Source: Teter CJ, Kando
JC, Wells BG. Major Depressive Disorder. In: DiPiro JT, Talbert
RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy:
A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7988626.
Accessed June 19, 2012
- Unipolar depression
- Major depression
- Affective disorder characterized by one or more major
depressive episodes without history of manic, mixed, or hypomanic
- Several social, developmental, and biologic theories proposed.
- Patient symptoms reflect changes in brain monoamine neurotransmitters,
specifically norepinephrine (NE), serotonin (5-HT), and
- Depression may be caused by decreased brain levels of
norepinephrine, 5-HT, and dopamine.
- Desensitization or downregulation of norepinephrine or 5-HT1A receptors
may relate to onset of antidepressant effects.
- Failure of homeostatic regulation of neurotransmitter systems,
rather than absolute increases or decreases in their activities,
may be involved.
- Potential link between 5-HT and norepinephrine activity—both
serotonergic and noradrenergic systems involved in antidepressant
- Increased dopamine neurotransmission in mesolimbic pathway
may be related to mechanism of action of antidepressants.
- In one survey, 16.2% of population had history
of major depressive disorder in their lifetime, and >6.6% had
episode within past 12 months.
- Women have lifetime rate 1.7–2.7 times greater than
- Adults 18–29 years of age have highest rates during
any given year.
- Depressive disorders common during adolescence, with comorbid
substance abuse, suicide attempts, and deaths occurring frequently.
- Depressive disorders and suicide tend to occur within families.
- Emotional symptoms:
- Diminished ability
to experience pleasure
- Loss of interest in usual activities
- Pessimistic outlook
- Crying spells
- Feelings of guilt
- Psychotic features (e.g., auditory hallucinations and delusions)
- Physical symptoms:
- Sleep disturbance
- Increased/decreased appetite
- Loss of sexual interest
- Gastrointestinal (GI) and cardiovascular complaints (especially
- Cognitive symptoms:
- Decreased ability to
- Slowed thinking
- Poor memory for recent events
- Psychomotor disturbances may include psychomotor retardation
(slowed physical movements, thought processes, and speech) or psychomotor
Means of Confirmation
- Obtain complete blood count (CBC) with differential, thyroid-stimulating
hormone, and serum electrolytes.
- Bipolar disorder or cyclothymia
- Adjustment disorder with depressed mood
- Premenstrual dysphoric disorder
- Major depression with postpartum onset: usually 2 weeks to
6 months postpartum
- Seasonal affective disorder
- Substance use disorders
- Medications (e.g., clonidine, propranolol, reserpine, isotretinoin)
- Eliminate or reduce acute symptoms.
- Minimize adverse drug effects.
- Ensure adherence with therapeutic regimen.
- Facilitate return to premorbid level of functioning.
- Prevent further depressive episodes.
- Antidepressants essentially equal in efficacy when administered
in comparable doses.
- Choice of antidepressant based on:
history of response
- History of familial response
- Concurrent medical conditions
- Presenting symptoms
- Potential ...