Major depressive disorder has significant potential morbidity and mortality, contributing to suicide, incidence and adverse outcomes of medical illness, disruption in interpersonal relationships, substance abuse, and lost work time. With appropriate treatment, 70-80% of individuals with major depressive disorder can achieve a significant reduction in symptoms.
Essential update: FDA approves new drug for major depression
In July 2013, the FDA approved the SNRI levomilnacipran (Fetzima, Forest Laboratories, Inc.) for the treatment of major depressive disorder in adults. The drug, available as a once-daily sustained-release formulation, has greater potency for norepinephrine reuptake inhibition than for serotonin reuptake inhibition in vitro without directly affecting the uptake of dopamine or other neurotransmitters.
Efficacy was demonstrated in a phase 3 trial which showed all 3 daily doses of levomilnacipran (40 mg, 80 mg, or 120 mg) improved symptoms compared with placebo. The most common adverse reactions were nausea, constipation, hyperhidrosis, increased heart rate, erectile dysfunction, tachycardia, vomiting, and palpitations
Signs and symptoms
Most patients with major depressive disorder present with a normal appearance. In patients with more severe symptoms, a decline in grooming and hygiene may be observed, as well as a change in weight. Patients may also show the following:
- Psychomotor retardation
- Flattening or loss of reactivity in the patient's affect (ie, emotional expression)
- Psychomotor agitation or restlessness
Major depressive episode
Among the criteria for a major depressive episode, at least 5 of the following symptoms have to have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood)
- Depressed mood: For children and adolescents, this can also be an irritable mood
- Diminished interest or loss of pleasure in almost all activities (anhedonia)
- Significant weight change or appetite disturbance: For children, this can be failure to achieve expected weight gain
- Sleep disturbance (insomnia or hypersomnia)
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness
- Diminished ability to think or concentrate; indecisiveness
- Recurrent thoughts of death, suicidal
- A pattern of long-standing interpersonal rejection ideation, suicide attempt, or specific plan for suicide
Diagnosis
Screening instruments
Self-report screening instruments for depression include the following:
- Patient Health Questionnaire-9 (PHQ-9): A 9-item depression scale; each item is scored from 0-3, providing a 0-27 severity score
- Beck Depression Inventory (BDI): A 21-question symptom-rating scale
- BDI for primary care: A 7-question scale adapted from the BDI
- Zung Self-Rating Depression Scale: A 20-item survey
- Center for Epidemiologic Studies-Depression Scale (CES-D): A 20-item instrument that allows patients to evaluate their feelings, behavior, and outlook from the previous week
In contrast to the above self-report scales, the Hamilton Depression Rating Scale (HDRS) is performed by a trained professional, not the patient. The HDRS has 17 or 21 items, scored from 0-2 or 0-4; a total score of 0-7 is considered normal, while scores of 20 or higher indicate moderately severe depression.
The Geriatric Depression Scale (GDS), although developed for older adults, has also been validated in younger adults. The GDS contains 30 items; a short-form GDS has 15 items.
Laboratory studies
No diagnostic laboratory tests are available to diagnose major depressive disorder, but focused laboratory studies may be useful to exclude potential medical illnesses that may present as major depressive disorder.
Management
In all patient populations, the combination of medication and psychotherapy generally provides the quickest and most sustained response.
Pharmacotherapy
Drugs used for treatment of depression include the following:
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin/norepinephrine reuptake inhibitors (SNRIs)
- Atypical antidepressants
- Tricyclic antidepressants (TCAs)
- Monoamine oxidase inhibitors (MAOIs)
- St. John's wort (Hypericum perforatum)
Psychotherapy
Types of psychotherapy that have been used for the treatment of major depressive disorder, especially in the pediatric population, include the following:
- Behavior therapy
- Cognitive-behavioral therapy
- Family therapy
- Group psychotherapy
- Interpersonal psychotherapy
- Interpersonal therapy
- Mindfulness-based cognitive therapy
- Psychodynamic psychotherapy
- Supportive psychotherapy
