Chapter 85: Major Depressive Disorder

KEY CONCEPTS

• Multiple guidelines are available to guide the treatment of major depressive disorder (MDD), including medication management. Clinicians treating individuals with MDD should be familiar with key tenets of these guidelines.

• Other potential causes of symptoms such as medical conditions, medications and other substances must be ruled out first when evaluating a patient for a diagnosis of MDD.

• The goals of treatment for MDD are the resolution of current symptoms (ie, remission) and the prevention of further episodes of depression (ie, relapse or recurrence).

• When counseling patients with MDD who are receiving antidepressant medications, the patient should be informed that adverse effects might occur immediately, while symptoms of depression may take 2 to 4 weeks to improve and up to 3 months for full resolution. Adherence to the treatment plan is essential for a successful outcome, and tools to help increase medication adherence should be discussed with each patient.

• Since available antidepressants are considered equally efficacious for MDD, factors such as comorbid medical conditions, age, side effect profile, and past history of response are used to guide medication selection.

• When determining if a particular medication is ineffective for a patient, it is essential to evaluate the dose and duration of treatment as well as patient adherence to the medication.

• Pharmacogenetic tests are now commercially available. However, there are no standard or well-accepted recommendations for the use of pharmacogenetic testing as it relates to antidepressant treatment of MDD.

• When evaluating response to an antidepressant, in addition to target signs and symptoms, the clinician must consider quality-of-life issues, such as social, and occupational functioning. In addition, the tolerability of the agent should be assessed because the occurrence of side effects may lead to medication nonadherence, especially in cases of recurrent episodes and long-term medication management.

Patient Care Process for Major Depressive Disorder

Collect

• Patient characteristics (eg, age, sex)

• Current and past medical/psychiatric history (including information on first-degree family members)

• Past medication history, including medications not tolerated and any medication allergies (also collect on first-degree family members)

• Social history (eg, tobacco, ethanol, and other substance use as well as social supports and/or stressors)

• Current medications including over-the-counter (OTC), herbal products, dietary supplements and medical or recreational marijuana

• Objective data

  • Blood pressure, heart rate, weight

  • Labs including thyroid function tests, serum creatinine, complete blood count (CBC), liver function tests, urine drug screen, blood alcohol level, serum drug levels and pharmacogenomics testing if available

  • Reported symptoms of depression or other rating scale assessment (eg, Patient Health Questionnaire 9 [PHQ-9], Beck Depression inventory [BDI]) (Table 85-2 and Chapter e79, “Evaluation of Psychiatric Illness”)

Assess

• Suicidality (eg, Columbia-Suicide Severity Scale)

• Severity of illness/need for hospitalization

• Impact of substance use on ...