 49
multimodal agents 70– DSM-5 criteria 28b interpersonal psychotherapy 58t
myocardial infarction (MI) pharmacogenetic testing 76 maintenance and prevention 60
6, 05–6 pharmacotherapy mindfulness-based cognitive
in comorbidities 03–4 therapy 57
problem-solving therapy 55
N comparative efficacy of
antidepressants 64–5 psychodynamic
negative cognitions 56t comparison with psychotherapy 53
negative inference 56t psychotherapy 55, 58 in special groups
neuroanatomical discontinuation 80, 82 children and adolescents
abnormalities 3f in elderly patients 03–4 08–9, 0b
neurobiology 3–8 maintenance medically ill patients 04
neurochemical treatment 80, 82b peripartum depression 07
abnormalities 4f safety 65–6 technology-assisted 59–60t
neurogenesis theory 9 selecting an psychomotor changes 25
neuroplasticity pathways 6f–7 antidepressant 63–4t psychomotor speed, patient
neuropsychology 8–22 in treatment-resistant descriptions and
neurosurgery 92–3 depression 96–8 neuropsychological
NMDA receptor 6f advantages and tests 39t
noradrenaline (norepinephrine) disadvantages 97t psychostimulants 97–8
3, 6f see also antidepressants psychotic (delusional)
norfluoxetine 66 phenelzine 75t depression 29t
index • 135
Q selegiline (deprenyl) 73, 75t
drug interactions 78t
vortioxetine 7t
ECT 90–
QTc interval increase, switching antidepressants 80 second-generation
citalopram 68 washout periods 8t antipsychotics 00
quetiapine-XR 63, 72, 73t, see also monoamine oxidase SIGECAPS mnemonic 24t
98, 00 inhibitors situational analysis 58
dosing recommendations 02t self-management 50– sleep abnormalities 8, 9f, 23
drug interactions 78t resources 5t sleep deprivation (wake
Quick Inventory for Depressive self-rated scales 47–8 therapy) 85–6t
Symptomatology, self- Sequenced Treatment social disability 5
rated (QIDS-SR) 47–8, Alternatives to Relieve social factors 2f
4t, 21–3 Depression (STAR*D) socioeconomic burden , 6–7f
study 98, 00 somatic symptoms 4
R summary of results 0t
serotonin (5-HT) 3, 6f
of anxiety 36
somatic treatments 85
racing thoughts 25 serotonin and noradrenaline deep brain stimulation 92
randomized controlled reuptake inhibitors electroconvulsive
trials (RCTs) of (SNRIs) 68 therapy 89–9
antidepressants 65 doses 69t exercise 87
rating scales 47–8, 4t and fatigue 42 levels of supporting
reactive depression 03 mechanism of action 69t evidence 86t
reboxetine 64, 68, 70t pregnancy 07 light therapy 87–8f
recurrence prevention side effects 69t limbic neurosurgery 92
psychotherapies 56, 60 washout periods 8t transcranial magnetic
see also maintenance treatment serotonin syndrome 73 stimulation 89
relapse rates 5 sertraline 65, 66, 67t vagus nerve stimulation
after ECT 9 breastfeeding 07 9–2, 93
repetitive transcranial magnetic in children and adolescents wake therapy (sleep
stimulation (rTMS) 89 09, 0b deprivation) 85–6t
evidence levels for 86t pregnancy 07 STAR*D (Sequenced Treatment
Research Domain Criteria SAD-HART study 06 Alternatives to Relieve
(RDoC) 25 see also selective serotonin Depression) study 98, 00
risk factors for depression 46b reuptake inhibitors summary of results 0t
postpartum depression 06 severe depression 30t stepped care 45
risperidone 00 severity of depression 27, 30t St John’s wort (hypericum) 83
dosing recommendations 02t sex differences in prevalence 3 stress response 7
sexual problems 23 subcallosal cingulate 20
pharmacotherapy 98 substance-induced mood
S side effects of disorders 3, 33b
SAD-HART (Sertraline antidepressants 66 suicide risk 6, 25
AntiDepressant Heart Sheehan Disability Scale 48 and antidepressants
Attack Randomized short-episode depression 28b 65–6, 08b
Trial) 06 side effects of treatments in young people 09
SAM-e (S-adenosylmethionine) 83 antidepressants 76 assessment of 46
screening 45–6b during adjunctive therapy 96 reduction of 47
in postpartum period 06 agomelatine 7t risk factors 47t
seasonal affective disorder (SAD) bupropion 68, 70t surgical treatments 93
8, 29t citalopram 67t deep brain stimulation 92
light therapy 87–8f desvenlafaxine 69t limbic neurosurgery 92
second-generation antipsychotics in elderly patients 04 vagus nerve
(SGAs) 72, 00, 02t escitalopram 67t stimulation 9–2
dose 73t, 02t levomilnacipran 69t switching antidepressants 76,
mechanism of action 73t management of 98 80f, 96–7
side effects 73t in medical illnesses 04 advantages and
selective serotonin reuptake mianserin 7t disadvantages 97t
inhibitors (SSRIs) mirtazapine 7t washout periods 8t
64, 66, 68 monoamine oxidase symptom rating scales 47–8
in children and adolescents inhibitors 75t symptoms , 23–5
09, 0b quetiapine-XR 72 associated clinical features 35
doses 67t reboxetine 70t anxiety 35–6
and fatigue 42 selective serotonin reuptake cognitive dysfunction 38–40
mechanism of action 67t inhibitors 66, 67t, 68 fatigue and low energy 42
in patients with cardiovascular selegiline 75t irritability and anger 36–8
disease 06 serotonin and noradrenaline pain 4
pregnancy 07 reuptake inhibitors 69t of bipolar disorder 32–3
side effects 67t, 04 tricyclics 72, 74t elderly patients 02
switching agents 96–7 venlafaxine 69t SIGECAPS mnemonic 24t
washout periods 8t vilazodone 7t variation with age 4
136 • index
T alternative medicine;
pharmacotherapy;
overdose 66
pregnancy 07
technology-assisted psychological treatments; use after ECT 9
psychotherapy 59–60t somatic treatments vilazodone 63, 67t, 70, 7t, 72
telephone-delivered CBT 59–60 treatment targets 48 drug interactions 79t
total sleep deprivation (TSD) 85–6t tricyclic antidepressants see also selective serotonin
transcranial magnetic (TCAs) 72 reuptake inhibitors
stimulation 89 adjunctive agents 97 vortioxetine 7t, 72
evidence levels for 86t in children and adolescents drug interactions 79t
tranylcypromine 75t 09, 0b effect on cognitive function 40
see also monoamine oxidase discontinuation 80
inhibitors doses 74t
treatment choice 49 drug interactions 76, 79t W
antidepressants 63–4t mechanism of action 74t wake therapy (sleep
psychotherapies 54–5 side effects 74t, 04 deprivation) 85–6t
Treatment for Adolescents washout periods 8t washout periods 80, 8t
with Depression Study triiodothyronine 97, 98 websites, resources for
(TADS) 09 STAR*D study 00 self-management 5t
treatment phases 48–9t twin studies –2, 2 weight changes 24
treatment-resistant side effects of
depression (TRD) antidepressants 66
assessment 95–6b U
CANMAT guidelines 99f undertreatment 8f
definition 95
pharmacological
untreated depression, costs of 7–8 X
strategies 96–8 X approach, switching
antidepressants 76, 80f
advantages and
disadvantages 97t
V
vagus nerve stimulation (VNS)
second-generation
antipsychotics 00, 02t 9–2, 93 Y
STAR*D study 98, 00, 0t evidence levels for 86t yoga 83
treatments 2 V approach, switching
antidepressants 76, 80f
availability of 8f
costs of 8–9 venlafaxine 68, 69t Z
perceived need for 8f broad-spectrum action 64 zeitgebers 8
see also antidepressants; discontinuation 80 ziprasidone 00
complementary and efficacy 65