Major depressive disorder

Source : Deja review, USMLE STEP 2 Lecture

Trigger
• 60 y/o woman, present with depressed mood after her son passed away. The patient report a 10kg
weight loss, decrease concentration, feeling helplessness & hopelessness, decrease energy & sleep

Definition
• Mood disorder, that present with at least 2 weeks of course of symptoms that change from patient
previous functional level. Must have depressed mood or anhedonia (inability to enjoy oneself)

Most common
• Age group : 20 – 40 y/o
• Gender : Female 2X – because hormonal differences, great stress

History
• Depressed mood – most of the day
• Anhedonia – most of the day
• Significant weight loss (>5% of body weight)
• Insomnia
• Psychomotor agitation or retardation
• Low energy
• Low concentration
• Feeling of worthlessness or guilt
• Recurrent thoughts about death

Most important thing to assess in patients suffering from depression is their suicidal status, which of
course determines her prognosis and whether or not you will admit her to the hospital for treatment

Physical examination
• Psychomotor retardation – stooped posture, slow movement, slow speech
• Cognitive impairment -  concentration & memory

Psychotic feature = Worse prognosis

Atypical features =  Appetite, Weight & Sleep

Incidence
• Risk of developing MDD in life time : 15%
• Risk of MDD causing Suicide : 15%

Causes & Pathogenesis

Dysfunction of Hypothalamic-pituitary-adrenal axis

•  Serotonin
•  Noradrenaline

Depression

Triggering factor
• Drug : Beta blocker, Corticosteroid, Benzodiazepine, Interferon
• Endocrine : Hypothyroid (T3/T4), Adrenal dysfunction ( Noradrenaline)
• Neurologic : Parkinson, Strokes, Dementia
• Metabolic disorder : Vitamin B12 deficiency
• Infection : HIV, Hepatitis – Stigma

Risk factor
• Chronic physical illness
• Substance : Alcohol or drug dependence
• Psychosocial stressor *
• Gender : Female
• Childbirth
• Family history of depression
• Previous depressive episodes

Diagnosis (DSM 4)

Condition Symptoms (Adult) Symptoms (Elderly)

> 4 of following symptoms SIGECAPS • Anxiety
+ At least 2 weeks • Sleep changes • Irritability
+ Must rule out any •  Interest • Weakness
substance use or medical • Guilt • Multiple somatic complaints
condition •  Energy » Headache
•  Concentration » Backache
• Appetite changes » Diarrhea or Constipation
• Psychomotor agitation or » Dizziness
retardation » Lethargy
• Suicidality » Numbness

Differential diagnosis
• Medical condition – Hypothyroidism, Parkinson’s diseas, Hypertension
• Substance induced
• Mood disorder
• Dysthymic disorder
• Bipolar disorder
• Dementia
• Schizoaffective disorder

Typical course of depressive episode

• Untreated : Last about 6-9 months
• 50% risk of recurrence
Subtypes of depressions:?

Treatment

Drug
• Continue anti-depressant for 9-12 months before tapered dose initiated
• During tapered phase, monitor for sign of relapse

Class Drug
Selective serotonin reuptake inhibitor (SSRI)
Selective noradrenaline reuptake inhibitor (SNRI)
Dopamine reuptake inhibitor (DRI)
Tricyclic antidepressant (TCA)
Monoamine oxidase inhibitor (MAOI)

Electroconvulsive therapy (ECT) – 2nd line treatment

Indication
• Suicide attempt
• Intolerant to medication

Individual psychotherapy
• To help patient deal with conflict, sense of loss

Cognitive therapy
• To change patient distorted thoughts about self, future

Differences between Grief & Depression

Difference Grief Depression

Symptoms • Sadness, tearfulness,  sleep,  appetite,  interest in the world
• Symptoms wax & wane • Symptoms pervasive &
unremitting
Shame & guilt • Not common • Common
Threaten suicide • Not common • Common
Duration symptoms • < 1 year • > 1 year
Duration to stable level • < 2 months • Not return to stable level
Treatment • Supportive psychotherapy • Antidepressant drug