1. MAJOR depressive DISORDER
By: Farrukh Hashmi MD
Board certified in psychiatry and NEUROLOGY
Lourdes Counseling Center
Reliance medical center

2. Major depressive disorder
Diagnosis Criteria According to DSM-V
Diagnostic Code (F32.X and F33.X)
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either
(1) depressed mood or (2) loss of interest or pleasure ( Anhedonia).

3. Major depressive disorder
Depressed mood most of the day
Markedly diminished interest or pleasure in all/almost all activities
Significant weight change not due to other medical condition
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Diminished ability to think or concentrate, or indecisiveness
Recurrent thoughts of death, SI w/ past attempt or specific plan

4. Major depressive disorder
In addition, the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
The episode is not attributable to the physiological effects of a substance or to another medical condition

5. Differential diagnosis of clinical depression
Major Depressive Disorder (MDD)
Bipolar Disorder
Seasonal Affective Disorder (SAD)
Psychotic Depression
Peripartum (Postpartum) Depression
Premenstrual Dysphoric Disorder (PMDD)
“Situational” Depression—Significant Life Changes
Dysthymia

6. Comorbidities of Depression
Depressive and anxiety disorders commonly occur together in patients presenting in the primary care setting
The presence of depressive/anxiety comorbidity substantially increases medical utilization
Is associated with greater chronicity, slower recovery, increased rates of recurrence, and greater psychosocial disability
Long-term treatment is indicated
SSRI (Selective Serotonin Reuptake Inhibitor) is preferred

7. Route to treatment Appearance of Symptoms but Lack of Insight
Life is not great but it goes on
Recognition of Changes in Mood
It’s caused by stress from work and family
Self-Medication
Alcohol, marijuana, and other illegal street drugs to enhance my mood
Visit to My PCP
Referral to a Specialist
Gaining insight and judgement toward my illness
Most patients resist of seeing a specialist unless it is strongly recommended by their PCPs

8. Route to Treatment
It is estimated that about 70% of visits to PCPs are psychosocial related issues
Different patients presents themselves differently. Gender/ Race
Only less than a quarter of those issues will be referred to a specialist
PCPs are often the final stop for most patients with mild to moderate psychiatric conditions

9. If things aren’t bad enough already…
Often time, there is also the issue of substance abuse
The National Bureau of Economic Research reports that people who have been diagnosed with a mental illness at some point in life consume 69 percent of the nation’s alcohol and 84 percent of the national’s cocaine
People who abuse substances are more likely to suffer from depression (substance induced depression)
People who are depressed may drink or abuse drugs to lift their mood(self medicated)

10. If things aren’t bad enough already…
Some diseases are also known to cause depression, including but not limited to:
Diabetes
Heart disease
Arthritis
Kidney disease
HIV/AIDS
Autoimmune such as Lupus and multiple sclerosis (MS)
Hypothyroidism
Fibromyalgia

11. Treatment for Depression
First, rule out other medical conditions that may cause depression
Medications
Therapy sessions (CBT is the most common type, but also not limited to psychoanalysis, psychodynamic, interpersonal, etc.)
Brain Stimulation Techniques—ECT and TMS

12. Medication for Depression
SSRI—Selective Serotonin Reuptake Inhibitor
SNRI—Serotonin and Norepinephrine Reuptake Inhibitor
TCA—Tricyclic Antidepressant
MAOI—Monoamine Oxidase Inhibitor
Others—stimulant

13. SSRI Citalopram Escitalopram Paroxetine Fluoxetine Sertraline
Vilazodone
Vortioxetine

14. SSRI general Side Effects
Drowsiness
Nausea
Dry mouth
Insomnia
Diarrhea
Nervousness, agitation or restlessness/ suicidal ideas
Dizziness
Sexual problems
Blurred vision
Headache / weight gain

15. SNRI
Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran

16. SNRI general Side Effects
Upset stomach
Insomnia
Sexual problems
Anxiety
Dizziness
Fatigue
Weight gain

17. TCA Amitriptyline Desipramine Doxepin Imipramine Nortriptyline
Protriptyline
Trimipramine

18. TCA General Side Effects
Stomach upset
Dizziness
Dry mouth
Changes in blood pressure, in blood sugar levels
Nausea
Weight gain
Sexual side effects

19. MAOI
Phenelzine
Tranylcypromine
Isocarboxazid

20. MAOI
Not very commonly prescribed due to severe interaction with other medications and food
Foods that can negatively react with the MAOIs include aged cheese, aged meats , Alcohol.

21. Others Bupropion Mirtazapine Trazodone Stimulants D-amphetamine
Methylphenidate

22. ECT Electroconvulsive therapy
Gold standard for treating MDD when standard treatments have failed
Major side effects include transient memory loss, along with nausea, headache, jaw pain or muscle ache
Refer to a specialist if your patient is interested in trying out ECT

23. TMS Transcranial Magnetic Stimulation Therapy
Less invasive than ECT, less side effects
Suitable for patients who are planning to become pregnant
Suitable for patients who are unable to tolerate side effects of most oral medications
Refer to a specialist if your patients express interest in this kind of treatment

24. Common Augmentation Medications
Lithium
Thyroid hormones

25. Suicide evaluation
-Vague suicidal ideas. -Actively thinking about committing suicide. -Making plans, giving away prized possessions, writing note, good bye letter. -Attempting suicide. -Committing suicide.

26. Suicide Risk evaluation ( cont)
Who attempts more ?
Who completes more and why?
Suicide gesture vs Lethality of attempt.
Most risky patient in your clinic or ER.

27. reference
DSM5 Diagnostic Criteria Major Depressive Disorder - Pearson Clinical
Substance Abuse and Depression - Kathleen Smith LPC, PhD