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Pathophysiology

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  • Prevailing hypothesis is dysregulation of 5-HT, NE, &/or DA (N Engl J Med 2007;358:55)

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Diagnosis & Evaluation

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Clinical Pearl 43-1

SIGECAPS

  • Useful acronym, to meet the dia-gnosis of major depression, a patient must have 4 of the symptoms plus depressed mood or anhedonia, for at least 2wk
  • Sleep disorder (either increased or decreased sleep), Interest deficit (anhedonia), Guilt (worthlessness, hopelessness, regret), Energy deficit, Concentration deficit, Appetite dis-order (either decreased or increased), Psychomotor retardation or agitation, Suicidality (Am Fam Physician 1998; 58:1617)
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Table 43-1 Diagnosis of Major Depressive Episode
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Treatment & Follow-Up

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  • Goal → remission of all symptoms of depression; continue medications for ≥4–9mo to prevent relapse (APA Guidelines for Major Depressive Disorder, 2010)

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Figure 43-1.
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Depression treatment algorithm (based on TMAP guidelines for depression).

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Pharmacologic Treatment

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  • SSRIs: inhibits 5-HT reuptake transporter
  • SNRI: inhibits 5-HT & NE reuptake transporters
  • Bupropion: inhibits DA & NE reuptake transporters
  • Mirtazapine: α2-antagonist which ↑ 5-HT & NE
  • Triazolopyridines: ↑ 5-HT, NE, & DA by 5-HT reuptake transporter inhibition & 5-HT2A antagonism
  • TCA: inhibits 5-HT & NE reuptake transporters but not 1st line due to multiple adverse effects & possibility of fatal overdose
  • MAOI: inhibits breakdown of 5-HT, NE, & DA but utilized as last line due to dietary restrictions & drug interactions

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Table 43-2 Pharmacotherapy for Depression

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