Major depressive disorder

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Community studies generally show a high prevalence of depression in different countries. Estimations of the so called point prevalence (the number of people meeting criteria of the disorder at a certain moment in time) vary between 5 and 7.5%. The one-year prevalence of major depressive disorder in the United States varies from 3% in the Epidemiological Catchment Area Study[1] to 10% in the National Co-morbity Study.[2]

Diagnosis

The core symptoms of depression are depressed mood and a lack of interest or pleasure from daily activities (anhedonia). Several additional features may be present, like lack of concentration, inappropriate guilt feelings, suicidal thoughts, psychomotor retardation or agitation and loss of libido. A diurnal variation, e.g. the symptoms are worse in the morning, may be present.

DSM-IV diagnostic criteria

Note: The American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders, forbids the unauthorized reproduction of their diagnostic criteria. A narrative of the DSM-IV-TR criteria follows. The DSM-IV has created nine diagnostic criteria based on symptoms of depression. At least five of these should be present for two weeks in the absence of other explanations for the symptoms.

Alternative diagnostic strategies

Patient Health Questionnaire 2

The Patient Health Questionnaire (PHQ2) is a shorter questionnaire that may be as sensitive as the DSM-IV.[3] It has also been validated in elderly patients.[4] The PHQ2 is positive if either of the following are positive:

"During the past month, have you often been bothered by:"

  1. "little interest or pleasure in doing things?"
  2. "feeling down, depressed, or hopeless?"

If the PHQ2 is positive, then the SALSA questionnaire may be used to increase specificity[5]. A positive test is one of the above answers positive and two of the answers below positive:

  1. Sleep disturbance nearly every day for the last 2 weeks?
  2. Have you experienced little interest or pleasure in doing things nearly every day for the last 2 weeks (Anhedonia)?
  3. Have you experienced Low Self esteem nearly every day for the last 2 weeks?
  4. Have you experienced decreased Appetite nearly every day for the last 2 weeks?"

Patient Health Questionnaire 9

If the patient is diagnosed with depression, the Patient Health Questionnaire 9 (PHQ9) may measure severity[6] and follow response to treatment.[7] A clinically relevant change is a PHQ-9 change of 5 or greater.[7] The PHQ-9 is available online in English and Spanish from the MacArthur Initiative.

Treatment

Treatment failure

Approximately 30% of patients have remission of depression with medications.[8] For patients with inadequate response, either adding sustained-release bupropion (initially 200 mg per day then increase by 100 mg up to total of 400 mg per day) or buspirone (up to 60 mg per day) for augmentation as a second drug can cause remission in approximately 30% of patients[9], while switching medications can achieve remission in about 25% of patients[10].

References

  1. ↑ Regier DA et al.(1993). The defacto US mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psych 50:85-94.
  2. ↑ Kessler RC et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psych 51:8-19.
  3. ↑ Spitzer RL, Kroenke K, Williams JB (1999). "Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire". JAMA 282 (18): 1737–44. PMID 10568646. [e]
  4. ↑ Li C, Friedman B, Conwell Y, Fiscella K (2007). "Validity of the Patient Health Questionnaire 2 (PHQ-2) in identifying major depression in older people". J Am Geriatr Soc 55 (4): 596–602. DOI:10.1111/j.1532-5415.2007.01103.x. PMID 17397440. Research Blogging.
  5. ↑ Brody DS, Hahn SR, Spitzer RL, et al (1998). "Identifying patients with depression in the primary care setting: a more efficient method". Arch. Intern. Med. 158 (22): 2469–75. PMID 9855385. [e]
  6. ↑ Kroenke K, Spitzer RL, Williams JB (2001). "The PHQ-9: validity of a brief depression severity measure". J Gen Intern Med 16 (9): 606–13. PMID 11556941. [e] Full text at PubMed Central
  7. ↑ 7.0 7.1 Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K (2004). "Monitoring depression treatment outcomes with the patient health questionnaire-9". Med Care 42 (12): 1194–201. PMID 15550799. [e]
  8. ↑ Trivedi MH, Rush AJ, Wisniewski SR, et al (2006). "Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice". The American journal of psychiatry 163 (1): 28–40. DOI:10.1176/appi.ajp.163.1.28. PMID 16390886. Research Blogging.
  9. ↑ Trivedi MH, Fava M, Wisniewski SR, et al (2006). "Medication augmentation after the failure of SSRIs for depression". N. Engl. J. Med. 354 (12): 1243–52. DOI:10.1056/NEJMoa052964. PMID 16554526. Research Blogging.
  10. ↑ Rush AJ, Trivedi MH, Wisniewski SR, et al (2006). "Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression". N. Engl. J. Med. 354 (12): 1231–42. DOI:10.1056/NEJMoa052963. PMID 16554525. Research Blogging.
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