Major Depressive Discorder

Ms. S is a 29-year-old woman who came in complaining of feeling down. Her other symptoms include decreased appetite, trouble sleeping, inability to concentrate at work, and low energy. According to the patient, her friends have told her that she doesn’t seem to be as interested in getting together for social events. Medical history is unremarkable, and denies intake of any medications. Thyroid studies are normal and no anemia on laboratory evaluation. There was nothing mentioned about a recent stressor in the patient’s life as well as about her family history.              

Depression has been mostly diagnosed clinically and in research using the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification from the American Psychiatric Association and the International Statistical Classification of Diseases and Related Health Problems (ICD) (Working Group of the Clinical Practice Guideline on the Management of Depression in Adults, 2014).

The underlying pathophysiology of major depressive disorder (MDD) has been associated with elevated baseline cortisol levels and a dysregulation of the cortisol-mediated stress response. In MDD, this response is slower to recover from a stressor. Another neurotransmitter being implicated is serotonin; lower levels have been linked to the diagnosis of MDD. Serotonin has been suggested to be involved in neurobiologic systems in the brain that respond to stressful or emotional stimuli (Buttaro, Trybulski, Bailey, Sandberg-Cook, 2013).               

Major depressive disorder affects females twice more likely than males, and individuals aged 30 to 60 years old have the highest rates. Furthermore, first-degree relatives of patients with MDD are 1.5 to 3 times affected with the same condition as compared with the general population (Buttaro et al., 2013).

There are no pertinent physical examination findings in MDD. During consultation, symptoms and risk factors are carefully elicited. Listen to and/or ask about recent life stressors, and changes in sleeping patterns, eating habits or activities. Patients may only present with persistent somatic issues. Although depression may be initially suspected, it is important to rule out other medical and psychiatric conditions. Medications can also have depressive symptoms as side effects. There are still no laboratory tests or imaging studies that can definitely diagnosed MDD. The diagnostic tests (e.g., nutritional, endocrine, and thyroid function) can be helpful to the extent of ruling out other medical conditions (Buttaro et al., 2013). The following conditions may present with depressive symptoms:

Medical conditions

• Endocrine/Metabolic
• Thyroid disease (hypo- or hyperthyroidism), diabetes, severe
• anaemia, Cushing's disease, Addison's disease, porphyria
• Infectious
• Tuberculosis,   Epstein-Barr   virus   infection,   HIV,   Tertiary   syphilis
• Neurological
• Alzheimer's disease, multiple sclerosis, Parkinson’s disease, stroke, epilepsy
• Neoplasms
• Carcinomatosis, pancreatic cancer
• Others
• Lues, chronic pain
• Mental Disorders
• Panic/anxiety disorder
• Obsessive compulsive disorder
• Bipolar disorder
• Dysthymia
• Adjustment disorders
• Negative schizophrenic symptoms

Drug consumption (Working Group of the Clinical Practice Guideline on the Management of Depression in Adults, 2014, p. 38)

Assessing the risk for suicide for patients with depression is very important. Approximately, people suffering from depression are at 20 times higher risk for suicide compared with the general population. The following should be determined from the patient’s history:

•             Presence of previous suicide attempts.

•             Substance abuse.

•             Specific symptoms such as hopelessness, anxiety, agitation or suicidal ideation.

•             Other risk factors such as comorbidity, chronicity, pain or disability, family history of suicide, social factors and a history of suicide in the environment. (Working Group of the Clinical Practice Guideline on the Management of Depression in Adults, 2014)

According to the US Preventive Services Task Force Recommendation, “effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches (eg, CBT or brief psychosocial counseling), alone or in combination” (Siu & the US Preventive Services Task Force, 2016, p. 383). The Kaiser Permanente Care Management Institute (2012) on the diagnosis and treatment of depression in adults reports, “any class of antidepressant (selective serotonin reuptake inhibitor [SSRI], tricyclic antidepressant [TCA], serotonin–norepinephrine reuptake inhibitor [SNRI], norepinephrine reuptake inhibitor [NRI], or dopamine agonist [DA]) is recommended for first-line treatment of MDD” (First-Line Treatment section).

The goals in the treatment of depression include:

•             reduction of symptoms,

•             improvement in the quality of living and daily functioning,

•             suicidal ideation is eliminated,

•             minimize adverse effects of the drug, and

•             prevention of relapse (Woo & Wynne, 2012)

The choice of antidepressant medication is determined by presenting symptoms, presence of comorbidities, interaction with other medications taken, tolerance to side effects, and patient preference. If the patient has a family member who is being treated for the same condition, also consider the medication that the blood relative has had good response with. It is likely that the patient will respond the same way (Woo & Wynne, 2012).

Ms. S decided to take a medication to treat her depression. She was initially prescribed with fluoxetine 20 mg daily.

Fluoxetine (Prozac) is a serotonin-selective reuptake inhibitor (SSRI) that blocks the transport mechanism allowing more serotonin (5-HT) to bind to its postsynaptic receptor. This action is said to improve symptoms of depression. SSRIs have equal efficacy with serotonin-norepinephrine reuptake inhibitors (SNRI) but are safer and with more tolerable side effects. Patient should be educated that there would be gradual improvement of her symptoms; full response is achieved after 2 to 4 weeks. Sleep and dysphoria are the last ones to improve. Within 8 to 12 weeks, advice the patient that her symptoms will be monitored until the full therapeutic effect of the medication is reached. Follow-up on the patient a week after treatment has been initiated. Depending on her response to fluoxetine, the dosage may be increased, augmented with another drug, or changed to another class of antidepressants. She might also need to be referred to a psychiatrist for further treatment. However, if her symptoms resolve, fluoxetine should be maintained at its effective dose for one year before tapering or discontinuing. Adverse effects of fluoxetine that the patient should be made aware of include anxiety, restlessness, drowsiness, constipation, orthostasis, and sexual dysfunction (e.g., decreased libido) (Woo & Wynne, 2012) .

The patient’s compliance to her treatment, specifically with intake of her medication should be reiterated during follow-up. Provide patient with a list of Web sites she can visit for additional information about her condition (e.g., National Institute of Mental Health).  Encourage the patient to report effects of her medication, both favorable and not. Emphasize that improvement of her symptoms does not necessarily mean that she may not need to continue her medication. She needs to understand that it may take a year or even longer for the brain to resume its proper functioning. Moreover, even after tapering and eventually discontinuing the medication, her symptoms may return prompting resumption of the drug. Thus, part of the education also is determining the symptoms of depression the patient should watch out for after her treatment has ended (Woo & Wynne, 2012) .