presenting symptoms
DESCRIPTION
A 70 year old woman was recently admitted after her son informed the doctor that she had been doing very poorly. The patient reports a 30 pound weight loss, decreased concentration, feelings of helplessness and hopelessness, decreased energy, depressed mood, and decreased sleep. - PowerPoint PPT PresentationTRANSCRIPT
• A 70 year old woman was recently admitted after her son informed the doctor that she had been doing very poorly. The patient reports a 30 pound weight loss, decreased concentration, feelings of helplessness and hopelessness, decreased energy, depressed mood, and decreased sleep.
Presenting Symptoms
• Depressed mood most of the day• Anhedonia during most of the day• Significant weight loss or weight gain• Insomnia or Hypersomnia• Psychomotor agitation or retardation• Fatigue or loss of energy nearly every day• Feelings of worthlessness and guilt• Diminished ability to concentrate• Recurrent thoughts about death
Physical Exam
DSM-IV Criteria for Major Depressive Episode and Major Depressive Disorder
Specific Components of Psychiatric Management
• Performing a diagnostic evaluation• Evaluating safety of the patient and others• Evaluating the level of functional impairments • Determining a treatment setting• Establishing and maintaining a therapeutic alliance• Monitoring the patient’s psychiatric status and safety • Providing education to patients and families, enhancing
treatment adherence• Working with patients to address early signs of relapse
Components of an Evaluation for Suicide Risk
• • Presence of suicidal or homicidal ideation, intent, or plans
• • Access to means for suicide and the lethality of those means
• • Presence of psychotic symptoms, command hallucinations,
• or severe anxiety• • Presence of alcohol or substance use• • History and seriousness of previous attempts• • Family history of or recent exposure to suicide
Factors to Consider in Choosing a First-Line Antidepressant Medication
• • Anticipated side effects and their safety or tolerability• • History of prior response in patient or family member• • Patient preference• • Cost• • Quantity and quality of clinical trial data• • MAOIs: generally reserve for patients who do not
respond to other treatments• • SSRIs or MAOIs: consider for patients with atypical
symptoms
Acute Phase
• Pharmacotherapy• Psychotherapy• Combination of medications plus
psychotherapy• ECT
Choice of specific pharmacologic treatment
Treatment
• SSRI• TCA• MAOI
Commonly Used Antidepressant Medications
Generic Name Starting Dose(mg/day)
Usual Dose
Tricyclics and tetracyclics
Tertiary amine tricyclicsAmitriptylineClomipramineDoxepinImipramineTrimipramine
25–502525–5025–5025–50
100–300100–250100–300100–300100–300
Commonly Used Antidepressant Medications
Generic Name Starting Dose(mg/day)
Usual Dose
Secondary amine tricyclicsDesipraminebNortriptylinebProtriptyline
25–502510
100–30050–20015–60
TetracyclicsAmoxapineMaprotiline
5050
100–400100–225
Commonly Used Antidepressant Medications
Generic Name Starting Dose(mg/day)
Usual Dose
SSRIsbCitalopramFluoxetineFluvoxamineParoxetineSertraline
2020502050
20–60c20–60c50–300c20–60c50–200c
Commonly Used Antidepressant Medications
Generic Name Starting Dose(mg/day)
Usual Dose
Dopamine-norepinephrine reuptake inhibitorsBupropionbBupropion, sustained releaseb
150150
300300
Serotonin-norepinephrine reuptake inhibitorsVenlafaxinebVenlafaxine, extended releaseb
37.537.5
75–22575–225
Commonly Used Antidepressant Medications
Generic Name Starting Dose(mg/day)
Usual Dose
Serotonin modulatorsNefazodoneTrazodone
5050
150–30075–300
Norepinephrine-serotonin modulatorMirtazapine 15 15–45
Commonly Used Antidepressant Medications
Generic Name Starting Dose(mg/day)
Usual Dose
Commonly Used Antidepressant Medications
Generic Name Starting Dose(mg/day)
Usual Dose
MAOIsIrreversible, nonselectivePhenelzineTranylcypromineReversible MAOI-AMoclobemide
1510
150
15–9030–60
300–600
Selective noradrenaline reuptake inhibitorReboxetine —d —d
Risk Factors for Recurrence of Major Depressive Disorder
• • Prior history of multiple episodes of major depressive disorder
• • Persistence of dysthymic symptoms after recovery from an episode
• of major depressive disorder• • Presence of an additional nonaffective
psychiatric diagnosis• • Presence of a chronic general medical disorder