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Chapter 43. Depression and Anxiety

Phillip Lai

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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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Table 43-1 Diagnosis of Major Depressive Episode

5 or more in the last 2wks & is a change from previous functioning; ≥1 symptom is either depressed mood or loss of interest or pleasure

  • Depressed mood, markedly diminished interest or pleasure, weight loss or weight gain/change in appetite, psychomotor agitation or retardation, fatigue of loss of energy, worthlessness or excessive or inappropriate guilt, ↓ concentration or indecisiveness, thoughts of death or suicide
  • Symptoms cause impairment in social, occupational, or other important areas or functioning
  • Symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)

Data from DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association, 2000).

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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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Table 43-2 Pharmacotherapy for Depression

Drug Name & Availability

Dosing

Common Adverse Effects & Contraindications

Drug-Drug Interactions

Clinical

Notes

Selective Serotonin Reuptake Inhibitors

Citalopram (Celexa®) 10mg/5mL syrup; 10, 20, 40mg ODT; 10, 20, 40mg tabs

10–40mg daily (max 40mg daily; 20mg >60yo)

AE: headache, nausea, diarrhea, sexual dysfunction, sedation, insomnia anxiety, sweating

CI: ALL concurrent use with MAOI or linezolid

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