Depression (Unipolar)

Published on 31/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1399 times

Chapter 18 Depression (Unipolar)

INTRODUCTION

Description: Depression is a biochemically mediated state in which anger, frustration, loss of pleasure, and withdrawal predominate. This must be separated from normal stress reactions and grief.
Prevalence: Twenty million American adults per year, one in six to eight lifetime risk, 6% to 14% of primary care visits, 2 : 1 female to male ratio (1 : 1 after age 55). Depression is the fourth most common reason to seek medical care.
Predominant Age: Rare before puberty, commonly begins in 20s to 30s, average 40.
Genetics: Possible defect on chromosome 11 or X.

ETIOLOGY AND PATHOGENESIS

Causes: Proposed—alteration in norepinephrine or serotonin through impaired synthesis of neurotransmitters, increased breakdown or metabolism of neurotransmitters, increased uptake of neurotransmitters.
Risk Factors: Strong family history (depression, suicide, alcoholism, substance abuse). Women are at greatest risk during adolescence (up to 60% meet criteria), the premenstrual period, pregnancy, the postpartum period, perimenopause, after pregnancy loss (three times risk) and with infertility (two times risk). Women are especially vulnerable to depression after giving birth.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Depressed mood or anhedonia plus five or more other symptoms over a 2-week period:

• Weight loss
• Sleep changes
• Psychomotor changes
• Fatigue
• Feeling of worthlessness or guilt
• Inability to concentrate
• Thoughts of death

(Hallucinations and delusions may appear in profound cases.)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Endocrine disorders (diabetes, pituitary, adrenal, thyroid)
• Malignancies
• Infections
• Neurologic disorders (organic brain disease)
• Autoimmune disease
• Cardiovascular, hepatic, or renal disease
• Vitamin or mineral deficiency or excess
• Medication side effect (cardiovascular drugs, hormones, anticancer agents, anti-inflammatory or anti-infective agents, amphetamines [withdrawal], l-dopa, cimetidine, ranitidine)

Associated Conditions: Chronic pain, sexual dysfunction, weight changes (up or down), bipolar disorders (manic depression), schizophrenia, and substance abuse.

Workup and Evaluation

Laboratory: No evaluation indicated (clinical diagnosis only).
Imaging: No imaging indicated unless organic brain syndrome is being considered.
Special Tests: Zung’s Self-Rating Depression Scale, Beck’s Depression Inventory, Criteria for Epidemiologic Studies Depression Scale, Children’s Depression Inventory, or similar tests.
Diagnostic Procedures: Complete evaluation to rule out organic cause. Depression scales are helpful but are not required.

Pathologic Findings

None.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, support, and evaluation of support systems available to the patient.
Specific Measures: Psychotherapy (patients with mild depression without psychosis), medical therapy (choose agent to optimize benefit, decrease risk, and avoid drug interactions), electroshock therapy in patients with refractory conditions (controversial).
Diet: No specific dietary changes indicated.
Activity: No restriction.
Patient Education: Reassurance, careful instruction on medication use; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP057 (Premenstrual Syndrome), AP091 (Postpartum Depression), AP106 (Depression).

Drug(s) of Choice

Tricyclic agents—amitriptyline (50 to 300 mg/day), doxepin (75 to 300 mg/day), imipramine (50 to 300 mg/day), nortriptyline (50 to 200 mg/day).
Monoamine oxidase inhibitors (MAOIs).
Selective serotonin reuptake inhibitors (SSRIs)—fluoxetine (10 to 80 mg/day), fluvoxamine (100 to 300 mg/day), paroxetine (10 to 50 mg/day), sertraline (50 to 200 mg/day).
Serotonin norepinephrine reuptake inhibitors (SNRIs)—venlafaxine (75 to 375 mg/day).
Noradrenergic and specific serotonergic agents—mirtazapine (15 to 45 mg/day).
Miscellaneous agents—nefazodone (200 to 600 mg/day), trazodone (150 to 400 mg/day), bupropion (300 to 400 mg/day).
Contraindications: See individual agents. Most agents are pregnancy category B. Many are contraindicated in patients with seizure disorders or cardiac arrhythmias (tricyclic agents).

image

Precautions: Monoamine oxidase inhibitors are associated with both treatment and adverse reactions that appear as emergencies. Overdoses may be lethal. Selective serotonin reuptake inhibitors are associated with nausea (20% to 35%) and sexual dysfunction (10% to 30%). Some agents can alter the dose or effectiveness of other drugs such as antihypertensive agents, digoxin, and antiseizure medications. Fluoxetine, sertraline, and paroxetine are best given in the morning. In September 2004 the U.S. Food and Drug Administration began considering a warning that some antidepressants may increase the risk of suicidal tendencies in children.
Interactions: Monoamine oxidase inhibitors and selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors may have lethal interactions and must not be used together. (Allow at least 2 weeks to elapse between therapies.) Avoid use of nonprescription drugs with pseudoephedrine, phenylephrine, or phenylpropanolamine.

Alternative Drugs

Additional tricyclic agents include clomipramine (100 to 250 mg/day), desipramine (50 to 300 mg/day), protriptyline (14 to 60 mg/day), and trimipramine (75 to 300 mg/day).
A large study conducted by the National Center for Complementary and Alternative Medicine has found that St. John’s wort is not effective for treating major depression.

FOLLOW-UP

Patient Monitoring: Normal health maintenance. Monitor for recurrence, substance abuse, or suicide. Patients must be monitored every 1 to 2 weeks after they start medication and reassessed at 6 weeks. Follow-up of treatment should continue every 3 months while therapy is maintained (6 months to 2 years).
Prevention/Avoidance: None.
Possible Complications: Increased risk of general medical disorders and worsened prognosis, disability, impaired function (family, work, social, sexual), chronic pain, mortality (30,000 suicides per year in United States; adolescent girls at greatest risk).
Expected Outcome: Medical therapy is associated with 85% to 90% success rates.

MISCELLANEOUS

Pregnancy Considerations: Up to 70% of patients have depressive symptoms and 10% to 15% meet the diagnostic criteria during pregnancy. Symptoms often mimic those of pregnancy itself. Depression may result in poor nutrition, increased substance abuse, and poor fetal outcome. Drug therapy should be avoided or used sparingly in pregnancy. Postpartum depression is seen by many as a special form of depression.
ICD-9-CM Codes: 311 (Depressive disorder, not elsewhere classified), 296.2 (Major depressive disorder, single episode), 296.3 (Recurrent), 625.4 (Premenstrual syndrome).

REFERENCES

Level II

Fava GA, Ruini C, Belaise C. The concept of recovery in major depression. Psychol Med. 2007;37:307.

Geddes J, Butler R, Hatcher S, et al. Depression in adults. Clin Evid. 2006;15:1366.

Thachil AF, Mohan R, Bhugra D. The evidence base of complementary and alternative therapies in depression. J Affect Disord. 2007;97:23. Epub 2006 Aug 22

Level III

American College of Obstetricians and Gynecologists. Treatment with selective serotonin reuptake inhibitors during pregnancy. ACOG Committee Opinion 354. Washington, DC: ACOG, 2006.

Association of Professors of Gynecology and Obstetrics. Depressive disorders in women: diagnosis, treatment, and monitoring. Washington, DC: APGO, 1997.

Beck A. Depression Inventory. Philadelphia: Center for Cognitive Therapy, 1991.

Fancher T, Kravitz R. In the clinic. Depression. Ann Intern Med. 2007;146:ITC1-ITC5.

Klein DF, Wender PH. Understanding depression: a complete guide to its diagnosis and treatment. New York: Oxford University Press, 1993.

Maurer D, Colt R. An evidence-based approach to the management of depression. Prim Care. 2006;33:923. vii.

McGrath E, Ketia GP, Strickland BR, Russo NF. Women and depression: risk factors and treatment issues. Washington, DC: American Psychological Association, 1990.

Norman TR, Burrows GD. Emerging treatments for major depression. Expert Rev Neurother. 2007;7:203.

Related posts:

Cervical Incompetence Forceps-Aided Delivery Eating Disorders: Anorexia Nervosa and Bulimia Bartholin’s Gland: Abscess/Infection Pre-Eclampsia and Eclampsia (Toxemia of Pregnancy) Breast: Galactocele