1. Major Depressive Disorder: Initial Treatment and Beyond
Todd S. Cox, MD, DFAPA
Assistant Professor
The Johns Hopkins University School of Medicine Georgetown University School of Medicine

2. Outline The Perspectives of Psychiatry
Major Depressive Disorder Defined
Initial Pharmacologic Approaches
Subsequent Treatment Approaches
Questions

3. Diagnosis specific visits
College Health Centers Visits Turner and Keller: College Health Surveillance Network, Journal of American College Health (Nov 2016)
Patients
Diagnosis specific visits
Diagnostic category n %
Per patient
99% CI
Preventive
393,220
49.0
905,517
2.303
2.297, 2.309
Respiratory
294,240
36.7
525,682
1.787
1.78, 1.793
Nonspecific
232,018
28.9
474,923
2.047
2.039, 2.055
Dermatologic
124,436
15.5
209,814
1.69
1.68, 1.70
Infectious (non-STI)
114,894
14.3
164,520
1.43
1.42, 1.44
Mental health
103,844
12.9
511,929
4.93
4.91, 4.95
Musculoskeletal
95,808
11.9
197,687
2.06
2.05, 2.08
Injuries
95,446
164,457
1.72
1.71, 1.73
Abdomen, digestive, gastro
89,943
11.2
138,256
1.54
1.53, 1.55
Eye, ear, mouth
86,453
10.8
133,898
1.55
1.54, 1.56
Female reproductive
73,056
9.1
120,662
1.65
1.64, 1.66
Urinary
65,351
8.1
99,156
1.52
1.50, 1.53
Allergies
52,404
6.5
117,415
2.24
2.22, 2.26
STIs
50,292
6.3
84,214
1.67
1.66, 1.69
Circulatory, lymph
45,113
5.6
69,777
1.53, 1.56
Neurologic
25,147
3.1
41,055
1.63
1.61, 1.65
Metabolic, endocrine
17,825
2.2
41,574
2.33
2.30, 2.36
Sleep
11,983
1.5
25,021
2.09
2.05, 2.12
Rehabilitation
4,368
0.5
8,522
1.95
1.90, 2.01
Male reproductive
3,118
0.4
3,740
1.20
1.15, 1.25
Developmental, congenital
1,393
0.2
5,491
3.94
3.80, 4.08

4. College Health Centers Mental Health Visits Turner and Keller: College Health Surveillance Network, Journal of American College Health (Nov 2016)
Patients
Visits
Mental health diagnosis n %
Per patient
99% CI
All mental health diagnoses
103,844
100
511,929
4.93
4.91, 4.95
Anxiety
46,008
44.3
192,130
4.18
4.15, 4.20
Depression
34,788
33.5
169,741
4.88
4.85, 4.91
Psychosocial stressors
19,910
19.2
80,461
4.04
4.00, 4.08
Adjustment disorders
17,397
16.8
70,271
Drug abuse
13,789
13.3
27,727
2.01
1.98, 2.04
ADHD
12,279
11.8
64,142
5.22
5.17, 5.28
Eating disorders
6,428
6.2
52,137
8.11
8.02, 8.20
Bipolar and psychotic disorders
5,958
5.7
30,734
5.16
5.08, 5.23
Alcohol disorders
4,548
4.4
16,656
3.66
3.59, 3.74
Personality disorders
1,397
1.3
9,097
6.51
6.34, 6.69

5. Psychiatry Psychiatrists = Experts of the Mind
The Brain -- Mind Problem
Biological underpinnings of feelings, thoughts, and behaviors
Symptoms in the Mind
The Medical Model Does Not Always Apply

6. Group A Delirium Dementias Schizophrenia
Mood Disorders (Major Depression, Bipolar Disorder)
Anxiety Disorders (GAD, OCD, Panic Disorder, Phobias, PTSD)
Neurodevelopmental Disorders
ADHD
Autism
Medical Disease with Symptoms in Mental Life (Syphilis, Hypothyroidism, etc.)

7. Group B
Cluster A Personality Disorders (Schizoid, Schizotypal, Paranoid)
Cluster B Personality Disorders (Antisocial, Narcissistic, Histrionic, Borderline)
Cluster C Personality Disorders (Dependent, Avoidant, Obsessive- Compulsive)
Mental Retardation/Intellectual Disability

8. Group C Substance-Related and Addictive Disorders
Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder, Pica)
Sexual Disorders/Paraphilias
Sleep Disorders/Sleep-Wake Disorders (?)
Gambling
Sick-Role Behavior/Conversion Disorder/Factitious Disorder
Malingering

9. Group D
Adjustment Disorders
Demoralization
Grief/Loss
Homesickness

10. Four Types of Problems/Issues in Mental Life
Group A
Group B
Group C
Group D
Delirium
Dementia
Schizophrenia
Mood Disorders
Anxiety Disorders
Neurodev. Disorders
ADHD
Autism
Medical Diseases
Cluster A Personality
Cluster B Personality Cluster C Personality Mental Retardation/
Intellectual Disability
Substance Disorders
Eating Disorders
Sexual Disorders/
Paraphilias
Sleep Disorders
Gambling
Sick Role
Malingering
Adjustment Disorders
Demoralization
Grief/Loss
Homesickness

11. The Perspectives of Psychiatry Paul McHugh and Phillip Slavney (1983, 1986, 1998)
DISEASE
DIMENSION
BEHAVIOR
LIFE STORY
Delirium
Dementia
Schizophrenia
Mood Disorders
Anxiety Disorders
Neurodev. Disorders
ADHD
Autism
Medical Diseases
Cluster A Personality
Cluster B Personality Cluster C Personality Mental Retardation/
Intellectual Disability
Substance Disorders
Eating Disorders
Sexual Disorders/
Paraphilias
Sleep Disorders
Gambling
Sick Role
Malingering
Adjustment Disorders
Demoralization
Grief/Loss
Homesickness

12. The Perspectives of Psychiatry
Four different types/groups of problems in mental life
There is biology (neuroscience) associated with each perspective
Each perspective is conceptually unique
Each perspective has targeted treatment approaches
Each treatment approach has side effects
Each perspective influences the others
The formulation of the patient incorporates all four perspectives

13. The Disease Perspective
What the patient HAS
Nature acting on the patient
Follows Medical Reasoning:
Etiology
Pathological Entity (Broken Part)
Clinical Syndrome
Treatment: Fix the Broken Part
Cure: Eliminate the Etiology
Red Ink: All Medications are TOXIC/Poison/Side Effects

14. The Dimensional Perspective
Who the patient IS
Traits: HOW MUCH or HOW LITTLE POTENTIAL
Bell Curve Distribution in the Population, Individual Variation
How much of a trait is not GOOD or BAD
In certain situations: ASSET or VULNERABILITY

15. The Dimensional Perspective
Dimensional Reasoning:
Potential Provocation Response
Treatment: Guidance, Road Map
Red Ink: PATERNALISM

16. The Behavior Perspective
WHAT the patient DOES
There are ANTECEDENTS to and CONSEQUENCES of Behavior that influence the continuation of Behavior
Some behaviors have intrinsic drives associated with them
(eating, sex, sleep, substance use)
Behaviors carry with them the element of CHOICE

17. The Behavior Perspective
Behavioral Reasoning
satiety
Antecedents Behavior Consequences
craving
Treatment: STOP the Behavior
Red Ink: STIGMA

18. The Life Story Perspective
WHAT the patient ENCOUNTERS
This is the patient’s NARRATIVE
Includes what they encounter and the meaning they derive

19. The Life Story Perspective
Life Story Reasoning:
SETTING SEQUENCE OUTCOME
Treatment: REINTERPRET/RESCRIPT the Narrative
Red Ink: CONDESCENCION (all interpretations contain the hostility of condescencion)

20. The Perspectives of Psychiatry

21. Major Depressive Disorder
A DISEASE of the Brain
What the patient HAS
It is NOT a trait (who the patient is)
It is NOT a behavior (what the patient is doing)
It is NOT a life story problem (what the patient is encountering)

22. Major Depressive Disorder
Etiology Genetics trigger Pathological Entity (Broken Part) Serotonin Dysregulation Clinical Syndrome Major Depressive Episode

23. Major Depressive Disorder
The treatment for Major Depression is TO FIX THE BROKEN PART
This treatment may include somatic treatments (e.g. medications, light therapy, ECT, TMS, Vagus Nerve Stimulation, etc.) and/or psychotherapy (CBT)
A priority of psychotherapy is to insure that the symptoms of the illness do not result in problematic behaviors or narratives

24. Major Depressive Disorder
Major Depressive Disorder ≠ Demoralization
Somatic Treatments/Medication for Major Depressive Disorder have no impact on the ”depression” associated with Demoralization, Grief, Adjustment Disorders, Homesickness

25. Major Depressive Disorder: Epidemiology
Lifetime prevalence: %
Point prevalence: General population: 5%, Medical Outpatients: %
World Health Organization: Depression leading cause of disability worldwide
M:F: 1:2
Mean Age of Onset: y.o. (50% onset between y.o.)
Mean Age of Onset of Bipolar Disorder: 20 y.o.
Genes explain 37% of etiology of Major Depression (75% of Bipolar Disorder)
Anticipation: Earlier age of onset in successive generations

26. Major Depressive Disorder: Symptom Domains
Mood
Mood=“seasons” Emotions=weather Affect=outward expression of mood
Sad, anxious, irritable, low, numb/flat mood
Vitality
Physical (energy, psychomotor retardation/agitation), Cognitive (focus, concentration, processing speed), Emotional (initiation, motivation, pleasure)
Neurovegetative Symptoms/Drives
Sleep, Appetite, Libido
Self Attitude
Self esteem, sense of self, possibility, hopefulness, influence/impact on future, suicidal ideation

27. Major Depressive Episode: Diagnostic Criteria
5+ of the following symptoms during the same 2-week period (at least one of the symptoms is either depressed mood or loss of interest or pleasure)
Depressed mood (children or adolescents: irritable mood)
Anhedonia (markedly diminished interest or pleasure)
Weight loss or weight gain
Insomnia or hypersomnia
Psychomotor retardation or agitation
Fatigue or loss of energy
Feelings of worthlessness or excessive guilt
Diminished ability to think, concentrate, or indecisiveness
Recurrent thoughts of death or suicide

28. Major Depressive Disorder: Course
Single episode: 20%-30% (older, less family history)
Recurrent: %
Median duration of episode: 6 months
Mean number of episodes in a lifetime: 5-6
Kindling: episodes promote episodes
Suicide in Major Depression: 9-15%

29. Medical Illnesses that May Present as a Depressive Disorder
Cancer
Pancreatic, Lung, Lymphoma
Infectious Disease
Influenza, EBV, Hepatitis, Encephalitis, Syphilis, HSV, Lyme, HIV
Endocrinologic Disorders/Nutritional Disorders
Hypo/Hyperthyroidism, Diabetes, Hyperadrenalism (Cushing’s), Adrenocortical Insufficiency (Addison’s), Hypo/Hyperparathyroidism, Hypogonadism, Anemia
Metabolic Disorders
Uremia, Hyponatremia, Hypercalcemia, B6/B12/Folate deficiency, D deficiency
Rheumatologic Disorders
SLE, all
Neurologic Disorders
Stroke, Tumor, Bleed, Concussion/Head Trauma, Seizures, Sleep Apnia, MS, NPH, Parkinson’s, Huntington’s

30. Medications/Substances that May Generate Depressive Disorder
Antihypertensives (reserpine, Beta Blockers, clonidine)
Reserpine, Methyldopa
Antineoplastic (Interferon, Tamoxifen, Vincristine)
Steroids
Oral Contraceptives/Hormone Replacement
Indomethacin, NSAIDs
Acetazolamide
Ethionamide
Amphotericin B
Metoclopramide, Cimetidine, H2-blockers
Benzodiazepines
Alcohol
Cannabis
Opioids
Amphetamines/Stimulants
Accutane (isotretinoin)

31. Treatment for Major Depressive Disorder
Antidepressants
Antidepressant Augmentation Strategies
Brain Stimulation
Light Therapy
Psychotherapy
Novel Treatments

32. Antidepressant Classes
Selective Serotonin Reuptake Inhibitor (SSRI)
Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
Dopamine Norepinephrine Reuptake Inhibitor
Serotonin Reuptake Inhibitor and Serotonin Agonist/Antagonist
Tricyclic Antidepressant (TCA)
Monoamine Oxidase Inhibitor (MAOI)

33. Selective Serotonin Reuptake Inhibitor (SSRI)
Fluoxetine (Prozac, Prozac Weekly) – MDD, OCD, Panic, Bulimia, PMDD
Sertraline (Zoloft) – MDD, OCD, Panic, PTSD, PMDD, Social Anxiety
Paroxetine (Paxil, Paxil CR)—MDD, OCD, Panic, Social Anxiety, GAD, PTSD, PMDD, Menopausal Hot Flashes
Fluvoxamine (Luvox, Luvox CR) – for OCD
Citalopram (Celexa) -- MDD
Escitalopram (Lexapro) – MDD, GAD

34. Selective Serotonin Reuptake Inhibitor (SSRI)
Mainstay for treatment of Major Depression and Anxiety Disorders
Considered first-line treatment for many patients
Side effects: GI Effects, Nausea (Sertraline), Insomnia and Anxiety (Fluoxetine), Constipation (Paroxetine), Sedation (Paroxetine), Weight Gain (Paroxetine), Sexual Side Effects (all, most with Paroxetine), Apathy, Headache
Rare: Hyponatremia, GI bleed
Significant P450 interactions: Fluoxetine, Fluvoxamine, Paroxetine
Fewest Drug-Drug interactions: Sertraline, Escitalopram

35. Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
Venlafaxine (Effexor, Effexor XR) – MDD, GAD, Social Anxiety, Panic
Duloxetine (Cymbalta) – MDD, GAD, Diabetic Peripheral Neuropathy, Fibromyalgia, Chronic Musculoskeletal Pain
Desvenlafaxine (Pristiq) – MDD
Levomilnacipran (Fetzima) – MDD
SNRI-like:
Mirtazapine (Remeron, Remeron ODT) -- MDD

36. Serotonin Norepinephrine Reuptake Inhibitor (SNRI)
Particularly helpful for physical symptoms associated with depression, chronic pain; also can be helpful with attention/concentration
Side Effects: Nausea, dizziness, insomnia, excessive sweating, constipation, dry mouth, decreased appetite, headache, sexual side effect
Venlafaxine/Desvenlafaxine: Dose-related BP elevations; hyponatremia/SIADH
Duloxetine: Rare cases of Hepatic Failure
Levomilnacipran: Nausea may be severe; rare urinary retention
Mirtazapine: Somnolence, increased appetite, weight gain, no sexual side effects; rare agranulocytosis/neutropenia

37. Dopamine Norepinephrine Reuptake Inhibitor
Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Forfivo XL)
MDD, Seasonal Affective Disorder, Smoking Cessation
Activating, decreased appetite, no sexual side effects (can reverse sexual side effects of other antidepressants), helps with concentration
Can be problematic for patients with anxiousness/irritability
Side Effects: agitation, insomnia, headache, nausea, vomiting, tremor, jerks, tachycardia, dry mouth, weight loss
Rare risk: Seizures (higher dosages, rapid dose increase), avoid in patients with binge/purge behavior
Can produce false-positive urine test results for amphetamines

38. Serotonin Reuptake Inhibitor and Serotonin Agonist/Antagonist
Trazodone (Desyrel) -- MDD (used mostly as a sleep agent off-label)
Side effects: orthostatic hypotension, priapism, drowsiness, dry mouth, blurred vision, nausea, vomiting
Vilazodone (Viibryd) -- MDD (take with food or serum levels reduced by %)
Side effects: diarrhea, nausea, vomiting, dry mouth, insomnia, dizziness, rare hyponatremia/SIADH
Vortioxetine (Trintellix) – MDD
Side effects: nausea, constipation, vomiting, sexual side effects, dry mouth, headache

39. Tricyclic Antidepressant (TCA)
Amitriptyline (Elavil) – MDD (metabolized to Nortriptyline)
Desipramine (Norpramin) – MDD
Nortriptyline (Pamelor) – MDD
Imipramine (Tofranil) – MDD (metabolized to Desipramine)
Clomipramine (Anafranil) – OCD
Side effects: sedation, dry mouth, constipation, weight gain, sexual side effects, urinary hesitation/retention, blurred vision
Therapeutic blood level monitoring
EKG monitoring (QTc prolongation, arrhythmias, AV block)
Overdose Toxicity with potentially serious cardia effects or fatality with as little as 10-day supply

40. Monoamine Oxidase Inhibitor (MAOI)
Isocarboxazid (Marplan) -- MDD
Phenelzine (Nardil) – MDD
Tranylcyparomine (Parnate) – MDD
Selegiline Transdermal (EMSAM) – MDD

41. Monoamine Oxidase Inhibitor (MAOI)
Non-selective Monoamine Oxidase Inhibitors
Particularly effective for ”atypical depression”: overeating, oversleeping, rejection sensitivity, mood reactivity
HYPERTENSIVE CRISIS concerns
Dietary Restriction: Avoid high tyramine, tryptophan, phenylalanine, or tyrosine (aged cheese, cured meats, fava or broad bean pods, tap/draft beers, Marmite, sauerkraut, soy sauce, over-ripe fruit, spoiled foods)
Medication Avoidance: Other antidepressants, stimulants, sympathomimetics, dextromethorphan, meperidine, disulfiram
Do not use within 5 weeks of Fluoxetine and 2 weeks of other antidepressants; wait 2 weeks after stopping MAOI to start other antidepressant
Side effects: dizziness, headache, orthostatic hypotension, dry mouth, constipation, drowsiness (Nardil), tremor, sweating, peripheral edema, sexual side effects, weight gain (Nardil)

42. Class Warnings for All Antidepressants
Suicide Risk
Black Box Warning: FDA (2004, 2007): children, adolescents, young adults (to age 24)
MONITORING WHEN INITIATING ANY ANTIDEPRESSANT
Mania Switch
Especially concerning when there is a family history of bipolar disorder
Serotonin Syndrome
Agitation, hallucinations, hyperthermia, tachycardia, autonomic instability, myoclonus, hyperreflexia, incoordination, nausea, vomiting, diarrhea
Discontinuation Syndrome
Short half life SSRIs and SNRIs
Dizziness, nausea, headache, irritability, insomnia, diarrhea, agitation, “electric shock” sensations, lethargy, abnormal dreams
Bleeding Risk
GI bleed, bruising, nosebleed
Particularly when used in conjunction with aspirin, NSAIDs, anticoagulants, antiplatelet agents

43. Which Antidepressant?
No agent is more efficacious than others in clinical trials (very few head-to-head studies)
USE THE SIDE EFFECT PROFILE TO THE PATIENT’S ADVANTAGE:
More activating: Wellbutrin, Prozac, Effexor, Pristiq, Viibryd
More sedating: Paxil, Remeron, TCAs
Increase appetite: Paxil, Remeron, TCAs, Nardil
Decrease appetite: Wellbutrin, Prozac, Effexor, Pristiq, Fetzima, Parnate
Wellbutrin is like ”fuel” and can heighten agitation, irritability, anxiety while waiting to treat the underlying depressive episode

44. R’s of Depression Treatment
No Response: improvement of <25% Partial Response: improvement of 25-49% Response: improvement of >=50% Remission: complete resolution of symptoms Relapse: return of depression symptoms within 6 months of remission Recovery: absence of symptoms for at least 6 months following remission Recurrence: new episode after recovery Resistant: failure of two or more trials Refractory: highly resistant to treatment and do not respond

45. Antidepressant Treatment
”Therapeutic Trial”: Therapeutic Dosage for 6-12 weeks to achieve remission
For moderate to severe Depression:
Antidepressant + CBT > Antidepressant > CBT
Patients who show little improvement (<25% reduction in symptoms) after 4-6 weeks, consider moving on to next option
Overall Response Rate with first agent: %
Overall Remission Rate with first agent: 33%
At least 6 Months of Being Episode Free Prior to Discontinuation
Discontinue Through Tapering

46. STAR*D: Sequenced Treatment Alternatives to Relieve Depression: DESIGN
Collaborative study on Depression treatment in 2006
4041 Outpatients
Main Focus: Treatment of patients when the first treatment is inadequate
Aim to be Generalizable to Real Clinical Situations
Minimal exclusion criteria
Incorporated patient preference
No blinding
Citalopram first, then 7 options including augmentation agents, additional antidepressants, CBT, new antidepressant
Four treatment levels

47. STAR*D: Sequenced Treatment Alternatives to Relieve Depression: RESULTS
With Citalopram: 33% remission, 47% response
Half the participants become symptom free after two treatment levels
Over all four treatment levels: 70% achieve remission
Withdrawal rates rose with each level (42% withdrew at Level 3)
Changing class of antidepressant was no better or worse than changing to a different agent in the same class
While some patients achieve benefit in the first 6 weeks, full benefit may require weeks
Difficult-to-treat Depression can get well after trying several treatment strategies, but the odds of beating the depression diminish with every additional treatment strategy

48. If At First You Don’t Succeed (with Remission)…..
No Response (<25%): Try a different antidepressant AND psychotherapy (CBT)
Partial Response (25-49%): Add another antidepressant (Wellbutrin may be a good choice) AND psychotherapy (CBT)
Response (>=50%): Augmentation OR Another Antidepressant AND/OR psychotherapy (CBT)

49. Augmentation Strategies
Lithium
Atypical Antipsychotics
Thyroid Hormone
Buspirone
Pindolol
Omega-3 Fatty Acids (Lovaza)
SAMe (S-adenosyl-l-methionine)
L-methylfolate (Deplin)
Modafinil
Stimulants
Light Therapy

50. Lithium
”Gold Standard” augmenting agent; first-line augmentation strategy;
Off-Label Use
50% respond to lithium augmentation within 2-6 weeks with blood levels between mmol/L
Some respond within two days
Most studies are in lithium augmentation of TCAs
Anti-suicide effects
Side effects: nausea, diarrhea, fine tremor, ataxia, polyuria, excessive thirst, memory difficulties, weight gain, hypothyroidism, acne, worsening psoriasis
Monitoring: renal function, cardiac arrhythmia, toxicity, thyroid functioning

51. Atypical Antipsychotics
FDA Approved for Augmentation:
Aripiprazole (Abilify) (activating)
Quetiapine (Seroquel) (sedating)
Brexpiprazole (Rexulti) (sedating)
Other Atypical Antipsychotics used off-label as augmentation agents
Side Effects: METABOLIC SYNDROME (less risk with Aripiprazole), akathisia (Aripiprazole and Brexpiprazole), tremors, hypotension, dizziness, dry outh

52. Thyroid Hormone More studies looking at triiodothyronine (T3)
20-50 mcg daily
2-4 weeks of treatment, 25%-50% response rates

53. Buspirone (BuSpar) Serotonin receptor partial agonist Efficacy in GAD
Off-Label use as antidepressant augmenting agent
40-70% response in some studies (although not replicated)
Side effects: dizziness, nervousness, nausea, headache, jitteriness
Must watch for Serotonin Syndrome
Buspirone can help minimize sexual side effects of other agents

54. Pindolol Beta Blocker with structural homology to serotonin
Off-label use as an antidepressant augmentation agent
Conflicting studies

55. Other Potential Augmenters
Omega 3 Fatty Acids (Lovaza): 1g/day, EPA>DHA
SAMe (S-adenosyl-l-methionine)
L-methylfolate (Deplin): genetic variations of MTHFR
Modafinil
Stimulants
Light Therapy: 50,000 Lux, particularly in Seasonal Affective Disorder

56. Brain Stimulation Electroconvulsive Therapy (ECT)
Superior to pharmacotherapy
70% remission, 90% response; 6-12 treatments, often more
No absolute contraindications (some say pheochromocytoma)
Short term memory difficulties
Transcranial Magnetic Stimulation (TMS)
FDA-approved for treatment resistant depression
Used in conjunction with antidepressant
Magnetic Seizure Therapy (MST)
Vagus Nerve Stimulation
Deep Brain Stimulation

57. Other Approaches to Refractory Depression
Sleep Deprivation
70% experience improvement in depressive symptoms
Improvement occurs only for a short duration of time (12-48 hours)
Ketamine/Esketamine
NMDA receptor antagonist
Transiently alleviate treatment refractory depression
Rapid response in at least 50% of patients (within minutes)
Effect dissipates by day 10-14
Side effects: large dissociative and psychotomimetic effects post infusion,
hemodynamic effects, blurred vision, dizziness, nausea, vomiting

58. CONCLUSIONS
Major Depressive Disorder (MDD) is a common, treatable illness
5-10% of college students presenting to health centers
MDD is distinct from other
Standard Treatment for MDD includes antidepressant medication and psychotherapy
Medication approaches, including the use of multiple antidepressants, augmentation agents, and psychotherapy (CBT) can result in remission rates close to 70%
Treatment Resistant and Refractory Depression can respond to other treatments, such as ECT, in close to 90% of patients

59. QUESTIONS?