Web Based Education Module 4: Diagnosis and Management …



Web Based Education Module 4: “Doc, I’m Tired and Have Little Energy”

FINAL DRAFT - CORE CONTENT

|OUTLINE |CONTENT |

|I. Case Based Introduction |Mr. George is a 44 year old male with a past medical history of hypertension for 4 years. He comes to this visit requesting his serology results from his last |

| |visit. At that time, he complained of feeling tired and having little energy especially in the morning hours. Mr. George denied shortness of breath, chest pains, |

| |palpitations, fevers, or anxiety. No GI complaints, no melena, no hematochezia. He read on the internet about thyroid disease, anemia, and Lyme disease which all |

| |could explain his symptoms. He has not been traveling outside of Manhattan and did not visit a wooded area recently. Those laboratory tests from his last visit one|

| |month ago are completely negative today. He also had a recent annual physical examination two months ago and everything was normal. |

| | |

| |Past Medical History – Hypertension |

| |Medication – Hydrochlorothiazide 25mg once a day |

| |Past Social History – Works as an office manager. Heavy stressors under a new boss. Married to his wife of 14 years, monogamous, and has one 10 year old daughter. |

| |Denies alcohol, drug, and tobacco use. Sexually active with his wife about once a year only – “as we just don’t have time or energy anymore.” No interpersonal |

| |conflicts at home with family, although she laments that they don’t go out much anymore. |

| |Family History – Father is alive and suffers from gout, hypertension, and cholesterol. Mother is alive and has been diagnosed with diabetes last year. |

| | |

| |ROS – He has trouble falling asleep almost every night and he wanted to ask you about “safe” sleeping pills that he heard about on television commercials. This has|

| |been going on for 8 weeks. |

| | |

| |PE – |

| |BP 135/80 P70 R21 Wgt 210 lbs (was 195 lbs 5 months ago) |

| |General – In no acute distress |

| |HEENT – WNL, No JVD, No thyromegaly or nodules |

| |Lungs – CTA B |

| |Cor – RRR No M |

| |Abd – S / NT Pos BS |

| |Ext – No C / C / E |

| |Neuro – No tremors; reflexes 2+ upper and lower extremities; normal hand to nose coordination, normal gait – essentially a normal neurological exam |

| |Psych – Admits to less pleasure in doing things he used to like to do, and feels down occasionally but does not feel he is depressed. He has increased appetite |

| |having gained 15 pounds since his visit 5 months ago. He attributed the weight gain to stress at work. Denies suicidal ideation or homicidal ideation. He also |

| |notices trouble concentrating at work and “can’t get into television shows or movies” in the same way he did prior. |

| | |

| |Labs: |

| |Guaiacs Neg x 3 |

| |TSH 1.44 (WNL 0.34 – 4.25) |

| |Chem 7 WNL |

| |Hct 40 |

| |Lyme Titers Neg |

| | |

| |Question 1) Mr. George feels tired and has little energy. His physical examination and lab work are negative. He completely denies being depressed. Upon further |

| |questioning he does describe losing interest in activities he used to like to do, increased appetite and weight gain, problems with concentration, and insomnia. At|

| |this point, Mr. George wants to know the next appropriate step in his assessment and management. Of the following, which one is the most appropriate |

| |recommendation? |

| | |

| |Perform a whole body CT or MRI scan to look for an occult source |

| |Recommend that Mr. George and his family go on a vacation |

| |Consider testing for underlying neurological disease |

| |Refer him to a gastroenterologist for a colonoscopy screen |

| |Have Mr. George complete a standardized screening questionnaire for depression |

| |Write him a prescription for sleeping medications |

| | |

| |The correct answer is e. Mr. George has many classic signs and symptoms of depression (e.g., anhedonia, insomnia, weight gain, etc.), and performing a standardized|

| |screening questionnaire for major depression is appropriate to assist in making the diagnosis. Many people who suffer from depression do not report a depressed |

| |mood. Although some neurological diseases can have depressive symptoms, major depression is much more common in the primary care setting and should be evaluated |

| |first. He also has no neurological findings. A colonoscopy would not seem appropriate in a 44 year old man at this point without gastrointestinal complaints, no |

| |findings of anemia, and weight gain. A whole body CT or MRI scan is not cost effective, and may cause more physical and emotional harm than benefit. Insomnia may |

| |be a sentinel symptom of depression, and prescribing sleeping medications without assessing the patient for depression would not be “best practice”. Although a |

| |vacation may be in order for Mr. George and his family, it will not effectively treat an underlying depressive disorder. |

|II. Facts About Depression |Web Based Education Module 4: “The Diagnosis and Management of Depression in The Primary Care Setting” |

| | |

| |Facts About Depression |

| | |

| |Depression is one of the most common conditions seen by primary care physicians second only to hypertension. The point prevalence in the outpatient primary care |

| |setting is between 4.8 – 8.6%, and the point prevalence in the inpatient setting is 14.6% Large scale studies have suggested that 7 – 12% of men will suffer an |

| |episode of major depression at one point in their lives, while the percentage for women is more on the order of 20 – 25%. Bipolar disorder is less common than |

| |depression (0.4% in men and 1.6% in women over their lifetimes) but has no gender difference. Depression can begin in early adulthood, with a peak onset between |

| |ages 20 – 30. Over half the people who experience an episode of major depression are at risk for a relapse and recurrence (Cutler, J. Charon, R. 1999). |

| | |

| |Depression costs the United States economy more than 43 million dollars every year in medical treatments and lost work productivity (Kahn, 1999). Globally, |

| |depression accounts for 4.4% of the disease burden, which is similar to that of diarrheal diseases and ischemic heart disease (Mann, 2003). 300 million people in |

| |the world suffer from depression with 18 million of them in the United States (Harvard Press, 1996). |

| | |

| |Depression has a high rate of morbidity and mortality when left untreated. Most patients do not necessarily complain of feeling depressed, but rather that they |

| |have a lack of interest or pleasure in activities, may have somatic complaints, or vague unexplained complaints. In one study, 69% of diagnosed depressed patients |

| |reported unexplained physical symptoms as their chief complaint (NYCDOH, 2006). Unlike patients with depression in psychiatric inpatient or outpatient care |

| |settings, persons suffering from depression in primary care settings often present as “undifferentiated” patients. |

| | |

| |Depression is often undiagnosed and untreated, and even when it is diagnosed it is often under treated. Primary care physicians must remain alert to effectively |

| |screen for depression in their patients. Barriers to effective screening include inadequate education and training, limited coordination with mental health |

| |resources, time constraints, poor systematic follow up, and inadequate reimbursement (NYCDOH, 2006). It is sometimes difficult for primary care providers to |

| |determine if a patient is depressed as opposed to experiencing a normal response to the challenges of everyday life. Gender, age, culture, and language of the |

| |patient and the physician may create further barriers. Furthermore, persons with mood disorders also may have enormous stigma associated with being mentally ill – |

| |and may see it as a sign of weakness, fear the criticism of other people, or be concerned that they will be institutionalized. |

| | |

| |Patients who suffer from diabetes, ischemic heart disease, stroke, or lung disorders that have concurrent depression have poorer outcomes than those without |

| |depression. Depressed patients have a higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide (Mann, 2005). Fifteen percent |

| |of patients with severe mood disorders die from suicide. In one study among older patients who committed suicide, 20% visited their primary care physician on the |

| |same day as their suicide (NYCDOH, 2006). |

|III. Goals and Objectives |Educational Goal: Students will be able to demonstrate competencies in knowledge, skills, and attitudes of an effective clinician in evaluating and caring for |

| |patients with depression and mood disorders in the primary care setting. |

| | |

| |Medical Knowledge |

| | |

| |The students will: |

| |Apply the nationally recognized guidelines for screening and diagnosing depression and other mood disorders in patient care. |

| |Apply the practice guidelines for the treatment of patients with major depressive disorders. |

| |Identify appropriate elements of a suicide risk assessment and action plan. |

| | |

| |Patient Care |

| | |

| |The students will: |

| |Recognize the importance of effective detection and treatment of depression in adults. |

| |Review the depressed mood algorithm and the DSM-IV to guide the differential diagnosis in the primary care setting. |

| |Identify manic and hypomanic symptoms associated with bipolar disorder in depressed patients. |

| |Formulate management plans for the longitudinal care of patients with depression. |

| |Develop prevention plans, including health education and behavioral change strategies, for patients with depression. |

| | |

| |Interpersonal and Communication Skills |

| | |

| |The student will: |

| |Explore relevant psychosocial and cultural issues that impact on care. |

| |Provide effective education and counseling to patients with mood disorders and their families. |

| |Demonstrate awareness of improved health care outcomes through effective communication and forming therapeutic alliances with patients. |

| |Discuss behaviors with patients, in an empathic, respectful and non judgmental manner. |

| | |

| |Practice Based Learning |

| | |

| |The student will: |

| |Use information technology to access medical information and support self-education and clinical decision making. |

| |Critically review the medical literature regarding new evidence based clinical trials and its implication on current treatment guidelines of depression and mood |

| |disorders. |

| |Use information technology to access patient and family education resources on depression. |

| | |

| |Professionalism |

| | |

| |The student will: |

| |Demonstrate professionalism by completing this web module during the assigned period. |

| | |

| |Systems Based Practice |

| | |

| |The student will: |

| |Identify which cases can be managed by the primary care physician and which should be referred for co-management with a specialist. |

| |Improve patient care outcomes through effective communication with other health care professionals, partnerships through community resources, and government |

| |agencies. |

|IV. The Etiology of Mood |The Etiology of Mood Disorders |

|Disorders | |

| |Neurotransmitters, genetics, and psychosocial stressors all seem to play a part in mood disorders. |

| | |

| |The same depressed patient may have variable clinical symptoms from one major depressive episode to another. Despite this variability, major depression may have |

| |the same underlying cause. The variable presentations may be due to differing patterns in neurotransmitter abnormalities. Deficiencies in serotonin, |

| |norepinephrine, dopamine, GABA, and peptide neurotransmitters (somastatin, thyroid-related hormones, and brain derived neurotrophic factors) have all been |

| |hypothesized as contributing to depression. Over activity in other neurotransmitters including substance P, and acetylcholine, and elevated serum cortisol (with |

| |lack of diurnal variation) has also been proposed to contribute to depression. |

| | |

| |Although no specific genes that affect neurotransmitters or hormones have been identified, both depression and bipolar disorder are clearly inheritable. The first |

| |degree relatives of a patient with recurrent major depression have a 1.5 – 3 times higher risk of depression themselves as compared to the general population. 27% |

| |of children with one parent with a mood disorder will develop a mood disorder themselves, and that increases to 50 – 75% if both parents are affected. First degree|

| |relatives of patients with bipolar disorder have an estimated 12% lifetime prevalence of bipolar disorder, which is 10 times higher than the general population |

| |(Cutler, J. Charon, R. 1999). Genetic predisposition is not enough to result in a patient with a mood disorder, however. Identical twins have incomplete |

| |concordance in regards to depression. Depression also occurs in patients with no family history of mood disorders, which may infer that they have another acquired |

| |biological deficiency such as a viral insult, genetic or perinatal insult, or vascular brain disease. |

| | |

| |Psychosocial stressors in combination with a genetic predisposition have been postulated to alter the size of neurons, neuronal function, repair capabilities, and |

| |production of new neurons. Elevated cortisol in some depressed patients may reduce hippocampus volume, especially if their depression has not been treated in some |

| |time. Brain imagery has also noted some altered structures, which suggest some changes in neurocircuitry. Psychosocial theories suggest that experiences of “loss” |

| |in certain vulnerable individuals may cause depression, either through trauma, parental loss, loss of love from others, or loss of self-esteem. |

| | |

| |[pic] |

| |“On the Threshold of Eternity / At Eternity’s Gate / Old Man in Sorrow” - Vincent van Gogh |

| | |

| |LINK: Vincent van Gogh (Wikipedia: ) |

|V. Diagnosing Mood Disorders |Screening for Depression |

|Screening for Depression | |

|Major Depressive Episode |The primary care physician’s most powerful screening tool for depression is patient observation and active listening skills. Most depressed patients do not |

|Approaches To The Clinical |realize they are depressed – and this is especially true in elderly patients. A physician should consider that a patient may have depression in the setting of |

|Interview |unexplained physical symptoms or complaints. The higher the number of somatic complaints that a patient has, the higher the risk that they may have a mood |

|Depressive Spectrum Disorders: |disorder. Other clues may be a patient with persistent worries or concerns about medical illness, complaints that do not respond to typical interventions, or |

|The Depressed Mood Algorithm |complaints outright of anxiety or panic attacks. Patients with substance abuse issues may also suffer from a mood disorder. A careful history of present illness, |

|Mood disorder due to a general |past medical history, social and family history, and review of systems may yield more important information for making the diagnosis. |

|medical condition | |

|Substance-induced depression |The primary care physician should ask open-ended questions of the patient about normal patterns as well as variations to determine baseline function and mood. |

|Dysthymic Disorder |Mood is a range of emotions that a person feels over a period of time, while affect is how a person displays his or her mood. The presence of a mood disorder may |

|Bereavement |affect a person’s concentration, attention, motivation, interest, and sleep, as well as energy level, hunger and satiety levels, sexual pleasure, and pain |

|Adjustment disorder with |sensation. These patients also frequently lose interest and lose pleasure (anhedonia) in things, people, or activities that they used to enjoy. Interruption in |

|depressed mood |personal relationships with others can be a side effect due to increasing anger and conflicts, lower frustration tolerance, or from apathy and lack of enthusiastic|

|Seasonal affective disorders |feelings towards other people. Patients with depression may become emotionally constricted and lose their emotional flexibility. |

|Postpartum depression | |

|Pseudodementia |Depression can impair cognitive function. Cognitive dysfunction is common and patients may state that when they watch television they lose the point of the story;|

|Manic and Hypomanic Symptoms and|they read the same page of a book over and over again without comprehension; or lose the point of conversations with other people. A depressed patient’s memories |

|Bipolar Disorders |may amount to more of selective recall, and normal perceptions may become distorted. Severe cognitive impairment due to depression is known as pseudodementia, and |

|Suicidal Patients – students to |may be seen in elder populations or patients with central nervous disorders. |

|identify | |

| |Psychomotor activity is usually decreased in depressed patients. Psychomotor retardation is present when thoughts, motor movements, or speech are slowed down. |

| |Psychomotor agitation can also occur and is present when patients experience unintentional and purposeless movements – such as unstoppable crying, pacing around a |

| |room, or hand-wringing. Frequently patients may complain of insomnia. In addition to having difficulty falling asleep, depressed patients typically wake up in the |

| |middle of the night or early in the morning with feelings of sadness, anxiety, or thoughts of dread or doom. They may also sleep excessively or stay most of the |

| |day in bed. |

| | |

| |Depressed patients may also have self-worth that goes through turbulent fluctuations. For depressed patients, past events may be viewed with extreme guilt and self|

| |criticism, and feelings of worthlessness. Patients may view themselves and their world as hopeless. Suicidal ideation or a history of suicidal attempts from the |

| |patient should be assessed. Asking depressed patients about recent bereavement is also important to note. |

| | |

| |A past medical history of prior episodes of depression is a very important question because you may be observing a relapsing episode. In addition, the physician |

| |should inquire about a previous history of bipolar disorder because inappropriate treatment with an antidepressant-therapy alone in these patients may precipitate |

| |a manic episode. It is also important to inquire about a family history of depression or bipolar disorder. |

| | |

| |When to think about screening adults for depression |

| | |

| |Personal previous history of depression or bipolar disorder |

| |First-degree biologic relative with history of depression or bipolar disorders |

| |Patients with chronic diseases |

| |Obesity |

| |Chronic pain (e.g., backache, headache) |

| |Impoverished home environment |

| |Financial strain |

| |Experiencing major life changes |

| |Pregnant or postpartum |

| |Socially isolated |

| |Multiple vague and unexplained symptoms (e.g., gastrointestinal, cardiovascular, neurological) |

| |Fatigue or sleep disturbance |

| |Substance abuse (e.g., alcohol or drugs) |

| |Loss of interest in sexual activity |

| |Elderly age |

| | |

| |Adapted from Sharp, LK, Lipsky MS. “Screening for depression across the lifespan: a review of measures for use in primary care settings.” American Family |

| |Physician. 2002; 66: 1001-1008 |

| | |

| |Question 2) Which are the current recommendations of United States Preventive Screening Task Force for screening adults for depression in primary care settings? |

| | |

| |No recommendation for or against routine screening for depression in primary care settings |

| |Screen only adults with positive risk factors for major depression, such as those with a positive family history or chronic pain |

| |Screen in all primary care practices because it is highly effective |

| |Screen only when the primary care practice has a psychiatrist on staff |

| |Screen only when systems are in place to ensure adequate treatment and follow up |

| | |

| |The correct answer is e. The United States Preventive Screening Task Force recommends “screening adults for depression in clinical practices that have systems in |

| |place to assure accurate diagnosis, effective treatment, and follow up” (USPSTF, 2006). The system in place to assure follow up and monitoring can be the primary |

| |care physician, their primary care colleagues, or properly trained staff such as nurses. Access to mental health services, outside the practice, is important |

| |should referrals be necessary for complicated cases (e.g., psychiatrists, therapists, emergency departments, etc.). The USPSTF recommends that clinicians provide |

| |depression screening to eligible patients because of fair evidence that screening improves important health outcomes and concludes that benefits outweigh harms. |

| |The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective, but the clinical impact of routine |

| |depression screening has not been studied in pediatric populations in primary care settings. (Source: United States Preventive Screening Task Force. Screening for |

| |depression: Recommendations and rationale. November 2006 Recommendations. ) |

| | |

| |There are many formal screening tools available such as the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire (GHQ), |

| |Center for Epidemiologic Study Depression Scale (CES-D), and the Patient Health Questionaire-2 (PHQ-2). The USPSTF does not recommend one screening test over |

| |another and the interval for screening that is considered optimal is unknown. Recurrent screening in patients with a history of depression, unexplained somatic |

| |symptoms, substance abuse, chronic pain, or co-morbid psychological conditions may be the most useful. Any screening test that is positive requires a full |

| |diagnostic interview that uses standard diagnostic criteria, Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) to determine the |

| |presence of major depressive disorder and/or dysthymia. |

| | |

| |The Patient Health Questionnaire - 2 (PHQ-2) is a validated primary care tool for depression screening, and is favored because of the relative ease of using a two |

| |question tool and because the USPSTF believes that with current available evidence it is as effective as longer screening tools. |

| | |

| |Patient Health Questionnaire – 2 (PHQ-2) |

| | |

| |Screen for depression by asking the following 2 questions: |

| | |

| |Over the past 2 weeks, have you been bothered by: |

| |little interest or pleasure in doing things? |

| |feeling down, depressed, or hopeless? |

| | |

| |A “no” response to both questions is a negative screen. |

| | |

| |A “yes” response to either question OR if the physician is still concerned about depression, then the physician should ask more thorough assessment questions |

| |using |

| |the Patient Health Questionnaire – 9 (PHQ-9). |

| | |

| | |

| |The Patient Health Questionnaire – 9 (PHQ-9) is a nine item questionnaire that can be completed by the patient before or during a primary care office visit. It is |

| |available in several languages. The PHQ-9 can reliably detect and quantify the severity of depression using the DSM-IV criteria for major depressive episode. The |

| |PHQ – 9 was created by Dr. Robert Spitzer, et al. at Columbia University and is copyright protected by Pfizer Inc. The PHQ – 9 is also useful for patient follow up|

| |visits to assess symptom management. Instructions on the use of the PHQ – 9 is available on the PDF files below: |

| | |

| |LINK: PDF of PHQ – 9 (English) |

| | |

| |LINK: PDF of PHQ – 9 (Spanish) |

| | |

| |Major Depressive Disorder |

| | |

| |Summary of DSM-IV Criteria for Major Depressive Episode |

| | |

| |If depressed mood or loss of interest or pleasure persists for more than at least a two-week period, consider the diagnosis of major depressive episode. The |

| |diagnostic criteria are summarized below: |

| | |

| |At least five of the following symptoms have been present during the same two-week period, nearly every day, and represent a change from previous functioning. At |

| |least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure: |

| |Depressed mood (or alternatively can be irritable mood in children and adolescents) |

| |Marked diminished interest or pleasure in all, or almost all, activities |

| |Significant weight loss or weight gain when not dieting |

| |Insomnia or hypersomnia |

| |Psychomotor retardation or agitation |

| |Fatigue or loss of energy |

| |Feelings of worthlessness or excessive or inappropriate guilt |

| |Diminished ability to think or concentrate |

| |Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide |

| |Symptoms are not accounted for by a mood disorder due to a general medical condition, a substance-induced mood disorder, or bereavement (normal reaction to the |

| |death of a loved one). |

| |Symptoms are not better accounted for by a psychotic disorder (e.g. schizoaffective disorder). |

| | |

| | |

| |A well-known mnemonic that is commonly used to remember the DSM-IV criteria is SIGECAPS: |

| | |

| |Sleep |

| |Interest (anhedonia) |

| |Guilt |

| |Energy |

| |Concentration |

| |Appetite |

| |Psychomotor |

| |Suicidality |

| | |

| |A major depressive episode can be associated with special features: melancholic, psychotic, or atypical. |

| | |

| |Patients with melancholic features will report nearly total anhedonia. Depressed patients with melancholia must have three of the following symptoms: diurnal |

| |variation (depression worse in the morning); pervasive and irremediable depressed mood; marked psychomotor retardation or agitation; significant weight loss or |

| |anorexia; excessive or inappropriate guilt; and early morning awakening. Depressed patients with melancholic features have the best response to pharmacotherapy. |

| | |

| |Depressed patients that have psychotic features such as hallucinations and delusions are at very high risk for suicide even if they deny suicidal ideation. These |

| |patients should be sent for hospitalization immediately and should be under the care of a psychiatrist. |

| | |

| |Patients with atypical features have milder depressed symptoms. Depressed patients with atypical features must experience mood reactivity as well as two of the |

| |following: leaden paralysis (enormous effort to walk or exert); hypersomnia; rejection hypersensitivity (even when the patient is not acutely depressed); |

| |overeating or weight gain. These patients respond less to tricyclic antidepressants. |

| | |

| |Approaches to Interviewing Patients with Suspected Depression |

| | |

| |Depressed patients may feel so helpless, hopeless, indecisive, or lacking in energy that physicians may need to take a more active role to engage the patient or to|

| |show their interest or concern. Again in major depression, the more common complaint is anhedonia and not depressed mood. Quiet listening and empathy are important|

| |approaches physicians can use with patients. A caring and nonjudgmental tone is critical to allay patient fears of the stigma of depression. Introducing the topic |

| |of depression with an educational statement first and then asking the patient for their response may help the patient not feel judged (example – “Patients who have|

| |had a heart attack sometimes get depressed or down after the event. Has this been happening to you recently?”). Making a statement instead of a question may allow|

| |the patient to have permission to be depressed and to know that you are willing and open to discussing the issue without judgment (example – “It sounds like you |

| |have been pretty down recently.”). |

| | |

| |Physicians may want to excuse depression symptoms in patients by attributing them to stressors or complications of life. Patients with increasing financial stress,|

| |work difficulties, and relationship problems should raise further possibility of major depression. |

| | |

| |These patients may be unduly critical of themselves but may also be critical of others including their doctors. It is important to recognize when they evoke |

| |frustration or anger in you so that you can avoid negative countertransference and avoid directing anger back at the patient. |

| | |

| |Depressive Spectrum Disorders: The Depressed Mood Algorithm |

| | |

| |Major depressive episode is just one of several depressive spectrum disorders. In addition, depression may be associated with chronic medical illnesses. The |

| |following “depressed mood algorithm” can be used in primary care settings to assist in making the differential diagnosis. |

| | |

| |Depressed Mood Algorithm |

| | |

| |[pic] |

| | |

| |Adapted with permission from “Depression” Janis Cutler MD and Rita Charon, MD. Primary Care Psychiatry and Behavioral Medicine:  Brief Office Treatment and |

| |Management Pathways.  Edited by RE Feinstein, AA Brewer.  Springer Publishing Co., New York, NY.  1999 |

| | |

| |Depression Due To General Medical Conditions |

| | |

| |Alterations in mood may be related to underlying medical conditions. Depression may be associated with other chronic medical diseases such as cancer, stroke, heart|

| |disease, endocrine disorders, neurological diseases, epilepsy, gastrointestinal diseases, rheumatologic diseases, and severe anemia. This depression is independent|

| |of the psychological impact of the stress of the illness, and is patho-physiologically related to the underlying condition. |

| | |

| |Medical Conditions Associated With Increased Incidence of Depression |

| | |

| |Cardiac disease |

| |Ischemic disease, Myocardial infarction |

| |Heart failure |

| | |

| |Cancer |

| |Brain cancer |

| |Pancreatic cancer |

| | |

| |Endocrine disorders |

| |Hyperthyroidism |

| |Hypothyroidism |

| |Diabetes |

| |Parathyroid dysfunction |

| |Cushing’s disease |

| | |

| |Gastrointestinal disorders |

| |Inflammatory bowel disease |

| |Irritable bowel syndrome |

| |Hepatic encephalopathy |

| |Cirrhosis |

| | |

| |Neurologic disease |

| |Stroke |

| |Chronic headache |

| |Dementias |

| |Traumatic brain injury |

| |Multiple sclerosis |

| |Parkinson’s disease |

| |Epilepsy |

| | |

| |Pulmonary disease |

| |Sleep apnea |

| |Reactive airway disease |

| | |

| |Rheumatologic disease |

| |Lupus |

| |Rheumatoid arthritis |

| |Chronic fatigue syndrome |

| |Fibromyalgia |

| | |

| |Metabolic disease |

| |Renal failure |

| |Electrolyte disturbances |

| | |

| |Infectious disease |

| |HIV disease |

| |Syphilis |

| |Hepatitis |

| |Lyme disease |

| | |

| |Hematologic disorder |

| |Severe anemia |

| | |

| | |

| |Identification of co-morbid disease or conditions is important in patients with depression. Primary care physicians should consider initial lab testing such as |

| |thyroid-stimulating hormone, complete blood count, and chemistry panel. The findings of the complete history and physical examination may clarify the need for |

| |further testing for other diseases or syndromes. |

| | |

| |Depression Impacting Existing Medical Illness |

| | |

| |Patients who suffer from diabetes, ischemic heart disease, stroke, or lung disorders and who have concurrent depression have poorer outcomes than those without |

| |depression. Depressed patients, in general, have a higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide. |

| | |

| |Question 3) Depression may affect the management of general medical illness. Which of the following statement is false? |

| | |

| |Patients with depression may exhibit maladaptive interpersonal behaviors which can make collaboration with physicians more challenging |

| |Patients with depression have higher rates of adverse health-risk behaviors when compared to non-depressed patients |

| |Patients with aversive symptoms such as pain are at an increased risk for developing depressive disorders |

| |The presence of a chronic medical illness is the most prevalent risk factor for the development of depression |

| |The importance of screening, diagnosing, and treating depression after a myocardial infarction has been well documented |

| | |

| |The correct answer is d. The presence of a chronic medical illness alone is not the most prevalent risk factor for developing depression. Depressed patients have |

| |higher rates of adverse health risk behaviors which may lead to higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide. |

| |Chronic pain is known to be a risk factor for developing depression. Depressed patients may express maladaptive interpersonal behaviors such as anger or |

| |non-adherence which may cause some conflict with their medical providers. Screening, diagnosing, and treating depression after a myocardial infarction has been |

| |found to be of benefit in these patients. |

| | |

| |Substance-induced depression |

| | |

| |Depression may be induced by substances ingested for recreation or mood alteration or from their withdrawal. These substances include alcohol, hypnotics, |

| |sedatives, opiates, marijuana, amphetamines, cocaine, and other designer drugs (e.g., ketamine, ecstasy). Prescription drugs used for medical treatment can also |

| |cause mood disturbances such as blood pressure medication (e.g., reserpine, propanolol), anticholinergics, steroids, oral contraceptives, psychotropic medications,|

| |and antineoplastic drugs. |

| | |

| |Dysthymic disorder |

| | |

| |Dysthymic disorder is a chronic form of depression. The signs and symptoms are milder but can cause much distress and dysfunction. The patient must have at least a|

| |two year history of complaints occurring on over half the days to make the diagnosis. It is important to distinguish dysthymic disorder from major depression |

| |because dysthymic disorder is more chronic and unremitting, and less responsive to pharmacotherapy. Family and friends may experience people with dysthymic |

| |disorders to be chronic complainers or pessimists. |

| | |

| |Summary of DSM-IV Criteria for Dysthymic Disorder |

| | |

| |Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least two years. Note: In |

| |children and adolescents, mood can be irritable and duration must be at least one year. |

| |Presence, while depressed, of two (or more) of the following: |

| |Poor appetite or overeating |

| |Insomnia or hypersomnia |

| |Low energy or fatigue |

| |Low self-esteem |

| |Poor concentration or difficulty making decisions |

| |Feelings of hopelessness |

| |During the two year period (one year for children and adolescents) of the disturbance, the person has never been without the symptoms in criteria A or B for more |

| |than two-months at a time. |

| |No major depressive episode has been present during the first two years of the disturbance (one year for children and adolescents); i.e, the disturbance is not |

| |better accounted for by chronic major depressive disorder, or major depressive disorder in patial remission. |

| |There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder. |

| |The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia, or delusional disorder. |

| |The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or general medical condition (e.g., |

| |hypothyroidism). |

| |The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. |

| | |

| | |

| |Bereavement |

| | |

| |Bereavement is a normal reaction to the loss of a loved one. It is accompanied by insomnia, sadness, weight loss, decreased appetite. Symptoms resolve normally |

| |within 2 months and do not require psychotherapy or pharmacotherapy. When symptoms persist beyond 2 months, the possibility of a diagnosis of major depression |

| |exists. Pathologic symptoms include thoughts of death beyond the wish to be with the lost loved one, excessive guilt, an overwhelming new sense of worthlessness, |

| |severe psychomotor retardation, hallucinations (other than transiently hearing the voice or seeing the image of the loved one), or the inability to perform usual |

| |tasks and obligations. |

| | |

| |Adjustment disorder with depressed mood |

| | |

| |Adjustment disorder with depressed mood is diagnosed when the patient has depressive symptoms or complaints within 3 months of an identifiable psychosocial |

| |stressor. Stressors may include academic failure, job loss, or divorce. The stressor causes depressed symptoms that do not meet the criteria for major depression |

| |or dysthymic disorder. The treatment of choice is psychotherapy over pharmacologic therapy. |

| | |

| |Seasonal affective disorders |

| | |

| |Major depressive episodes that have a seasonal pattern, particularly with the start of fall or winter, or when natural daylight decreases, are considered seasonal |

| |affective disorders. The diagnosis can not be made if there is a clear psychosocial stressor related to the change in season. These patients respond to standard |

| |antidepressants and psychotherapy, in addition to light therapy. |

| | |

| |Depression in pregnancy and postpartum depression |

| | |

| |Question 4) You have a 28 year old woman who is in her third trimester of pregnancy. She has been diagnosed with severe depression and is under the care of a |

| |psychiatrist. She wants to discuss with you the risk of taking antidepressants during the rest of her pregnancy. Which of one of the following statements is true? |

| | |

| |If she takes an SSRI (selective serotonin reuptake inhibitor), her newborn has a small risk of developing a transient withdrawal syndrome that may consist of |

| |inconsolable crying, irritability, tachypnea, thermal instability, and poor muscle tone. |

| |If she takes an SSRI (selective serotonin reuptake inhibitor), her newborn has a small risk of developing a permanent serotonin syndrome that may consist of |

| |inconsolable crying, irritability, tachypnea, thermal instability, and poor muscle tone. |

| |If she takes an SSRI, her newborn will likely be larger than a newborn delivered by a mother not taking antidepressants. |

| |Tricyclic antidepressants have teratogenic effects. |

| |She should stop any antidepressant a few weeks prior to her due date to prevent neonatal withdrawal syndrome. |

| | |

| |The correct answer is a. Selective serotonin reuptake inhibitors are the agents of choice. Selective serotonin reuptake inhibitors and tricyclic antidepressants |

| |appear to have no teratogenic effects. There is also a small but significant risk of “withdrawal syndrome” in the newborn if serotonergic antidepressants are taken|

| |during the third trimester. This “withdrawal syndrome” consists of irritability, inconsolable crying, tachypnea, thermal instability, and poor muscle tone but is |

| |usually mild and transient. More recently, a case-control study reported a possible association between SSRI use in late pregnancy and persistent pulmonary |

| |hypertension in the offspring. |

| | |

| |Although depression in pregnancy and postpartum depression is beyond the scope of this web module, it is important for primary care physicians to be aware of |

| |screening these patients for timely intervention. |

| | |

| |Medical management of depressed patients during pregnancy usually stirs discomfort in physicians because of fear of teratogenic effects in the fetus. Adverse |

| |effects of not treating this population are well documented, as well as the safety profiles of commonly prescribed psychiatric medications. Selective serotonin |

| |reuptake inhibitors are the agents of choice. Fluoxetine and tricyclic antidepressants appear to have no teratogenic effects, and new data shows similar safety |

| |profiles for other selective serotonin reuptake inhibitors. The mood stabilizers (e.g., dilantin, valproic acid, carbamazepine) appear to be teratogenic. The |

| |decisions regarding the use of psychiatric medications should be individualized. The most important factor is usually the patient’s level of functioning in the |

| |past when she was not taking medications. There is a small but significant risk of “withdrawal syndrome” in the newborn if serotonergic antidepressants are taken |

| |during the third trimester. This “withdrawal syndrome” consists of irritability, inconsolable crying, tachypnea, thermal instability, and poor muscle tone but is |

| |usually mild and transient. Overall, pregnant patients, once identified with depression, should be under the care of a psychiatrist and an obstetrician or family |

| |physician with experience in high risk obstetrics. Psychotherapy has also been found to be useful in these women. |

| | |

| |Postpartum depression typically occurs within one month of delivering a baby. Normal “baby blues” can begin 24 hours after delivery and last up to 10 days. |

| |Postpartum depression is not different from a major depressive episode, but the primary care physician or obstetrician should recognize the symptoms as immediate |

| |interventions can have positive outcomes for the mother and baby. One important challenge is that the onset of postpartum depression frequently occurs before the |

| |patient is seen for a routine six-week postpartum visit. The risk-benefit decision about whether to start antidepressants in a breastfeeding woman is based on the |

| |severity of the depression and the need for pharmacotherapy, rather than any known risks to the infant. |

| | |

| |More information on treatment of depression in pregnancy, postpartum women, and breastfeeding woman can be found in this web module’s library. |

| | |

| |LINK: Ward, R. Zamorski, M. “Benefits and Risks of Psychiatric Medications in Pregnancy” Am Fam Physician. 2002;66:629-36,639. |

| | |

| |LINK TO RESOURCE FOR PATIENTS AND DOCTORS ON PREGNANCY AND DEPRESSION: |

| | |

| |Depression in the Elderly and Pseudodementia |

| | |

| |QUESTION 5) Which one of the following statements is true about depression in the elderly? |

| | |

| |Physicians are more likely to diagnose depression correctly in the elderly than in younger people. |

| |Depression in the elderly is less important than in younger patients because depression is a normal part of the aging process. |

| |Patients who are elderly when their first depressive episode occurs have a relatively high likelihood of developing recurring chronic depression. |

| |Risk factors for depression in elderly persons include a history of depression, chronic medical illness, male sex, being single or divorced, brain disease, alcohol|

| |abuse, use of certain medications, and stressful life events. |

| |The long term prognosis for the elderly suffering from depression is poor even with treatment. |

| | |

| |The correct answer is c. As in younger populations, depression in the elderly is often not diagnosed and not treated by physicians. A popular misconception by |

| |patients, families, and physicians is that depression is a normal part of the aging process. Risk factors for depression in elderly persons include a history of |

| |depression, chronic medical illness, female sex, being single or divorced, brain disease, alcohol abuse, use of certain medications, and stressful life events. |

| |Patients who are elderly when their first depressive episode occurs have a relatively high likelihood of developing recurring chronic depression. With proper |

| |diagnosis and management, depression in the elderly is treatable and has a good prognosis. (Source: Birrer, RB, Vemuri SP. Depression in later life: A diagnostic |

| |and therapeutic challenge. Am Fam Physician 2004; 69 (10): 2375-2382) |

| | |

| |Depression in the elderly is not part of the normal aging process. This common misconception may lead elderly patients, or their families, not to seek appropriate |

| |help. It can also lead physicians to miss the diagnosis of depression in the elderly and leave it untreated. A common complaint in elderly patients is not |

| |depression but insomnia, anorexia, and fatigue. Treatment with antidepressants, especially selective serotonin reuptake inhibitors can be useful. Patients who are |

| |elderly when they have their first episode of depression have a relatively higher likelihood of developing chronic and recurring depression. The prognosis for |

| |recovery is equal in young and old patients, although remission may take longer to achieve in older patients. |

| | |

| |Pseudodementia, associated with severe depression, can be easily mistaken for dementia, especially in the elderly or persons with underlying neurological disease |

| |(e.g., strokes, etc). The symptoms of pseudodementia include marked psychological distress, inability to concentrate or complete daily tasks, and marked cognitive |

| |dysfunction. Differentiating between dementia and pseudodementia is important. Typically, patients suffering from pseudodementia will exhibit profound concern |

| |about their impaired cognitive function, in contrast with patients with a diagnosis of dementia, who may tend to minimize their disability. In addition to |

| |pharmacotherapy, electroconvulsive therapy may be warranted in patients with pseudodementia. |

| | |

| |All patients with depression of all ages, including the elderly, should have a mini-mental status examination at baseline. Patients successfully treated of their |

| |major depression will see their pseudodementia and cognitive dysfunction improve. |

| | |

| |[pic]Reproduced with permission from Birrer, R., Vemuri, S. “Depression in Later Life: A Diagnostic and Therapeutic Challenge.” American Family Physician. |

| |2004;69:2375-82. |

| | |

| |More information on depression in the elderly is available in this web module’s library. |

| |LINK TO: Birrer, RB, Vemuri SP. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician 2004; 69 (10): 2375-2382 |

| | |

| |Manic and Hypomanic Symptoms: Bipolar Disorder |

| | |

| |Question 6) You are evaluating a 35 year old male in your primary care practice. He has a history of depression and occasional panic attacks. His previous |

| |physicians treated his panic symptoms with selective serotonin reuptake inhibitors (SSRIs) approved for panic disorders but the medications made him more restless,|

| |agitated, and unable to sleep. Upon further questioning, you discover he has been having symptoms with impairing depressive episodes and anxiety since late |

| |childhood. His father was hospitalized with a manic episode on one occasion. Upon further exploration, which one of the following would be most specific for |

| |confirming the diagnosis of bipolar disorder? |

| | |

| |His brother has a confirmed diagnosis of bipolar I disorder |

| |His sister has a confirmed diagnosis of bipolar II disorder |

| |The patient has symptomatic improvement on lithium |

| |His mother’s mania improved with lithium |

| |The patient has had a hypomanic episode |

| | |

| |The correct answer is e. The risk of having bipolar disorder is higher in persons with first degree relatives with bipolar disorder. Incidental improvement of |

| |symptoms with lithium may also provide clues. Of all these findings, the most specific to the diagnosis is the patient having a hypomanic episode himself. (Source:|

| |American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 text revision, American Association, 2000. Washington DC) |

| | |

| |A major depressive episode can appear as a unipolar disorder, but all primary care physicians should be aware that this presentation may be part of an underlying |

| |bipolar disorder. Primary care physicians who diagnose and treat patients with depression should carefully assess patients for a history or current complaint of |

| |manic and hypomanic symptoms. Misdiagnosis of a bipolar disorder patient presenting with major depressive symptoms can lead to mistreatment with antidepressants |

| |alone, which may precipitate a manic episode. A manic mood is characterized by irritability or abnormal euphoria. Hypomania can be seen as a lesser degree of mania|

| |that lasts for a shorter duration. Hypomanic patients usually can continue with their normal life routines and don’t require hospitalization. A patient with a |

| |“mixed state” has to technically satisfy all the criteria of a major depressive disorder and mania at the same time. DSM-IV criteria for mania and hypomania can be|

| |found on the next table. Patients with bipolar disorder should be referred for collaborative care with a psychiatrist. |

| | |

| |Summary of DSM-IV Criteria for Manic Episode |

| | |

| |A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting 1 week (or any duration if hospitalization is necessary). |

| |During the period of the mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a|

| |significant degree: |

| |Inflated self-esteem or grandiosity |

| |Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) |

| |More talkative than usual or pressure to keep talking |

| |Flight of ideas or subjective experience that thoughts are racing |

| |Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) |

| |Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation |

| |Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual |

| |indiscretions, or foolish business investments) |

| |The symptoms do not meet the criteria for a Mixed Episode. |

| |The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or |

| |to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. |

| |The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical |

| |condition (e.g. hyperthyroidism). |

| |Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g. medication, electroconvulsive therapy, light therapy) should not count |

| |toward the diagnosis of Bipolar I Disorder. |

| | |

| |Summary of DSM-IV Criteria for Hypomanic Episode |

| | |

| |A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual |

| |non-depressed mood. |

| |During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a |

| |significant degree: |

| |Inflated self-esteem or grandiosity |

| |Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) |

| |More talkative than usual or pressure to keep talking |

| |Flight of ideas or subjective experience that thoughts are racing |

| |Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) |

| |Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation |

| |Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual |

| |indiscretions, or foolish business investments) |

| |The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. |

| |The disturbance in mood and the change in functioning are observable by others. |

| |The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic |

| |features. |

| |The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical |

| |condition (e.g. hyperthyroidism). |

| |Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g. medication, electroconvulsive therapy, light therapy) should not count |

| |toward the diagnosis of Bipolar II Disorder. |

| | |

| | |

| |Assessing The Risk of Suicide |

| |[pic] |

| |“The Scream” – Edvard Munch |

| | |

| |LINK: Edvard Munch (Wikipedia: ) |

| | |

| |Patients with depression may be at increased risk for suicide (Kahn, 1999. NYCDOH, 2006, Mann, 2005). Any patient that has a positive screening for depression |

| |should be evaluated for suicide risk. Asking about suicidal thoughts can save the patient’s life. Contrary to many physicians’ fear, asking about suicidal plans or|

| |ideation does not make patients more prone to commit suicide. Patients are usually relieved that they have been asked about their feelings and thoughts. Asking |

| |about suicidal ideation or plans conveys your interest in their well-being. |

| | |

| |Questions in Assessing Suicidal Risk |

| | |

| |Current thoughts of harming or killing self |

| |Current plans to harming or killing self |

| |Prior suicide attempts (critical indicator of future suicide risk) |

| |Family history of mood disorder, alcoholism, or suicide |

| |Actions or threats of violence to others |

| |Access to firearms |

| |Male |

| |Elderly |

| |Significant comorbid anxiety or psychotic symptoms and active substance abuse |

| |Poor social support system or living alone |

| |Recent loss or separation |

| |Hopelessness |

| |Preparatory acts (e.g., putting affairs in order, suicide notes, giving away personal belongings) |

| | |

| | |

| |Physicians can initiate the topic of suicidal ideation with questions about the patient’s feelings about life. |

| |“Did you ever wish you could go to sleep and never wake up?” |

| |“Have you ever felt life was not worth living?” |

| | |

| |Depending on the response, more specific questions about suicidal ideation can be asked. |

| |“Do you ever feel others would be better off without you?” |

| |“Are you having thoughts about killing yourself?” |

| |“Have you thought about killing or hurting others?” |

| | |

| |If suicidal ideation is elicited, physicians should ask patients if they have a suicidal plan (e.g., how, when, where). A patient that is actively thinking about |

| |suicide and has a plan for suicide constitutes a medical emergency. This is especially true in patients with previous suicide attempts. 911 should be called for |

| |safe transport to the nearest emergency room for psychiatric care. Prediction of which patients with suicidal ideation will attempt or commit suicide is very poor.|

| | |

| |The Institute of Mental Health has made recommendations for physicians who are assisting potentially suicidal patients. It is important to monitor your own |

| |reactions to a suicidal patient. Stay calm and don’t appear threatened so that the patient feels secure and maintains the doctor-patient dialogue. Listen |

| |attentively so that the patient feels validated about their distress and is not ignored. Avoid judgmental statements. Emphasize that suicidal feelings worsen with |

| |stress, but is a treatable condition. Also highlight that suicide causes family members and friends great pain that lasts for years. Make it clear to the patient |

| |that he or she will have input into their treatment along with you and the psychiatric team as part of a partnership. |

| | |

| |Question 7) Outpatients at risk for suicide should not receive large supplies of antidepressants in case of overdose. Which one of the following statements is true|

| |about antidepressants and suicide? |

| | |

| |Fluoxetine has been shown to lead to more suicide attempts in adolescents than use of placebo. |

| |Norepinephrine reuptake inhibitors (NRIs) are less like than selective serotonin reuptake inhibitors (SSRIs) to be associated with suicidal thoughts in |

| |adolescents. |

| |Tricyclic antidepressants (TCAs) are more lethal in overdose than SSRIs. |

| |Suicide rates are higher with TCAs than with SSRIs. |

| | |

| |The correct answer is c. Tricyclic antidepressants are more lethal in overdose over selective serotonin reuptake inhibitors. The risk of suicide in all patients |

| |who are recovering from major depression may transiently increase during initial treatment, but whether antidepressants possibly cause increased suicide risk is |

| |extremely controversial. Increased energy to act on suicidal ideation is only one of the possible explanations currently under consideration. Monitoring patients |

| |closely during treatment is paramount and is part of “psychiatric treatment”. Fluoxetine is the only antidepressant found to be effective in children and |

| |adolescents, but close surveillance for suicidal ideation or plans is again warranted. The average risk of suicide in general was 4% with antidepressants and 2% on|

| |placebo. (Sources: Jick SS, Dean AD, Jick H. Antidepressants and suicide. BMJ 1995; 310 (6974): 215-218; Simon GE. How can we know whether antidepressants |

| |increase suicide risk? Am J Psychiatry 163:1861-1863, 2006.) |

| | |

| |A link to a recent article on whether antidepressants increase suicide risk and the advent of “black box” warnings is available in the library. |

| | |

| |LINK: Simon GE: How can we know whether antidepressants increase suicide risk? Am J Psychiatry 163:1861-1863, 2006. |

|VI. Treatment Recommendations |Treatment Recommendations for Major Depressive Disorder |

|for Major Depressive Disorder | |

| |Successful treatment of major depressive disorder starts with a thorough assessment of the patient. As discussed previously and based on recommendations of the |

| |American Psychiatric Association, healing begins with “psychiatric management” of the patient, followed by three phases of treatment. This may be done by the |

| |primary care physician, and / or psychotherapist, and / or psychiatrist depending on the history, complexity, and degree of severity of the depression. The |

| |following recommendations are for Major Depressive Disorder, and although no existing scientific literature has been established – it may apply to other syndromes |

| |such as dysthymic disorder. |

| | |

| |Psychiatric Management |

| | |

| |Perform a diagnostic evaluation to determine if the diagnosis of depression is warranted or if other psychiatric or medical conditions exist. |

| |History of present illness and current symptoms |

| |Psychiatric history (e.g., symptoms of mania, previous history of psychiatric treatment, response to previous psychiatric treatments) |

| |General medical history |

| |History of substance abuse disorders |

| |Personal history (e.g. psychological development, response to major life events and transitions) |

| |Social history |

| |Occupational history |

| |Family history |

| |Medication review |

| |A review of systems |

| |A physical examination |

| |A mental status examination |

| |Diagnostic studies as indicated (e.g., TSH, CBC, Basic Chemistry Profile) |

| | |

| |Evaluate for the safety of the patient and of others. This evaluation is crucial. |

| |Presence of suicidal or homicidal ideation or plans |

| |Access to a means for suicide and the lethality of the means (e.g. access to handguns) |

| |Presence of psychotic symptoms (e.g. command hallucinations or delusions) |

| |Severe anxiety |

| |Concurrent alcohol or substance use |

| |History of previous attempts |

| |Family history of suicide |

| |Recent exposure to another person who committed suicide |

| | |

| |Evaluate functional impairment by assessing: |

| |Interpersonal relationships |

| |Work |

| |Living conditions |

| |Health and medical related needs |

| | |

| |Determine a treatment setting. This can vary from ambulatory settings with a primary care provider only, ambulatory settings with a primary care provider in |

| |conjunction with a psychiatrist, day programs, to involuntary psychiatric hospitalization. Criteria for involuntary hospitalization are usually set by local |

| |jurisdictions. Patients should be treated in the setting that is the safest and is the most effective. The setting should be reassessed at follow up visits. The |

| |following situations require referral to psychiatrist: |

| |Suicide risk |

| |Bipolar disorder or manic episode |

| |Psychotic symptoms |

| |Severe decrease in level of functioning (e.g., unable to care for self) |

| |Recurrent depression |

| |Chronic depression |

| |Depression that is refractory to treatment |

| |Cardiac disease that requires tricyclic antidepressants treatment (contraindication) |

| |Need for electroconvulsive therapy (ECT) |

| |Lack of available support system |

| |Any diagnostic or treatment questions |

| | |

| |Establish and maintain a therapeutic alliance. Major depression is a chronic disease and it requires that the patient actively engages and adheres to long periods |

| |of treatment. Symptoms of major depressive disorder (e.g., poor motivation, cognitive dysfunction, pessimism, etc.), side effects of medications, and |

| |misunderstandings between the physician and patient can be major obstacles to adherence. |

| |Pay attention to concerns patients and their families. |

| |The physician should be aware of any transference or countertransference issues with the patient (e.g., frustration or anger from or toward the patient, etc.). |

| | |

| |Continue to monitor the patient’s psychiatric status and safety. With treatment, some symptoms may improve while others emerge. |

| |Significant changes in psychiatric status or emergence of new symptoms requires diagnostic and management reassessment. |

| | |

| |Provide patient education and, if appropriate, to the patient’s family. Effective education will allow patients to make informed decisions about their treatment |

| |and improve adherence. |

| |Emphasize that major depression is a “real” illness and not a moral defect. |

| |Effective treatment is available and necessary. |

| |Discuss anticipated side effects of treatments. |

| |Education of family and friends is important |

| |Support groups are available for patients and their families |

| | |

| |Enhance treatment adherence. |

| |It is critical for the physician to monitor the patient closely especially as they begin to feel better as the patient may start to focus on the side effects of |

| |treatment rather than the benefits. |

| |The patient should be encouraged to verbalize any concerns or issues. |

| |Review with the patient when and how often to take their medication. |

| |Explain that beneficial effects may take 2 – 4 weeks to be noticed. |

| |Explain the need to continue taking the medication even after the patient feels better. |

| |Remind the patient the need to consult with a physician before stopping medication. |

| |Explain to the patient how to access you, a colleague, or the health care team in case a question or problem arises. |

| |Consider issues of polypharmacy especially in elderly patients. |

| |Consider the financial impact of medications on patients. |

| |Encourage the family to help in the process of adherence. |

| | |

| |Work with the patient to address early signs of relapse. |

| |Exacerbations and relapse are common in major depressive disorder, and patients and families should be educated on this point. |

| |A review of signs and symptoms of relapse with the patient is critical as the next episode may contain different depressive characteristics. |

| |Emphasize the need to seek early treatment and intervention if symptoms arise to prevent a full-blown exacerbation. |

| | |

| |The three phases of treatment of major depression |

| | |

| |Treatment consists of three phases: |

| | |

| |Acute Phase – Remission is induced (minimum 6 – 8 weeks in duration). |

| |Continuation Phase – Remission is preserved and relapse prevented (usually 16 – 20 weeks in duration). |

| |Maintenance Phase – Susceptible patients are protected against recurrence or relapse of subsequent major depressive episodes (duration varies with frequency and |

| |severity of previous episodes). |

| | |

| |Remission and relapse have been defined by the American Psychiatric Association. Remission is the return to the patient’s baseline level of symptom severity and |

| |functioning. Remission should not be confused with significant but incomplete improvement. Relapse is the re-emergence of significant depressive symptoms or |

| |dysfunction after remission has been achieved. |

| | |

| |Acute phase treatment |

| | |

| |The goal of acute phase treatment is to induce remission and typically lasts a minimum 6 – 8 weeks in duration. |

| | |

| |For patients with mild to moderate depression, the initial treatment modalities may include pharmacotherapy alone, psychotherapy alone, or the combination of |

| |medical management and psychotherapy. As stated prior, psychiatric management must be integrated into treatment regardless of the initial approach. |

| | |

| |Antidepressant medications |

| | |

| |Antidepressant medications can be used as initial treatment modality by patients with mild or moderate depression. Clinical features that may suggest that |

| |antidepressant medication is preferred over other modalities are a positive response to prior antidepressant treatment, significant sleep and appetite disturbance,|

| |severity of symptoms, or anticipation by the physician that maintenance therapy will be needed. Patient preference for antidepressant medication alone should be |

| |taken into consideration. Most primary care physicians can medically manage these patients in their practices as long as they continue to monitor the patient’s |

| |symptoms closely. The frequency of monitoring in the acute phase of pharmacotherapy is from once a week to multiple times a week. |

| | |

| |Psychotherapy |

| | |

| |Psychotherapy alone may be considered as initial treatment modality for patients with mild to moderate depressive disorder. Clinical features that suggests the use|

| |of psychotherapy over other modalities are the presence of psychosocial stressors, interpersonal difficulties, intrapsychic conflict, and any axis II comorbidities|

| |(personality disorders as per DSM-IV). In addition, patient preference for psychotherapy alone should be taken into consideration, as well as a woman’s desire to |

| |get pregnant, be pregnant, or to breastfeed. Most primary care physicians will refer these patients to a professional psychotherapist for management. The frequency|

| |of monitoring in the acute phase of psychotherapy is from once a week to multiple times a week. |

| | |

| |Combination antidepressant medication and psychotherapy |

| | |

| |The combination of antidepressant medication and psychotherapy may be the initial treatment approach for patients with moderate depression in the presence of |

| |psychosocial stressors, interpersonal difficulties, intrapsychic conflict, and any axis II comorbidities. Combination therapy may also be appropriate for patients |

| |with only partial remission on one type of treatment, or with a history of poor adherence to treatment. Most primary care physicians can medically manage these |

| |patients while referring them to a professional psychotherapist for co-management. |

| | |

| |Initial acute phase treatment approaches for patients with severe depressive symptoms |

| | |

| |Antidepressant medications alone can be used as initial treatment modality by patients with severe depression. There is insufficient evidence that psychotherapy |

| |alone is effective for patients with severe depression. The combination of antidepressant medication and psychotherapy may be the initial treatment approach for |

| |patients for patients with severe depression in the presence of psychosocial stressors, interpersonal difficulties, intrapsychic conflict, and any axis II |

| |comorbidities. Patients with depression and psychotic symptoms, catatonia, or severe impairment may be considered for combination therapy with antidepressants, |

| |antipsychotics, and / or electroconvulsive therapy (ECT). Patient with severe depression are usually referred for care under a psychiatrist. |

| | |

| |Assessing an adequate response in the acute phase with mild to moderate depression |

| | |

| |Although the goal of acute phase treatment is to return patients to their functional and symptomatic baseline, it is common for patients to have a substantial but |

| |incomplete response to acute phase treatment. Structured tools that measure depression severity and functional status may be used for follow up assessment (e.g., |

| |PHQ- 9, Beck Depression Inventory, etc.). It is important to not conclude treatment for these patients at this phase as it may be associated with poor functional |

| |outcomes. The degree of an “adequate response” to treatment of depression has been loosely defined: non-response is the decrease in baseline symptoms of 25% or |

| |less; partial response is a 26 – 49% decrease in baseline symptoms; partial remission is 50% or greater decrease in baseline symptoms with residual symptoms; and |

| |remission is the complete absence of symptoms). When patients have not fully responded at this phase, the most important first step is increasing the dose. |

| | |

| |Overall, if after the initial 4 – 8 weeks there is not a moderate improvement in baseline symptoms in the acute phase, then a reassessment of the diagnosis, |

| |medication regimen and / or psychotherapy, adherence, substance or alcohol use is in order. Increasing the treatment dose is the first step to be considered. If 4 |

| |– 8 weeks after the increase of treatment dose there is not a moderate improvement in symptoms, another review should occur. Other treatment options should then be|

| |considered in consultation with a psychiatric specialist. |

| | |

| |Question 8) From our initial opening clinical case, Mr. George is a 44 year old male who you found to have major depression. Administration of a standard |

| |depression questionnaire (such as the PHQ – 9) found his depression to be of moderate severity. You started him on antidepressants. You see him 8 weeks later after|

| |starting the antidepressant medication and his appetite is back, he is sleeping well, and concentrating better at home and at work. He still feels tired but denies|

| |feeling depressed. He still has not assumed his normal social activities. You re-administer the same standard depression questionnaire, and conclude that he has |

| |achieved partial remission. Reassessment has found no issues with substance abuse or adherence issues with his medications. After this initial reassessment, which |

| |one of the following is the most appropriate first step in treatment options? |

| | |

| |Maintain the current dosage of medication and see him back in 4 to 8 weeks. |

| |Increase the dose of the medication and see him back in 4 to 8 weeks. |

| |Change the medication. |

| |Recommend adjunct psychotherapy. |

| |Consult with a psychiatrist. |

| | |

| |The correct answer is b. In the acute phase of treatment, if after 4 – 8 weeks there is not a moderate improvement in baseline symptoms in the acute phase, then a |

| |reassessment of the diagnosis, medication regimen and / or psychotherapy, adherence, substance or alcohol use is in order. The first step is increasing the dose of|

| |the medication since he achieved only partial remission at the initial dose. If after another 4 – 8 weeks, Mr. George is not improved, consideration can be given |

| |to again increasing the dose of the medication, changing to a different medication, or begin adjunct psychotherapy. If 4 – 8 weeks after the change in treatment |

| |there is not a moderate improvement in symptoms, another review should occur. Other treatment options should then be considered in consultation with a psychiatric |

| |specialist – or at any time the primary care physician feels improvement is not optimal. (Source: Working Group on Major Depressive Disorders. Practice Guidelines |

| |for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) |

| | |

| |Continuation Phase Treatment |

| | |

| |Patients who have been treated with antidepressant medications in the acute phase should be maintained with this regimen to prevent relapse. This “continuation |

| |phase” should last for 16 – 20 weeks after remission. “Psychiatric management” should continue in this phase. The American Psychiatric Association recommends the |

| |medication doses used in the acute phase be maintained in the continuation phase. There is increasing data to support the continued use of specific effective |

| |psychotherapy in this phase. The use of ECT in this phase has not been well researched. The frequency of visits in the continuation phase may vary. Stable patients|

| |may be seen once every 2 – 3 months. Patients in active psychotherapy may be seen several times a week. |

| | |

| |Patients who remain stable throughout the continuation phase, and who are not candidates for the maintenance phase (e.g., recurrent relapsing chronic depression, |

| |etc.), can be considered candidates for discontinuation of treatment. |

| | |

| |QUESTION 9) A 35 year old female returns for a follow visit after you have successfully treated her first episode of uncomplicated major depression. After 6 weeks |

| |of treatment with an antidepressant, all of her depressive symptoms have resolved. Based on the evidence, the total length of treatment with antidepressants should|

| |be at a minimum: |

| | |

| |3 months |

| |6 months |

| |9 months |

| |12 months |

| |Indefinite |

| | |

| |The correct answer is b. Based on the treatment recommendations of the American Psychiatric Association, this uncomplicated patient with her first major depressive|

| |episode would have had an initial six weeks of antidepressant treatment. This six week period in the acute phase of treatment has apparently induced complete |

| |remission of symptoms. The evidence would recommend another 16 – 20 weeks of continuation phase treatment. The minimum total length of acute and continuation phase|

| |treatment for this patient would be about 6 months. (Source: Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With |

| |Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) |

| | |

| |Maintenance Phase Treatment |

| | |

| |Between 50 – 85% of patients with a single major depressive episode will have another episode. Maintenance phase treatment is designed to prevent recurrence. |

| |Issues to consider in using maintenance phase treatment are severity of episodes (e.g., suicidal ideation or attempts, psychotic symptoms, functional impairment); |

| |risk of recurrence (e.g., residual symptoms between episodes, number of recurrent episodes); comorbid conditions; side effects experienced with continuous |

| |treatment; or patient preference. |

| | |

| |The same treatment that was effective in the acute and continuation phase should be continued in the maintenance phase. The doses of medication in the previous |

| |phases are usually maintained. The type of psychotherapy employed dictates the frequency of visits in the maintenance phase (e.g., cognitive behavioral therapy and|

| |interpersonal therapy decrease to once a month, while psychodynamic psychotherapy maintains the same previous frequency). Combination therapy (psychotherapy and |

| |pharmacotherapy) may be beneficial for some patients although it is not well studied. Patients with recurrent moderate or severe depressive episodes who don’t |

| |respond well to pharmacotherapy may be candidates for periodic ECT. Frequency of visits in the maintenance phase can vary as in the continuation phase. |

| | |

| |The length of maintenance treatment that is optimal is unknown. Factors that may influence this period may be frequency and severity of recurrent episodes, |

| |persistence of symptoms after a period of recovery, tolerability of treatment, and patient preference. Some patients may require indefinite maintenance treatment. |

| | |

| |Question 10) For which one of the following patients is a trial of discontinuation of antidepressant medication appropriate? |

| | |

| |A 30 year old male with is his first lifetime episode of major depression who is now asymptomatic after taking his medication for 3 months. |

| |A 50 year old female with depression and an anxiety disorder with her fourth episode of major depression, which has taken 6 months of medication and is now |

| |asymptomatic. |

| |A 40 year old male with is third lifetime episode of major depression who has taken medication for 12 months and is now asymptomatic. |

| |A 40 year old female with her first lifetime episode of major depression who is now asymptomatic after taking 12 months of medication |

| | |

| |The correct answer is d. The 40 year old male and 50 year old female with recurrent episodes of major depression may benefit from longer or indefinite treatment. |

| |The 30 year old male with his first episode and who is now asymptomatic after 3 months of medication has not completed the recommended length of continuation phase|

| |treatment. The 40 year old female with her first lifetime episode of major depression who is now asymptomatic after taking 12 months of medication is the only |

| |possible candidate for a trial of discontinuation but still needs monitoring and education on relapse. (Source: Working Group on Major Depressive Disorders. |

| |Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) |

| | |

| |Discontinuation of active treatment |

| | |

| |The factors to discontinue treatment are based on the same considerations in deciding on using maintenance phase therapy: frequency and severity of recurrent |

| |episodes, dysthymic symptoms between episodes, the presence of other psychiatric disorders, the presence of chronic general medical disorders, or patient |

| |preference. If maintenance pharmacotherapy is discontinued, it is recommended to taper the medication over several weeks. Slow tapering may allow the physician to |

| |detect emerging symptoms and restore the medical management to full therapeutic doses. Discontinuation syndromes (e.g., mood disturbances, sleep, energy, and |

| |appetite) can appear much like relapses but are in fact due to lack of tapering of medications. Patients on short acting agents are more prone to discontinuation |

| |syndromes and should be tapered over longer periods of time. Signs and symptoms of relapse should again be reviewed with the patient once discontinuation of |

| |treatment has occurred. |

|VII. Medical Management of |First line choices of antidepressant drugs |

|Depression | |

| |QUESTION 11) Which one of the following statements is true regarding the effectiveness of antidepressants agents for treating major depression? |

| | |

| |Selective serotonin reuptake inhibitors (SSRIs) are the most effective class of antidepressants. |

| |Tricyclic antidepressants (TCAs) are the most effective class of antidepressants. |

| |Serotonin-norepinephrine reuptake inhibitors are the most effective class of antidepressants. |

| |Monoamine oxidase inhibitors (MAOIs) are the most effective class of antidepressants. |

| |All classes of antidepressants are equally as effective. |

| | |

| |The correct answer is e. Although there may be specific class considerations for use of one medication over another for a particular patient, all classes of |

| |antidepressants are equally effective. (Source: Mann, JJ., “The Medical Management of Depression” New England Journal of Medicine. 2005 Oct 27;353(17):1819-34.; |

| |and Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric |

| |Association. 2000. Washington D.C.) |

| | |

| |Antidepressant medications’ effectiveness is generally comparable across classes and within classes of medications. The medications differ in side effect |

| |profiles, drug-drug interactions, and cost. The history of a positive response to a particular drug for an individual or a family member, as well as patient |

| |preferences, should also be taken into account. Most psychiatrists agree that an SSRI should be the first line choice. The dual action reuptake inhibitors |

| |venlafaxine and bupropion are generally regarded as second line agents. Tricyclics and other mixed or dual action inhibitors are third line, and MAOI’s (monoamine|

| |oxidase inhibitors) are usually medications of last resort for patients who have not responded to other medications, due to their low tolerability, dietary |

| |restrictions, and drug-drug interactions. Most primary care physicians would prefer that a psychiatrist manage patients requiring MAOI’s. |

| | |

| |The recommended starting dose of antidepressants is illustrated in the table below from Mann JJ., “The Medical Management of Depression” New England Journal of |

| |Medicine. 2005 Oct 27;353(17):1819-34. Titration of the drug to therapeutic levels is done over the initial weeks of treatment. The rate of titration may depend on|

| |the patient’s age, the development of side effects, and comorbid conditions. In the geriatric population, the starting dose is usually half the recommended |

| |starting dose for other adults. |

| | |

| |Classification, Doses, Safety, Side Effects of Antidepressants |

| |[pic] |

| |[pic] |

| |Table reproduced with permission from the Massachusetts Medical Society. Taken from Mann, JJ., “The Medical Management of Depression” New England Journal of |

| |Medicine. 2005 Oct 27;353(17):1819-34. Copyright © 2005 Massachusetts Medical Society. All rights reserved. |

| | |

| |As stated prior, the patient should be monitored over time for improvement, exacerbation of depression, suicidal feelings, side effects, and adherence. All |

| |antidepressants may induce a manic episode in patients susceptible to bipolar disorder. The frequency of monitoring can vary from once a week to multiple times a |

| |week. Monitoring can be done via face-to-face visits, telephone contact via the physician and patient, or the patient and nursing staff. This can be a challenge in|

| |clinical practice, but there are novel approaches for improving systems for monitoring depressed patients in primary care settings (available in the library of |

| |this module). |

| | |

| |LINK: Oxman, T., et al. “A Three-Component Model for Reengineering Systems for the Treatment of Depression in Primary Care.” Psychosomatics 2002; 43:441-450. |

| | |

| |Antidepressant Medications |

| | |

| |Most antidepressant agents amplify norepinephrine or serotonin signaling by inhibiting their reuptake at the synaptic cleft. |

| | |

| |Selective serotonin reuptake inhibitors (SSRIs) |

| | |

| |Clinical trials have found little difference in efficacy and tolerability amongst the various SSRIs. SSRIs tend to be well tolerated as compared with other |

| |classes of antidepressants. The half life of all of the SSRIs is long enough to allow for once a day dosing, which improves patient adherence. Of note, |

| |fluoxetine is the only antidepressant found to be effective in controlled trials treating depressed children and adolescents. SSRIs have fewer cardiovascular |

| |effects than tricyclic antidepressants. |

| | |

| |Tricyclic antidepressants (TCAs) and Norepinephrine reuptake inhibitors (NRIs) |

| | |

| |TCAs and NRIs are older classes of antidepressants. They may be more effective in severe depression or depression with melancholic features. They may also be |

| |more effective than SSRIs for depression that has predominant physical symptoms or pain. TCAs and NRIs tend to have cardiac conduction effects and thus they are |

| |not the drug of choice in patients with cardiovascular conditions, particularly conduction defects. They are also contraindicated in people with benign prostatic |

| |hypertrophy, urinary retention, and closed angle glaucoma. |

| | |

| |Dual action antidepressants |

| | |

| |Venlafaxine, milnacipran, duloxetine are serotonin-norepinephrine reuptake inhibitors. They block monoamine transporters much more selectively than the TCAs and |

| |NRIs and thus have less cardiac-conduction effects. Venlafaxine has been shown to be more effective than SSRIs or TCAs through higher rates of remission in severe |

| |depression. Duloxetine is as effective as the SSRI paroxetine. Both duloxetine and paroxetine are also effective in treating chronic pain and diabetic neuropathy. |

| | |

| |Bupropion inhibits norepinephrine and dopamine, but not serotonin, reuptake. It has similar efficacy to TCAs and SSRIs, but has less diarrhea, nausea, |

| |somnolescence, and sexual side effects than SSRIs. Bupropion also can be used as an adjunct in smoking cessation (although some health insurance companies will pay|

| |for buproprion as an antidepressant but not as a smoking cessation medication). |

| | |

| |Monoamine oxidase inhibitors (MAOIs) |

| | |

| |MAOIs nonselectively block Mao A and B isoenzymes, and have similar efficacy to TCAs. Again, MAOIs are not considered first line choice due to the side effect |

| |profile, drug-drug interactions, and the need to adhere to a low tyramine diet to prevent a hypertensive crisis. Under the care of a psychiatrist, MAOIs may be |

| |more effective than TCAs for atypical depression which is characterized by extreme fatigue, sensitivity to rejection, or troubled relationships. |

| | |

| |Newer antidepressant therapies |

| | |

| |Nefazodone blocks 5-HT serotonin receptors thus enhancing serotonin in synaptic clefts. It has an efficacy similar to SSRIs, and tends to be sedating. |

| | |

| |Mirtazapine blocks alpha 2 – adrenergic receptors, specific serotonin receptors, and histamine receptors to enhance norepinephrine in the synaptic cleft. It is as |

| |effective as SSRIs and TCAs. Mirtazapine tends to be quite sedating and to cause significant weight gain. |

| | |

| |Considerations before switching antidepressants |

| | |

| |As mentioned prior, patients getting the same dose of an antidepressant and not achieving a response should consider having their antidepressant dose increased |

| |before changing the medication altogether. Before the medication is switched, the primary care physician should reassess the diagnosis; consider increasing the |

| |antidepressant dose; assess the patient for adherence; consider alcoholism or substance-abuse; and re-evaluate for coexisting medical conditions and use of |

| |non-psychiatric drugs that may contribute to treatment failure. |

| | |

| |It is generally recommended that patients who don’t have a response to an SSRI should be switched to an antidepressant in another class. Similarly, if a dual |

| |action antidepressant has been used first, a switch to an SSRI should be considered. For patients with a partial response to one antidepressant, a second |

| |antidepressant from another class can be added for augmentation. |

| | |

| |Adjunct medications |

| | |

| |There are other medications that are used in conjunction with antidepressants to augment their effects. Mood stabilizers, such as lithium can prevent manic and |

| |depressive episodes in bipolar patients. Lithium can also be an effective augmenting agent in patients who don’t have an effective response to antidepressants |

| |alone. Antipsychotic medications can be added to antidepressants to treat depression with psychotic features. |

| | |

| |Anxiety: Antidepressants and Anxiolytics |

| | |

| |In major depression with comorbid anxiety or panic disorder (15 – 30% of cases), depression and anxiety symptoms resolve with antidepressant treatment. SSRIs and |

| |TCAs may initially worsen the anxiety. This can be avoided by starting at lower doses and titrating up more slowly. |

| | |

| |Benzodiazepines are used as an adjuvant in 30 - 60% of cases of depression with anxiety or insomnia. Benzodiazepines improve antidepressant response, but can cause|

| |sedation, memory loss, and dependence and withdrawal syndromes. Benzodiazepines should be used on a limited basis to avoid dependency; avoided in those with a |

| |history of alcohol or drug abuse; and be used with extreme caution in geriatric populations who don’t metabolize the drugs well and can cause increased cognitive |

| |dysfunction, falls, and death. In general, benzodiazepines should not be used as the primary pharmacologic agent in any patient with major depression and anxiety |

| |disorders. |

|VIII. Psychotherapeutic |Psychotherapeutic Management of Depression |

|Management of Depression | |

| |Psychotherapy may be a first line therapy choice for mild depression particularly when associated with psychosocial stress, interpersonal problems, or with |

| |concurrent developmental or personality disorders. Psychotherapy in mild to moderate depression is most effective in the acute phase, and in preventing relapse |

| |during continuation phase treatment. Psychotherapy is not appropriate alone for severe depression, psychosis, and bipolar disorder. For more severe depression, |

| |psychotherapy may be appropriate in combination with the use of medications. The most effective forms of psychotherapy are those with structured and brief |

| |approaches such as cognitive behavioral therapy, interpersonal therapy, and certain problem solving therapies. Regardless of the psychotherapy initiated, |

| |“psychiatric management” must be integrated at the same time. Primary care physicians should be aware of the different psychotherapy approaches so that they can |

| |understand what their patients are undergoing and what goals they are trying to achieve. |

| | |

| |Studies indicate that the use of cognitive therapy modalities is most effective (Rupke, 2006); Cognitive behavioral therapy (CBT) is most frequently cited in |

| |studies as highly effective in treating depression. However, interpersonal psychotherapy and problem oriented psychotherapy have also been considered as desirable|

| |and cost effective when compared to more traditional models of psychotherapy. |

| | |

| |Cognitive Behavioral Therapy (CBT) |

| | |

| |CBT targets thoughts and behaviors that need to be changed. Based on the premise that behaviors have their roots in thoughts, this approach assumes that depression|

| |is rooted in pessimistic thoughts and excessive self-criticism. The goal of the therapy is to recognize what triggers certain thoughts and behaviors and to alter |

| |your routines through direction and action. Learning to substitute healthy thoughts for negative thoughts will improve a person’s mood, self-concept, behavior and |

| |physical state. Behavior change is the primary goal with internal change as a byproduct. Initially, in treating depression, behavioral principles are used to |

| |overcome a patient’s inertia and to reinforce positive activities. An important part of CBT for depression is scheduling pleasurable activities, especially with |

| |others, that usually give positive reinforcement. Other CBT techniques include graded tasks and homework assignments as well as acting out difficult behavioral |

| |situations. Emphasis is on the present rather than on the past. The combination of CBT and antidepressants has been shown to effectively manage severe or chronic |

| |depression and for adolescents with depression. CBT has been shown to reduce relapse rates and effectively manage residual symptoms. |

| | |

| |LINK TO LIBRARY ARTICLE: “Cognitive Therapy” AAFP |

| | |

| |Interpersonal Therapy (IPT) |

| | |

| |Based on the belief that depression is caused by problems in important interpersonal relationships, this approach focuses on teaching about the connection between |

| |interpersonal problems and depression. Depression is viewed as arising out of conflict or loss in interpersonal relationships. A key feature is the compiling of |

| |an interpersonal inventory that lists and examines all the patient’s relationships. In this approach the number of sessions is generally limited over a period of |

| |several months. Treatment is divided into three stages: assessment, practice and termination, with emphasis on relapse prevention skills and techniques. Focus is |

| |on present events rather than past history and on learning ways to improve important relationships in the present and to have more positive interactions. Patients|

| |are taught not only to identify but to deliberately tolerate feelings. According to this model, as relationships improve, so should the patient’s mood. The model |

| |incorporates psychoeducation; is “medication friendly”; and agrees with a medical model of depression. Unlike CBT, IPT does not involve formal homework or rely on |

| |extensive paperwork, although patients are encouraged to develop skills and experiment between sessions. IPT is particularly useful for patients who find |

| |psychodynamic approaches mystifying, and has been modified for use with adolescents. |

| | |

| |Problem Solving Therapy (PST) |

| | |

| |Problem solving therapy is a brief, focused form of cognitive therapy that focuses on the problems a person is currently facing and on helping to find solutions to|

| |these problems. Based on studies that have demonstrated links between poor problem solving abilities and the etiology and maintenance of psychological disorders,|

| |this approach is often used in the treatment of depression. Problem focused methods involve changing the situation itself, whereas emotion-focused strategies |

| |involve changing one’s reaction to the situation. Problem solving strategies work well in addressing and solving problems encountered in everyday situations where|

| |a change in behavior can have positive results. Individuals are taught to identify, discover and invent effective responses for specific problematic situations. |

| |The goal is to provide clients with a set of tools on how to effectively manage life’s stress in order to decrease distress, enhance sense of control, and improve |

| |quality of life. Interventions include didactic explanations, training exercises, practice opportunities, and homework to practice between sessions. PST sessions |

| |are often conducted in groups as well as individual sessions. It is often less expensive than other forms of treatment and can easily be performed by health care |

| |professionals. PST has been shown to be effective in treating depression in adults of all ages and is thought to be particularly effective in treatment of older |

| |adults. |

|IX. Other Therapies |Other Therapeutic Options |

| | |

| |Combination of medications and psychotherapy |

| | |

| |There are very few clinical trials to guide with a specific selection of the optimal combination of antidepressants and psychotherapy. The same considerations in |

| |selecting monotherapy of antidepressants or psychotherapy apply. Monitoring with the same frequency for side effects, efficacy, adherence, and safety are the same |

| |in combination as when either therapy is given alone. If after 4 – 8 weeks there is not a moderate improvement in baseline symptoms, then a reassessment of the |

| |diagnosis, medication regimen, adherence, substance or alcohol use is in order. Change in treatment can be considered. If 4 – 8 weeks after the change in treatment|

| |there is not a moderate improvement in symptoms, another review should occur. Other treatment options should be considered in consultation with a psychiatric |

| |specialist if the patient fails to respond. |

| | |

| |Electroconvulsive therapy (ECT) |

| | |

| |ECT is exclusively available through an experienced psychiatric specialist. Remission rates with ECT are around 60 – 80 percent in severe major depressive disorder|

| |(UK ECT Review Group, Lancet 2003), and the maximum response is usually 3 weeks after treatment. ECT is the first line treatment when there is severe depression |

| |with psychotic features, psychomotor retardation, or resistance to medications. Suicidal patients and pregnant patients may also have rapid benefits from ECT. ECT |

| |consists of 6 – 12 treatments (2 to 3 times a week). Because the relapse rate after ECT is more than 50 percent, most psychiatrist start prophylactic treatment |

| |with antidepressants and adjuvant medications such as lithium. Postictal confusion, retrograde and anterograde memory impairment usually improves in a few days. |

| | |

| |St. John’s wort |

| | |

| |[pic] |

| |QUESTION 12) A 35 year old male who is HIV positive, takes antiretroviral medications, and lives with severe major depression has achieved remission of his |

| |depression on his SSRI but complains of lack of sexual libido. He read some information about St. John’s wort and asks if it would be appropriate to treat his |

| |depression. Which one of the following statements is appropriate advice to this patient: |

| | |

| |St. John’s wort is more effective than placebo in patients with severe major depression. |

| |St. John’s wort is not effective for treatment of major depression. |

| |St. John’s wort is safe for use in people taking HIV antiretroviral medications. |

| |St. John’s wort is safe and effective in combination with SSRIs and TCAs. |

| |St. John’s wort is safe and effective in combination with MAOIs. |

| | |

| |The correct answer is b. St. John’s wort is a plant product commonly used to treat depression. Although two dozen trials have been conducted on the use of St. |

| |John’s wort in depression, most have had significant flaws in design and do not enable meaningful interpretation. The results of a randomized, double-blind, |

| |placebo-controlled clinical trial conducted between November 1998 and January 2000 in 11 academic medical centers in the United States with 200 participants found |

| |that St. John’s wort was not effective in the treatment of major depression (Sources: Shelton RC, Keller M, Gelenberg A, et al. Effectiveness of St. John’s wort in|

| |major depression: a randomized controlled trial. JAMA. 2001 (15); 285: 1978-1986). Information on combination of St. John’s wort and SSRIs and TCAs is unknown. St.|

| |John’s wort and combination of MAOIs is contraindicated. (Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major|

| |Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) St. John’s wort is not a drug and thus is not regulated by the FDA, thus there is a |

| |lack of standardized preparations. Patients living with HIV / AIDS and on antiretroviral treatment should be made aware that St. John’s wort is contraindicated |

| |because it lowers the serum levels of their antiretroviral cocktail. |

| | |

| |ST JOHNS WORT LINK PDF: National Center for Complementary and Alternative Medicine. Herbs At A Glance: St. John’s Wort. National Center for Complementary and |

| |Alternative Medicine Web site. National Institutes of Health. Accessed at |

| | |

| |LINK: : Shelton RC, Keller M, Gelenberg A, et al. Effectiveness of St. John’s wort in major depression: a randomized controlled trial. JAMA. 2001 (15);285: |

| |1978-1986 |

|X. Living With Depression |Living With Depression |

| | |

| |The Personal Experience |

| |[pic] |

| |“Self Portrait” – Frida Kahlo |

| | |

| |LINK: Frida Kahlo (Wikipedia: ) |

| | |

| |Patients living with depression have enormous obstacles to overcome. Recognizing in oneself the symptoms and signs of depression can be difficult. People who |

| |suffer from depression describe the experience as a feeling of isolation, a feeling of being cut off from the people around them, almost of being “emotionally |

| |underwater”, of losing interest in physical contact and in sexual relationships, and of excessive worry. They may lack any energy in getting out of bed or to leave|

| |home. They may become emotionally distant and not talk to others. They may blame themselves for a moral defect for persistently feeling down. Although some may |

| |become aware their feelings are not normal, they may not want to seek help due to fear of stigma or fear of institutionalization. Cultural and social factors may |

| |make it even more difficult to seek help. In some cultures, it is not appropriate to discuss feeling depressed or may be seen as an “imaginary disease”. Men may |

| |feel that being depressed is a sign of weakness, and because discussing feelings is not “masculine” – may make males feel even more isolated. Depression is an |

| |agonizing experience. |

| | |

| |HANDOUTS for SPECIAL POPULATIONS |

| |Mens Guide |

| |Womens Guide |

| |Latino Americans |

| |Asian Americans |

| |African Americans |

| |Native Americans |

| | |

| |VIDEO CLIP OF CBS CORRESPONDANT FROM BACKPACK FULL OF BRICKS |

| | |

| |With treatment and education, persons with depression can have functional and meaningful lives. It requires ongoing personal acknowledgement of the illness, and |

| |surveillance and recognition of signs. It requires the support of family and friends. A compassionate and vigilant primary care physician should also be part of |

| |depression monitoring and support. |

| | |

| |The Effect On Families |

| | |

| |The effect and impact on family, friends, and coworkers of a person who suffers from depression can be tremendous. Their families and friends may not recognize |

| |depressive symptoms, or dismiss the signs as either a normal reaction to life events, or ascribe the symptoms as the person being “difficult” or “moody”. Some |

| |friends and families may stop socializing with a depressed loved one because the experience can be difficult or frustrating. They may begin to resent the depressed|

| |person. Even when depression is evident, families and friends may believe that a person can just “stop” being depressed, or that the person with depression is |

| |“acting out” at them. Others may think that they may be the sole solution to solving their loved one’s depression (e.g., “Maybe if I do things differently? Maybe |

| |if I can kid them out of their depression? Maybe if we went on vacations more often?”), or may suffer tremendous guilt about the situation. It can be difficult for|

| |families to accept the illness. Some families become socially isolated over secrecy over their loved one’s condition. Families and friends benefit by learning |

| |about the illness of depression, and understanding what is not in their control and how they can be supportive. Support groups for friends and families of those |

| |living with depression also exist. Family and friends also have to find time to take care of themselves. Primary care physicians can be very effective in education|

| |and providing support to family and friends. |

| | |

| |VIDEO CLIP OF FAMILY EXPERIENCE FROM BACKPACK FULL OF BRICKS |

| | |

| |Patient and Family Education Resources |

| | |

| |LINK |

| | |

| | |

| | |

| |Wellness Guide for Patients With Depression and Their Friends and Families PDF |

| | |

| |The Arts and Depression |

| | |

| |The arts have long explored the experience of living with depression and its’ effects on others. Film, plays, books, and art can provide us with window into the |

| |world of a person coping with chronic depression and associated mental health illnesses. A physician can learn much empathy and compassion for these persons |

| |thorough these powerful artistic expressions. |

| | |

| |Film |

| | |

| |“Ordinary People” (1980) |

| |Director: Robert Redford |

| |LINK: |

| | |

| |“Pollock” (2000) |

| |Director: Ed Harris |

| |LINK: |

| | |

| |“The Snake Pit” (1948) |

| |Director: Anatole Litvak |

| |LINK: |

| | |

| |“Sophie's Choice” (1982) |

| |Director: Alan Pakula |

| |LINK: |

| | |

| |“Reality Bites” (1994) |

| |Director: Ben Stiler |

| |LINK: |

| | |

| |“Wild Strawberries” (1957) |

| |Director: Ingmar Bergman |

| |LINK: |

| | |

| |Plays |

| | |

| |“Monster in A Box” (1992) – LINK TO VIDEO CLIP FROM BACKPACK FULL OF BRICKS |

| |“Gray’s Anatomy” (1994) |

| |Playwright: Spalding Gray |

| | |

| |“Proof” (2001) |

| |Playwright: David Auburn |

| | |

| |“4.48 Psychosis” (1999) |

| |Playwright: Sarah Kane |

| | |

| |Books |

| | |

| |“The Bell Jar” (1963) |

| |Author: Sylvia Plath |

| | |

| |“The Sorrows of Young Werther” (1774) |

| |Author: Johann Wolfgang von Goethe |

| | |

| |“Unholy Ghost: Writers on Depression” (2002) |

| |Edited by: Nell Casey |

| | |

| |“Girl Interrupted” (1994) |

| |Author: Susanna Kaysen |

| | |

| |“One True Thing” (2006) |

| |Author: Anna Quindlen |

| | |

| |Arts |

| | |

| |“On the Threshold of Eternity / At Eternity’s Gate / Old Man in Sorrow” - Vincent Van Gogh |

| |“The Scream” – Edvard Munch |

| |“Self Portrait” – Frida Kahlo |

|XI. Conclusion |Summary |

| | |

| |Depression is one of the most common conditions in primary care, but is often unrecognized, undiagnosed, and untreated. Depression has a high rate of morbidity and|

| |mortality when left untreated. Most patients suffering from depression do not complain of feeling depressed, but rather anhedonia or vague unexplained symptoms. |

| |All physicians should remain alert to effectively screen for depression in their patients. There are several screening tools for depression that are effective and |

| |feasible in primary care settings. An appropriate history, physical, initial basic lab evaluation, and mental status examination can assist the physician in |

| |diagnosing the patient with the correct depressive spectrum disorder (including bipolar disorder). Primary care physicians should carefully assess depressed |

| |patients for suicide. Depression in the elderly is not part of the normal aging process. Patients who are elderly when they have their first episode of depression |

| |have a relatively higher likelihood of developing chronic and recurring depression. The prognosis for recovery is equal in young and old patients, although |

| |remission may take longer to achieve in older patients. Elderly patients usually start antidepressants at lower doses than their younger counterparts. |

| | |

| |Most primary care physician can successfully treat uncomplicated mild or moderate forms of major depression in their settings with careful psychiatric management |

| |(e.g., close monitoring of symptoms, side effects, etc.); maintaining a therapeutic alliance with their patient; pharmacotherapy (acute, continuation, and |

| |maintenance phases); and / or referral for psychotherapy. The following situations require referral to psychiatrist: suicide risk, bipolar disorder or a manic |

| |episode, psychotic symptoms, severe decrease in level of functioning, recurrent depression and chronic depression, depression that is refractory to treatment, |

| |cardiac disease that requires tricyclic antidepressants treatment, need for electroconvulsive therapy (ECT), lack of available support system, and any diagnostic |

| |or treatment questions. |

| | |

| |Antidepressant medications’ effectiveness is generally comparable across classes and within classes of medications. The medications differ in side effect |

| |profiles, drug-drug interactions, and cost. The history of a positive response to a particular drug for an individual or a family member, as well as patient |

| |preferences, should also be taken into account. Most psychiatrists agree that an SSRI should be the first line choice. The dual action reuptake inhibitors |

| |venlafaxine and bupropion are generally regarded as second line agents. Tricyclics and other mixed or dual action inhibitors are third line, and MAOI’s (monoamine|

| |oxidase inhibitors) are usually medications of last resort for patients who have not responded to other medications, due to their low tolerability, dietary |

| |restrictions, and drug-drug interactions. Most primary care physicians would prefer that a psychiatrist manage patients requiring MAOI’s. |

| | |

| |Psychotherapy may be a first line therapy choice for mild depression particularly when associated with psychosocial stress, interpersonal problems, or with |

| |concurrent developmental or personality disorders. Psychotherapy in mild to moderate depression is most effective in the acute phase, and in preventing relapse |

| |during continuation phase treatment. Psychotherapy is not appropriate alone for severe depression, psychosis, and bipolar disorders. For more severe depression, |

| |psychotherapy may be appropriate in combination with the use of medications. The most effective forms of psychotherapy are those with structured and brief |

| |approaches such as cognitive behavioral therapy, interpersonal therapy, and certain problem solving therapies. Regardless of the psychotherapy initiated, |

| |“psychiatric management” must be integrated at the same time. |

| | |

| |Patients, who live with depression, and their family and friends, have enormous challenges to overcome. Primary care physicians can provide compassionate care, |

| |important education, psychiatric monitoring, social support, reassurance, and advocacy for these patients and their loved ones. |

| | |

| |Link To Survey Monkey Feedback and Content Questions |

|XII. Bibliography |Bibliography |

| | |

| |Ables, A. et al. “Antidepressants: Updates on New Agents and Indications” Am Fam Physician. 2003; 67:547-54. |

| | |

| |American Broadcasting Company. “Depression: A Backpack Full of Bricks”. March 9, 2004. Films For Humanities and Sciences. |

| | |

| |American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 text revision, American Association, 2000. Washington DC |

| | |

| |Birrer, RB, Vemuri SP. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician 2004; 69 (10): 2375-2382 |

| | |

| |Cutler, J. Charon, R. “Depression” from Primary Care Psychiatry and Behavioral Medicine:  Brief Office Treatment and Management Pathways.  Edited by RE Feinstein, |

| |AA Brewer.  Springer Publishing Co., New York, NY.  1999 |

| | |

| |Dietrich, A., et al. “Re-engineering systems for the treatment of depression in primary care: cluster randomized controlled trial.” BMJ 2004;329 |

| | |

| |Gaynes, B., et al. “Screening for Suicide Risk in Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force” |

| |Ann Intern Med. 2004; 140:822-835. |

| | |

| |Jick SS, Dean AD, Jick H. Antidepressants and suicide. BMJ 1995; 310 (6974): 215-218.) |

| | |

| |Kahn, David. “Mood Disorders”. Psychiatry, edited by JL Cutler, ER Marcus.  WB Saunders, Philadelphia, PA. 1999 |

| | |

| |Lewis-Fernandez, R. et al., “Depression in US Hispanics: Diagnostic and Management Considerations in Family Practice” J Am Board Fam Pract 2005;18: 282–96. |

| | |

| |Mann, JJ., “The Medical Management of Depression” New England Journal of Medicine. 2005 Oct 27;353(17):1819-34 |

| | |

| |Morris, Jane, “Interpersonal psychotherapy – a trainee’s ABC?” in Psychiatric Bulleting (2002), 26, 26-28. |

| | |

| |National Center for Complementary and Alternative Medicine. St. John’s Wort and the Treatment of Depression. National Center for Complementary and Alternative |

| |Medicine Web site. Accessed at on June 30, 2005. |

| | |

| |New York City Department of Health and Mental Hygiene. “Detecting and Treating Depression in Adults.” City Health Information. 25 (1): 1-8. |

| | |

| |Nezu, Arthur, et al., “Managing Stress through Problem Solving” in STRESS NEWS, Vol. 13 No.3, July |

| | |

| |Oxman, T., et al. “A Three-Component Model for Reengineering Systems for the Treatment of Depression in Primary Care.” Psychosomatics 2002; 43:441-450. |

| | |

| |Reid, Cary M., Ph.D., M.D., “Determining the Feasibility of a Cognitive-Behavioral Therapy for the Treatment of Co-Occurring Chronic Back Pain and Depression Among|

| |Persons Ages 60 Years and Above” Aetna INteliHealth: Depression July 12, 2005 () |

| | |

| |Remick, R. “Diagnosis and management of depression in primary care: a clinical update and review.” CMAJ 2002;167(11):1253-60 |

| | |

| |Rost. K., et al. “Managing Depression as a Chronic Disease; a randomized trial of ongoing treatment in primary care.” BMJ October 2002; 325 |

| | |

| |Rupke, Stuart, et al., “Cognitive Therapy for Depression” Am Fam Physician, 2006: 73, 83-86 |

| | |

| |Sharp, LK, Lipsky MS. “Screening for depression across the lifespan: a review of measures for use in primary care settings.” American Family Physician. 2002; 66: |

| |1001-1008 |

| | |

| |Shearer, S., et al. “Excessive Worry.” Am Fam Physician 2006;73:1049-56, 1057-8. |

| | |

| |Shelton RC, Keller M, Gelenberg A, et al. “Effectiveness of St. John’s wort in major depression: a randomized controlled trial.” JAMA. 2001 (15);285: 1978-1986 |

| | |

| |Simon GE., “How can we know whether antidepressants increase suicide risk?” Am J Psychiatry 163:1861-1863, 2006. |

| | |

| |The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Vol. |

| |1 Cambridge, Mass.: Harvard University Press, 1996. |

| | |

| |Thimbault, J., et al. “Efficient Identification of Adults with Depression and Dementia.” Am Fam Physician 2004;70:1101-10. |

| | |

| |UK ECT Review Group, Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361: 799-808. |

| | |

| |United States Preventive Screening Task Force. Screening for depression: Recommendations and rationale. November 2006 Recommendations. |

| | |

| | |

| |Ward, R. Zamorski, M. “Benefits and Risks of Psychiatric Medications in Pregnancy” Am Fam Physician. 2002;66:629-36,639. |

| | |

| |Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. |

| |2000. Washington D.C. |

| |Credits |

| | |

| |Written and Created by Pablo Joo MD |

| |Center for Family Medicine – New York Presbyterian / Columbia University College of Physicians and Surgeons |

| |Director of Predoctoral Education |

| | |

| |Contributing Writer: “Psychotherapeutic Management of Depression” segment |

| |Cathie Vourkas, ACSW |

| |Behavioral Scientist, Center for Family Medicine |

| |New York Presbyterian / Family Medicine Residency Program |

| | |

| |Contributing Writer: “First line choices of antidepressant drugs” segment |

| |Janis Cutler, MD, Dept. of Psychiatry |

| |New York Presbyterian / Columbia University College of Physicians and Surgeons |

| | |

| |Creative Direction and Production |

| |Michelle V. Hall |

| |Columbia Center for New Media, Teaching and Learning – Columbia University |

| | |

| |Medical Education Curriculum and Research Contributor |

| |Sharon K. Krackov, Ed.D |

| |Center for Education Research and Evaluation – Columbia University Medical Center |

| | |

| |Contributing Editors |

| |Janis Cutler, MD, Dept. of Psychiatry |

| |New York Presbyterian / Columbia University College of Physicians and Surgeons |

| | |

| |Edgar Figueroa MD, MPH, Family Medicine |

| |Director of Student Health Services |

| |Weill Medical College of Cornell University |

| | |

| |Columbia P&S Primary Care Clerkship Co-Directors |

| |Primary Care Clerkship Co-directors |

| |Rebecca Kurth MD – Department of Medicine |

| |Pablo Joo MD – Center for Family Medicine |

| |New York Presbyterian / Columbia University College of Physicians and Surgeons |

| | |

| |This Columbia P&S Primary Care Clerkship Web Education Module was made possible by a generous grant the Columbia University Primary Care Education and Research |

| |Gift Fund. |

-----------------------

YES

Dysthymic disorder

If NO,

Has the depressed mood or anhedonia and milder associated symptoms been present for at least 2 years?

NO

Depressive disorder not otherwise specified or no disorder

YES

Adjustment disorder with depressed mood

If NO,

Are the symptoms due to a stressor?

NO

Major depressive disorder

YES

Bereavement

If YES,

Are they best explained by bereavement?

If YES,

Are associated symptoms present?

Is the depressed mood or anhedonia present for at least 2 weeks?

NO

YES

Substance-induced disorder

Is a substance directly responsible for the symptoms?

NO

YES

Mood disorder due to a general medical condition

Is a general medical condition directly responsible for the symptoms?

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