Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2892_Библиотеки_им_академика_М_И_Перельмана
.pdf
270 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
ANSWERS TO CASE 25:
Major Depression and Other Mood Disorders
Summary: This 38-year-old woman presents with
Weight loss, fatigue, and insomnia of 3 months’ duration
Anhedonia and feelings of worthlessness
Feelings of intense guilt regarding past failed relationships
Denial of any recent medication, illicit drug, or alcohol use
Mental status examination significant for depressed mood, psychomotor slowing, and
poor concentration
Most likely diagnosis: Major depression.
Next step: Check thyroid-stimulating hormone, basic metabolic panel, and com-
plete blood count.
Important considerations and potential complications: Rule out other medical diag-
noses, such as hypothyroidism, anemia, diabetes, and infectious processes that
could mimic some symptoms of depression. Review any recent medication changes
for agents that may contribute to these symptoms (eg, beta-blockers, steroids,
sedatives, chemotherapy agents); verify that no substance use disorder is present.
Screen for bipolar disorder and inquire about a family history of mood disorders;
investigate and address suicidal ideation.
ANALYSIS
Objectives
1. Recognize common presenting signs and symptoms of major depressive
disorder. (EPA 1, 2, 10)
2. Be able to verbalize the multifactorial pathogenesis of depressive disorders.
(EPA 12)
3. Describe the treatment of depressive disorders and the sequelae of this
condition. (EPA 4, 12)
4. Be familiar with the appropriate follow-up of this condition. (EPA 4, 9)
5. Recognize the need for assessing suicide risk. (EPA 10)
Considerations
The vignette is a common presentation of major depressive disorder. The patient
often presents with symptoms of fatigue, insomnia, and mood swings and often
does not report mood changes unless specifically asked. The astute clinician will
recognize this pattern as depression. Symptoms of depressive disorder, such as
poor concentration and impaired working memory, may limit your patient’s ability
to provide a good history. Close friends and family can help make the diagnosis
clearer with the patient’s permission.
SECTION II: CLINICAL CASES 271
https://t.me/medicina_free
The diagnosis of major depressive disorder can made because she meets at
least five of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) diagnostic criteria during a 2-week period that represents a change from
her previous level of functioning. At least one of the symptoms must be either
depressed mood or loss of interest or pleasure.
Treatment is based on severity of symptoms, and the clinician must specifically
and directly address the patient’s risk of harming self or others. If the patient is
actively suicidal, such as describing the desire to hurt him- or herself and having
a plan to do so, then hospitalization may be necessary. Similarly, if the patient is
unable to perform self-care, hospitalization should be considered. If the patient
does not have suicidal ideations, is not assessed as a risk to self or others, and has
support at home, then outpatient therapy with close follow-up is usually appropriate, with follow-up generally at 1- to 2-week intervals until stable.
APPROACH TO:
Major Depressive Disorder and Other Mood Disorders
DEFINITION
MAJOR DEPRESSIVE DISORDER (MDD): Symptoms lasting for 2 consecutive
weeks and occurring nearly every day. Must have five of the nine diagnostic criteria
listed in the DSM-5, and one of them must be depressed mood or anhedonia.
DSM-5 criteria:
1. Depressed mood
2. Anhedonia: Diminished interest or pleasure
3. Change in appetite or weight: Decreased appetite, or increased appetite associated with specific food cravings; significant weight loss or weight gain
4. Change in sleep patterns: Insomnia or hypersomnia
5. Change in activity: Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Change in cognition: Diminished ability to think or concentrate;
indecisiveness
9. Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific
plan
Also,
Symptoms cause clinically significant distress or impairment of functioning.
Symptoms are not a result of the direct physiologic effects of a substance
or a generalized medical condition.
272 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
There has never been a manic or hypomanic episode.
Symptoms are not better explained by schizoaffective disorder, schizo-
phrenia, schizophreniform disorder, delusional disorder, or other psychotic disorders.
CLINICAL APPROACH TO DEPRESSIVE DISORDER
Epidemiology
Depression has a lifetime prevalence of 7% to 12% in men and 20% to 25% in
women. Risk factors for developing depression are family or personal history of
depression, female sex, younger age, traumatic brain injury, chronic medical illnesses, chronic pain, low income, low self-esteem, poor social support, chronic
minor daily stress, and being single, divorced, or widowed. Untreated depressive
disorder can lead to suicide, and those with depression carry a suicide risk of 0.5%
to 4% increase from the general population.
Screening. Screening for depression is recommended by the US Preventive
Services Task Force (Grade B) starting at age 12 when there are systems to ensure
accurate diagnosis, treatment, and follow-up. Adult screening can be completed using
the two-question Patient Health Questionnaires (PHQ2), followed up with the
PHQ9 if positive. For older adults who are healthy or have mild-moderate cognitive
impairment, the Geriatric Depression Scale or Cornell Scale for depression may
be used. The Beck Depression Inventory and Children’s Depression Inventory should
be used in children, and the PHQ2 and PHQ9 may be used in adolescents. In pregnant and postpartum women, the Edinberg Depression scale can be used. Screening
for depression is a Merit Incentive Payment System (MIPS) quality measure.
Pathophysiology
Etiology. The etiology of depressive disorder is likely “part nature, part nurture”
due to a complex interaction of genetic, psychosocial, and neurobiologic factors.
Adverse life events may trigger those with a genetic risk. Theoretical psychosocial
contributors include stressful life events, particularly involving loss of a loved one,
early childhood stress, and lack of positive reinforcement. MDD does not require
such events, and those with seemingly stable lives may still experience intense suffering from this disease. Depression runs in families without a clear inheritance
pattern. Multiple neurotransmitter systems are involved, including the serotoninergic, noradrenergic, and dopaminergic systems. This mechanism is supported by the
known action of antidepressant medications, which have demonstrated response
and remission of this disease.
Differential Diagnosis. Bereavement can be defined as a depressed mood and
impaired functioning following the loss of a loved one. Although once considered
an exclusion criterion for the diagnosis of depression—as grief is expected following a major loss—patients with significant depressive symptoms during bereavement may be diagnosed with depression based upon the amount of functional
impairment the patient is experiencing.
Dysthymic disorder is a low-grade, chronic down mood that may not reach
the typical lows of major depression but is long standing, often existing for years.
SECTION II: CLINICAL CASES 273
https://t.me/medicina_free
It is often associated with low self-esteem, chronic stress, poor mood modulation,
and poor stress coping techniques.
Morbidity and Mortality. Major depressive disorder causes significant morbidity and mortality in numerous ways. The World Health Organization stated that
depression is the fourth leading cause of disability in the world and that it causes
more disability and social impairment than diabetes, arthritis, hypertension, or
coronary artery disease. Depression is frequently reported in persons with underlying medical conditions, such as stroke, Parkinson disease, traumatic brain injury,
diabetes, coronary atherosclerotic disease, and terminal illnesses.
There is a bidirectional finding in that patients with MDD are more likely to
develop atherosclerotic coronary artery and cerebrovascular disease, diabetes, and
osteoporosis. Depression is a common occurrence following myocardial infarction
and stroke. Persons with depression and preexisting cardiac disease have three times
greater risk of dying after a heart attack than do patients without depression. Patients
with coexisting MDD and diabetes have more microvascular and macrovascular
complications. Studies also show that persons with depression have a greater chance
of developing or dying from cardiovascular disease, even after controlling for other risk
factors. Depression also contributes to the disruption of interpersonal relationships,
the development of substance abuse, and absenteeism from work and school.
All depressed patients should be screened for suicidal and homicidal ideations.
A history of suicide attempts or violence is a significant risk factor for future attempts.
MDD plays a role in more than half of all suicide attempts. Women, especially those
younger than age 30 years, attempt suicide more frequently than men, but men are more
likely to complete suicide. Firearms are the most commonly used method in completed
suicides. Table 25–1 lists the risk factors for suicide attempts and completed suicides.
Table 25–1 • RISK FACTORS FOR SUICIDE
Demographic, social, and
environmental factors
Historical factors Family history of suicide
Psychiatric and behavioral
factors
Data from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
Washington, DC: American Psychiatric Association Press; 2013; Ebert MH, Loosen PT, Nurcombe B, Leckman JF, eds.
CURRENT Diagnosis & Treatment: Psychiatry. 2nd ed. 2008. Copyright © McGraw Hill LLC. All rights reserved; U.S.
Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care:
recommendation statement. Am Fam Physician. 2015 Feb 1;91(3):190F-190I.
Males more likely to complete; Females more likely to attempt
Age > 65 more likely to complete; age < 30 more likely to attempt
American Indian, Alaska Native, non-Hispanic white
Social isolation (divorced, widowed, living alone)
Lesbian, gay, bisexual, or transgender
Stressful life events
Access to firearms
History of suicide attempt and lethality of prior attempt
Concurrent chronic medical illness
Major depression, substance abuse (especially alcohol), schizophrenia,
panic disorder, borderline personality disorder
Symptoms: hopelessness, anhedonia, insomnia, severe anxiety,
panic attacks, impaired concentration, psychomotor agitation
274 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
Clinical Presentation
As alluded to in the opening case, patients often present with fatigue or poor concentration, and mood symptoms need to be specifically elicited from the patient.
The cardinal symptoms are anhedonia and down mood. It is important to note that
the physical symptoms are manifestations of the disease and should respond to
treatment. The mnemonic SIGECAPS is helpful in remembering common features
and stands for
Sleep (decreased or increased)
Interest (decreased/anhedonia)
Guilt
Energy (decreased)
Concentration (reduced)
Appetite (decreased or increased)
Psychomotor slowing
Suicidal ideation
Some typical nonspecific symptoms of depression include headache, neck or
back pain, joint pain, abdominal pain, constipation, poor sleep, weakness, and
fatigue. The elderly may present with confusion or a general decline in function
(pseudodementia). Children and adolescents may present with irritability. The
diagnosis of MDD should be considered in scenarios where a patient presents with
multiple unrelated physical symptoms.
A mental status examination is very important, including mood, affect, appearance, behavior, speech, and thought process and content. Those who have more
severe symptoms may reveal a decline in grooming or hygiene along with weight
changes. Speech may be normal, slow, monotonic, or lacking in content. Pressured
speech is suggestive of mania, whereas disorganized speech suggests the need to
evaluate for psychosis. The thought content of patients with depression includes
feelings of inadequacy, helplessness, hopelessness, or feeling overwhelmed. Psychomotor retardation can manifest as slowing of movements or reactions, especially in
the elderly. The physical examination should include evaluation for possible underlying causes of depressed mood, and a cognitive examination may be helpful in
older adults.
Treatment
Pharmacotherapy with psychotherapy is more effective than either pharmacotherapy
or psychotherapy alone; however, either may be pursued alone based on patient
comfort and severity of disease. Patients should be encouraged to pursue both therapies to improve chances of success. Initial pharmacotherapy should be based on
the health care provider’s familiarity with medication, anticipated safety and tolerability, anticipation of adverse effects, and history of prior treatments. The PHQ9
can be used to assess symptom severity and track improvement over time.
SECTION II: CLINICAL CASES 275
https://t.me/medicina_free
Antidepressant agents work by increasing the amount of neurotransmitter available in the synaptic cleft. This is accomplished by (1) enhancing neurotransmitter
release, (2) reducing neurotransmitter breakdown, or (3) inhibiting the reuptake of
the neurotransmitter by the presynaptic neuron. There are a few effective antidepressants that do not have a fully elucidated mechanism of action.
An adequate trial of an antidepressant requires a minimum of 4 to 6 weeks on
an appropriate dose. Up to half of patients do not respond to the first antidepressant they try and will need to be switched to another agent. However, treatment
failures typically result from medication nonadherence, inadequate duration of
therapy, or inadequate dosing. No class of medication has been proven to be more
effective than other classes. Response (in improvement in symptoms) occurs in
63% of patients after 8 to 12 weeks and remission (resolution of symptoms) in
47% of cases.
Maintenance therapy should be pursued based on the number of major
depressive episodes, duration of episode, and severity of symptoms. After a
first episode of major depression, treatment should continue for at least 4 to
9months after stability is achieved. For a patient with two or three episodes,
3years is a reasonable duration of therapy, with consideration of lifelong therapy in a patient with a serious suicide attempt. The need for lifelong therapy
increases with each episode of depression. All antidepressants carry a Food and
Drug Administration “black box” warning that they increase the risk of suicidal
thoughts and behaviors in children, adolescents, and young adults, especially in
the first months of treatment. Table 25–2 lists the medications used in the treat-
ment of depression.
Selective Serotonin Reuptake Inhibitors. Because of their efficacy and safety,
selective serotonin reuptake inhibitors (SSRIs) are frequently used as firstline agents for the treatment of depression. SSRIs are first line for children.
Fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), and escitalopram
(Lexapro) have been approved for use in children. SSRIs increase the amount
Table 25–2 • MEDICATIONS USED IN THE TREATMENT OF DEPRESSION
SSRIs SNRIs TCAs Atypical MAOIs
Fluoxetine
(Prozac)
Paroxetine
(Paxil)
Sertraline
(Zoloft)
Fluvoxamine
(Luvox)
Citalopram
(Celexa)
Escitalopram
(Lexapro)
SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant;
MAOI, monoamine oxidase inhibitor.
Venlafaxine
(Effexor)
Duloxetine
(Cymbalta)
Mirtazapine
(Remeron)
Desvenlafaxine
(Pristiq)
Doxepin
Imipramine
Amitriptyline
(Elavil)
Nortriptyline
(Pamelor)
Desipramine
(Norpramin)
Clomipramine
(Anafranil)
(Sinequan)
(Tofranil)
Bupropion
(Wellbutrin)
Amoxapine
(Asendin)
Trazodone
(Desyrel)
Phenelzine (Nardil)
Tranylcypromine
(Parnate)
Selegiline transdermal
(Emsam)
276 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
of the neurotransmitter serotonin (5-hydroxytryptamine) available to the postsynaptic neuron by blocking the presynaptic removal of serotonin. Common side
effects include sexual dysfunction, weight gain, nausea/gastrointestinal disturbance, insomnia or somnolence, and agitation. When used in combination with an
other serotonergic agent, the clinician should be aware of the possibility of developing serotonin syndrome.
Serotonin-Norepinephrine Reuptake Inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) affect both the serotonergic and noradrenergic systems,
preventing norepinephrine and serotonin reuptake. Their side effects are similar
to SSRIs. They can be used as first-line treatment for depression and, because of
their effects on two neurotransmitter systems, may be used as second-line agents
in SSRI failure.
Tricyclic Antidepressants. Tricyclic antidepressants (TCAs) are older agents that
affect, to varying degrees, the reuptake of norepinephrine and serotonin. They are
effective for the treatment of depression, and because they have been in use for many
years, they are inexpensive. However, they have numerous side effects, including
antimuscarinic effects (dry mouth, blurry vision, constipation, urinary retention,
and sinus tachycardia); histamine blockade (sedation, drowsiness, weight gain);
and alpha-1-receptor blockade (orthostatic hypotension and sedation). TCAs also
carry a significant risk of lethality in an overdose. Because of these side effects and
risks, TCAs have largely been replaced by other agents.
Atypical Agents. Atypical agents may have an unknown mechanism of action but
likely have similar effects on neurotransmitters as other antidepressants. They are
often utilized for their side-effect profile or to alleviate sexual disturbances caused
by typical agents. Bupropion is associated with increased risk of seizure at higher
doses and is contraindicated in patients with a history of seizure disorders and
anorexia. Trazodone carries the risk, although rare, of causing priapism. It is also
highly sedating and is frequently used as a sleep aid. Mirtazapine can be a good
choice for patients with insomnia or anorexia, as it can improve sleep latency and
duration and stimulate appetite.
Monoamine Oxidase Inhibitors. Monoamine oxidase inhibitors (MAOIs) cause
increased amounts of serotonin and norepinephrine in the cleft by inhibiting
breakdown. MAOIs require a low tyramine diet to reduce the risk of hypertensive
crisis and interact with numerous medications, with a significant risk of dangerous complications. Therefore, MAOIs should be restricted to patients who do
not respond to other treatments and should only be prescribed by experienced
clinicians.
Strategies to consider when there is an inadequate response to initial medication and psychotherapy include optimizing the medication dose, changing medications, or adding an antidepressant from a different pharmacological class (not
an MAOI). Patients who are refractory to medications should be referred to a
psychiatrist who can consider the following: electroconvulsive therapy (ECT),
MAOI therapy, transcranial magnetic stimulation, and lastly, vagus nerve stimulation (for patients who are refractory to at least four adequate treatment trials,
including ECT).
SECTION II: CLINICAL CASES 277
https://t.me/medicina_free
CLINICAL APPROACH TO OTHER MOOD DISORDERS
Anxiety Disorders
Anxiety disorders are a group of mood disorders that are characterized by worry
and distress. Patients with anxiety disorders are at high risk for developing comorbid
depression.
Generalized Anxiety Disorder (GAD): Patients with GAD have excessive and
difficult-to-control worry and anxiety that causes physical symptoms, including restlessness, irritability, sleep disturbance, and difficulty concentrating.
Panic Disorder: Panic disorder is characterized by recurrent panic attacks,
which are defined as periods of intense fear of abrupt onset. They often live in
fear of the next episode.
Obsessive-Compulsive Disorder (OCD): OCD manifests as either obsessions
(recurrent, intrusive thoughts) or compulsions (repetitive behaviors) that are
unreasonable, excessive, and cause much distress to the patient.
Posttraumatic Stress Disorder (PTSD): PTSD is a response to a severe trau-
matic event in which the patient suffers fear, helplessness, or horror and reliving of the event.
Phobia: A phobia is an irrational fear that causes a conscious avoidance of a
situation, subject, or activity. These can become debilitating when this phobia
is of commonly encountered subjects.
Bipolar Disorder
Bipolar disorder affects genders equally and often presents in young people. It is
characterized by fluctuations (“cycling”) between periods of mania and depression. Symptoms of mania include the abrupt onset of elevated or irritable mood,
inflated self-esteem, decreased need for sleep, pressured speech, racing thoughts,
distractibility, increased goal-directed activity, and engaging in pleasurable activities with potentially painful consequences. Concomitant substance abuse should
always be investigated. Episodes of mania must last at least 1 week (or any duration if hospitalization is needed) and occur during a distinct period, not continuously. Continuous behavior of this type suggests personality disorders or
schizophrenia. A single episode of mania is sufficient for the diagnosis of bipolar
disorder. All patients diagnosed with depression should be questioned about mania
since the treatments are different and SSRIs can trigger manic episodes. Bipolar
disorder is typically treated with mood stabilizers, which include valproate, carbamazepine, and lithium.
CASE CORRELATION
See also Case 36 (Family Violence), Case 41 (Substance Use Disorder),
and Case 59 (Opioid Use Disorder and Chronic Pain Management).
278 CASE FILES: FAMILY MEDICINE
https://t.me/medicina_free
COMPREHENSION QUESTIONS
25.1 A 62-year-old man presents for a follow-up office visit for severe depression.
He has been seen for 2 months by his provider. His symptoms have included
crying episodes, insomnia, and decreased appetite. He has suicidal ideations
and states that he has a gun in his home that he might use. He has had auditory
hallucinations, saying he hears a voice telling him that his wife is the devil. His
symptoms have not been relieved by maximum doses of sertraline (Zoloft),
venlafaxine (Effexor), or citalopram (Celexa). He is currently taking duloxetine
(Cymbalta), which has also failed to improve his symptoms. Which of the
following would most likely provide the most rapid relief of his symptoms?
A. Electroconvulsive therapy
B. Bupropion (Wellbutrin)
C. Stopping duloxetine and starting on an MAOI
D. Behavioral modification
25.2 A 40-year-old woman sees you in the office for follow-up of treatment for
recurrent depression. Her symptoms have improved slightly after 2 months
of fluoxetine (Prozac) 10 mg a day and weekly counseling sessions with a
psychologist. She states that she is still having feelings of “low energy” and
“crying episodes.” She is having no medication side effects, and both she and
her husband state that she is taking her medication regularly. Which of the
following would be the most appropriate next step?
A. Continue with your current plan and give it more time.
B. Increase the fluoxetine dose to 20 mg daily and continue counseling.
C. Discontinue fluoxetine and start paroxetine 10 mg daily.
D. Continue fluoxetine and add bupropion as adjunctive therapy.
E. Discontinue medications and arrange for psychiatric consultation for ECT.
25.3 Three weeks ago, you started a 22-year-old man on sertraline for his first
episode of major depressive disorder. Today, you receive a telephone call from
his mother stating that he has not slept in days, is speaking very rapidly, and
has maxed out his credit card buying electronic equipment. Which of the
following is the most likely explanation for this situation?
A. He is having a medication side effect.
B. He is secretly taking too much of his sertraline.
C. The sertraline has unmasked underlying bipolar disorder.
D. The sertraline has precipitated a hyperthyroid state.
ANSWERS
25.1 A. This patient has psychotic depression with suicidal ideation and has not
responded to maximum doses of several antidepressants. He is more likely
to respond to ECT than to counseling (answer D) or a change in medication
SECTION II: CLINICAL CASES 279
https://t.me/medicina_free
(answers B and C). Most studies have shown that ECT produces significant
response within the first week of therapy and complete remission within
3 to 4 weeks. This is much faster than the 3 to 4 weeks of lag time from antidepression pharmacological therapy.
25.2 B. The most common causes of treatment failure or poor response to
therapy are inadequate medication dosing, inadequate length of treatment,
or nonadherence. In this setting, where the patient is adherent and has
had adequate time for response, increasing the dose of medication from
10 mg (a low starting dose) to 20 mg would be your first step. Typically,
antidepressant medication dosages can be increased after 4 weeks of treatment if the response is inadequate. Answer A (continue current plan and
give more time) is not necessary since 2 months are an adequate time for
response. Answer C (discontinue fluoxetine and start paroxetine) would be
an option if the patient had significant side effects, but this patient has no
side effects. Adding a second antidepressant (answer D) would be indicated
if the patient continued to be symptomatic despite the maximum amount of
one agent. Answer E (discontinue medication and start ECT) would be an
option if pharmacological therapy were found to be ineffective or if a rapid
response were required.
25.3 C. In bipolar patients, the use of an SSRI can precipitate a manic state. It is
critically important to assess for a history of manic episodes prior to starting
antidepressant therapy. In some cases, bipolar disorder may initially present
as major depression, so the institution of antidepressant medication may
unmask an undiagnosed bipolar condition. Another condition to assess for in
this situation is the concomitant use of recreational drugs, such as cocaine or
methamphetamine. Sertraline does have some side effects (although much
less than the older tricyclic agents), but “mania” is not a typical side effect
(answer A). Instead, the typical side effects include sexual dysfunction, dizziness, and nausea.
CLINICAL PEARLS
» While working up a diagnosis of depression, other medical diagnoses,
such as hypothyroidism, anemia, diabetes, or infectious processes, that
could mimic some symptoms of depression must be ruled out.
» Always investigate the use of alcohol and drugs when evaluating for
mood disorders.
» Suicidal and homicidal ideation should always be investigated and thor-
oughly addressed when evaluating depression.
» The addition of any new medication should be investigated to ensure it is
not contributing to the patient’s symptoms.
Соседние файлы в папке Библиотека им академика М.И. Перельмана