Major Depressive Disorder Tx

Question 1

How to measure remission

Answer 1

Tools for symptom severity (PHQ-9)
Ask about side effects
Ask about adherence
Ask about functional status

Question 2

If no remission achieved, patient is vulnerable

Answer 2

More sig psychosocial disability
3x faster relapse
Signifies a more chronic illness if the was the first MDE
Even mild residual symptoms place patients at more risk for relapse than a history of MDE

Question 3

Continuation Phase: Goal of Treatment

Answer 3

Sustain Remission

Question 4

Continuation Phase: Treatment

Answer 4

Monitor for early signs of relapse
Systematic review of symptoms, side effects, adherence and functional status
Medications continued for 4-9 months
Depression-focused CBT to prevent relapse
If ECT was used in the acute phase, pharmacotherapy

Question 5

If ECT was used in acute phase, what pharmacotherapy is best?

Answer 5

Lithium and nortriptyline

Question 6

Which symptoms of depression will subside first?

Answer 6

Vegetative symptoms

Question 7

Maintenance Phase: Goal of treatment

Answer 7

Prevent recurrence

Question 8

Rate of MDE recurrence

Answer 8

50-85%

Question 9

MDE increases risk for…

Answer 9

Other affective episodes like mania and hypomania

Question 10

If ≥ 3 MDE or chronic MDE…

Answer 10

Some form of maintenance therapy will be needed indefinitely

Question 11

Each MDE increases risk of recurrence by…

Answer 11

16%

Question 12

Discontinuation Phase

Answer 12

Treatment free without recurrence
Taper meds over several weeks
Inform pt of chances of relapse, and make a plan if sx recur
Monitor for several months
How to measure remission

Question 13

Discontinuation Phase: What to do if recurrence of symptoms?

Answer 13

Initiate a full acute phase treatment plan.

Question 14

Risk for recurrence of MDD

Answer 14

Persistence of subthreshold symptoms
Prior Hx of multiple MDE
Severity of initial and subsequent episodes
Early age of onset
Additional non-affective psych diagnosis
Presence of chronic medical disorder
+ family history of psych illness, esp. mood disorder
Ongoing psychosocial stress and impairment
Negative cog style
Persistent sleep disturbances

Question 15

Psychotherapy for maintenance

Answer 15

Monthly Interpersonal Therapy
CBT over 2 years as effective as meds
Medication and psychotherapy may be more effective than either as single therapy
Some studies indicate that monthly therapy is as effective as maintenance meds

Question 16

Acute Phase Treatment Goals

Answer 16

Achieve remission
3 weeks of absence of sad mood and reduced interest
No more than 3 remaining symptoms