UW cases: MDD Flashcards
(1) 52 y/o man + increasing fatigue and poor concentration at work over the past month. The patient is a biology professor at a local university. He reports that he has been through a “tough year” because his 19-year-old son died of a heroin overdose 6 months ago and his book was recently rejected for publication. He sleeps 12-14 hours a day but does not feel well rested. He is frequently late for his morning office hours because it is difficult for him to get out of bed. He says, “I’m so distracted at work I forget what I’ve already lectured on and end up repeating myself.” The patient has stopped exercising and socializing with friends, saying, “After work, all I want to do is go straight home and get back into bed.” Physical examination shows no abnormalities. Mental status examination shows a tired, strained appearance and sad mood. He has no suicidal ideation. Which of the following is the most likely diagnosis?
MDD major depressive disorder.
Sad mood, loss of interest, fatigue, hypersomnia, and impaired concentration lasting ≥2 weeks.
Depressive symptoms were likely triggered and/or exacerbated by bereavement and professional setbacks, they are persistent, severe, and functionally impairing.
(1) Adjustment disorder with depressed mood is characterized by ?
by depressive symptoms that develop in response to a stressor but is not diagnosed when criteria are met for another disorder, such as MDD.
(2) A 60-year-old woman with a history of locally advanced breast cancer comes to the office for scheduled follow-up. The patient underwent a lumpectomy followed by radiation therapy and completion of chemotherapy 6 months ago. She is currently taking an aromatase inhibitor. The patient feels that the fatigue she experienced during her chemotherapy has not improved. She has been sleeping poorly and recently left her volunteer job at the library because she is “too distracted to sit and alphabetize books.” The patient had previously been meeting weekly with friends for lunch but has not replied to recent invitations. Since her last appointment 3 months ago, she has lost 3 kg (6.6 lb); otherwise, vital signs are within normal limits, there are no changes on physical examination, and laboratory and imaging studies are unremarkable. When informed of these normal results, she says, “That’s good to hear, but I’m anxious that the cancer is coming back. Why else would I feel so tired all the time?” Which of the following is the most likely explanation of this patient’s condition?
MDD (vs depressive disorder due to another medical condition)
MDD. She has loss of interest (eg, no longer meeting her friends for lunch), impaired concentration (eg, too distracted to alphabetize books), sleep disturbance, weight loss, and social isolation (eg, not responding to invitations) lasting >2 weeks, strongly suggestive of MDD.
(2) Physicians should not assume that depression is a normal reaction to a cancer diagnosis or that impairment in sleep, appetite, and energy level are due to the cancer or its treatment. Patients with cancer can be safely and effectively treated with psychotherapy and/or antidepressant medications.
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(2) Depressive disorder due to another medical condition is only diagnosed when there is???
When there is evidence that the mood disturbance is the direct result of another medical condition (eg, hypothyroidism, Parkinson disease).
In the absence of any findings on physical examination or laboratory and imaging studies, this patient’s depression is unlikely due to breast cancer recurrence or another undiagnosed medical condition.
(2) MDD. This patient’s symptoms are more severe than would be seen in a normal reaction and are causing significant distress and functional impairment. Further assessment and treatment are indicated.
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(3) A 45-year-old man comes to the office due to fatigue and sleep difficulties for the past month. He describes feeling exhausted when he awakens and has to force himself to get out of bed and get dressed for work. The patient reports having difficulty falling asleep at night and usually watches television in bed for a few hours. On the weekends, he takes 2- to 3-hour naps during the day. The patient also has difficulties concentrating and has become increasingly anxious about his work performance and losing his job due to feeling tired. He says, “I’ve missed several deadlines and keep making the same accounting mistakes. I’ve been fired before and now I’m afraid it’ll happen again. How will I support my family if that happens?” The patient has stopped cycling with friends and has not kept up with other hobbies. Medical history is noncontributory. Vital signs and physical examination are unremarkable apart from a 4.5-kg (9.9-lb) weight gain. BMI is 25 kg/m2. Laboratory studies, including thyroid function tests, are within normal limits. The patient appears restless and tired. He has no suicidal ideation. Which of the following is the most appropriate next step in management of this patient?
Escitalopram and CBT on depression (cia vienintelis ats buvo apie depresija, kiti apie insomnia)
(3) anhedonia examples?
(eg, stopped spending time with friends, discontinued hobbies [eg, cycling])
(3) MDD. Combined therapy consisting of antidepressant plus psychotherapy is more effective than either alone.
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(4) A 31-year-old woman comes to the office due to fatigue and weight gain. She has felt tired over the past 2 months and is upset that she has been craving junk food and has gained 8 pounds. She says, “I have been under some stress at work lately, and I guess I’ve been eating and sleeping more as a way to cope and escape. I know I’ve gained weight but I feel slow—like my legs are in cement blocks.” The patient sleeps 10-12 hours a day but still feels tired throughout the day. She is feeling “down” and stopped socializing with friends “because I feel that I look awful and don’t want to be around anybody.” However, she was able to enjoy a recent family reunion and was excited to meet her newborn nephew for the first time. The patient has no medical or psychiatric history. She has 1-2 glasses of wine 3 times a week and uses cannabis approximately once a month. Physical examination is normal. On mental status examination the patient appears sad and tired but is able to smile when appropriate. Laboratory evaluation, including complete blood count and thyroid function tests, is within normal range. Which of the following is the most likely diagnosis?
MDD (atypical depression - MDD subtype, bet buvo tipo ats MDD)
This patient’s 2-month history of depressed mood (eg, feeling “down”), social isolation (loss of interest), fatigue (loss of energy), hypersomnia, leaden paralysis (“my legs are in cement blocks”), and weight gain is most consistent with the atypical subtype of major depressive disorder (MDD).
(4) A core feature of atypical depression is ?
mood reactivity (ie, positive responsiveness to pleasant events);
other characteristic features include increased appetite or weight gain, hypersomnia, leaden paralysis (heavy feeling in limbs), and hypersensitivity to rejection.
(4) In contrast, the melancholic subtype of MDD is characterized by?
weight loss, insomnia, and pervasive anhedonia with an inability to respond to positive events.
(5) A 58-year-old woman comes to the office due to depressed mood and hopelessness for the past 2 months. She has no interest in her hobbies or exercising and feels emotionally detached from her family and friends. The patient awakens every night at 2 AM and is up for the day at 4 AM. Her appetite is poor, and her children and husband have to remind her to eat. Her symptoms have caused her to take a leave of absence from work, and she has difficulty sustaining her attention to read a book or follow a television program. She has no suicidal thoughts. The patient has a history of depression beginning at age 22 and has had 5 lifetime episodes of major depression with one psychiatric hospitalization following a suicide attempt at age 32. She has not been hospitalized since then. Previous treatments have included paroxetine, escitalopram, and venlafaxine. She is not on any medication currently. Major depressive disorder is diagnosed, and the patient is started on venlafaxine as she recalls having an excellent response to this medication in the past. At her 2-week follow-up, she is showing signs of improvement. Which of the following is the most appropriate treatment plan for this patient?
Continue venlafaxine indefinitely
(5) Major depressive disorder is a highly recurrent illness for most patients.
Due to the high risk of recurrence, patients with ≥2 episodes are candidates for maintenance antidepressant treatment (ie, continuing antidepressants beyond the continuation phase of ~6 months following remission).
(5) Other indications for maintenance therapy (due to high risk of recurrence) include early age of onset (≤18), persistent residual depressive symptoms, and comorbid psychiatric disorders. Maintenance therapy can be continued for ~1-3 years.
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(5) However, patients with a history of highly recurrent illness (eg, ≥3 lifetime depressive episodes), chronic episodes (≥2 years), severe ongoing psychosocial stressors, or severe episodes (eg, suicide attempts) are candidates for maintaining antidepressant treatment indefinitely.
This patient’s highly recurrent and severe episodes (ie, 5 previous major depressive episodes and a suicide attempt) make her an appropriate candidate for maintaining antidepressant pharmacotherapy indefinitely. Recurrent major depression may be conceptualized as a chronic illness similar to other chronic medical diseases (eg, hypertension, diabetes) that often require long-term medications.
(5) The dose that achieves remission should be maintained. Reducing the dose had been associated with an increased risk of recurrence.
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(6) A 49-year-old woman comes to the office due to low mood. The patient has a 3-month history of worsening sadness, increased appetite with weight gain, and difficulty falling and staying asleep. She was dismissed from her part-time sales job 2 months ago due to poor performance and has been “too tired” to look for a new job. The patient’s husband is threatening to leave her, and she has little contact with family or friends. She says, “My life is a mess, and I’m not sure that my marriage can be saved. I’ve had thoughts of taking all of my medications at once.” The patient admits to drinking increased amounts of alcohol “to cope.” She has hypothyroidism treated with levothyroxine; last year she had an episode of major depression for which she is currently on a maintenance dose of sertraline. Physical examination, including neurologic examination, shows no abnormalities. The patient is anxious, sad, and physically restless. She weeps softly throughout the interview, especially when discussing her marriage. Which of the following is the most appropriate next step in management?
Hospitalization
(6) She has suicidal ideation with a specific plan in mind and access to means (eg, taking all her medications).
Performing a suicide risk assessment is critical in determining the appropriate level of care (ie, outpatient vs. inpatient). Patients with active suicidal ideation (eg, thoughts of taking action to harm oneself) are at greater risk than patients with passive suicidal ideation (eg, wish to be dead or go to sleep and not wake up). Patients should be asked if they have thought of a specific method and the lethality of the method, whether any preparations (eg, hoarding pills) have been made, and if they have access to the means to commit suicide. Recent stressors and the adequacy of social supports should also be considered.
(6) kitas ats: Inadequately treated hypothyroidism may be contributing to the patient’s depression. However, thyroid function tests should be obtained prior to adjusting the levothyroxine dose, and hospitalizing the patient takes precedence.
kitas ats: Increasing the dose of sertraline or changing the patient’s antidepressant are treatment options but would not precede choosing inpatient level of care.
(6) The efficacy of a “contract for safety,” in which the patient agrees not to act on suicidal thoughts and seek help instead, has not been demonstrated. It may provide a false sense of security to the clinician and place the patient at risk in an unsupervised setting.
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(7) 54 male + bad relationships with wife because he snores + sleeps pooly + 175cm, 118kg. Dx?
Depressive disorder due to another medical condition.
Appropriate treatment of OSA (eg, positive airway pressure, oral appliances) has been shown to improve associated depressive symptoms.
Major depressive disorder is not diagnosed when symptoms are caused by a medical condition, as in this patient.
(7) Diagnosis of primary mood disorders (eg, major depressive disorder) requires exclusion of medical and substance-induced causes.
Untreated obstructive sleep apnea can present with symptoms that overlap with depression (eg, low mood, fatigue, sleep disturbance, impaired concentration).
(8) 48y/o man + follow-up appointment. He has a DM2, HTN, and MDD. Over the past year, the patient has been treated with fluoxetine 20 mg for depression, which was subsequently increased to 40 mg. He says, “I feel about 50% better. I’m definitely less sad, and I’m somewhat more interested in my work and spending time with family. However, I still feel like my energy is low. I used to go to the gym or attend my son’s soccer games on weekends, but now all I want to do is rest in bed or on the couch. I’m frustrated because I’m eating too much and haven’t been able to lose any weight.” Physical examination and routine laboratory tests are unremarkable. Which of the following medications would be most appropriate to augment this patient’s antidepressant therapy?
BUPROPION
Bupropion has activating effects and a favorable side-effect profile (no weight gain or sexual side effects), making it a preferred choice for this patient with low energy and weight gain.
(8) For patients who have had a partial response (generally defined as 25%-50% improvement) to first-line treatment and are tolerating their current medication, major augmentation strategies include adding an antidepressant with a different mechanism of action, a second-generation antipsychotic (eg, aripiprazole), lithium, triiodothyronine, or psychotherapy.
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(8) This patient with persistent symptoms of low energy and increased appetite had a partial response to first-line treatment with fluoxetine, a selective serotonin reuptake inhibitor (SSRI). Bupropion, a norepinephrine-dopamine reuptake inhibitor, has been shown to be an effective augmentation strategy to SSRI therapy.
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(8) Unlike partial responders, nonresponders (ie, patients with little to no improvement or unacceptable tolerability to first-line therapy) generally benefit from ???
switching to a different antidepressant
(8) The antidepressant mirtazapine can be used as augmentation, but its adverse effects of sedation, fatigue, and weight gain would make it a poor choice for this patient.
