This Clinical Handbook for the Management of Mood Disorders will equip clinicians with the knowledge to refine their diagnostic skills and implement treatment plans for mood disorders based on the most up-to-date evidence on interventions that work. Covering the widest range of treatments and techniques, it provides clear guidance for the management of all types and subtypes of both minor and major depression. Chapters cover the latest and most innovative treatments, including use of ketamine, deep brain stimulation and transcranial magnetic stimulation, effective integration of pharmacological and psychotherapeutic approaches, as well as providing a thought-provoking look at the future research agenda and the potential for reliable biomarkers. This is the most comprehensive review of depression available today. Written and edited by leading experts mostly from Columbia University, this is an essential resource for anyone involved in the care and treatment of patients with mood disorders.
'This is the most comprehensive book on mood disorders available, and it is written by top experts in the field. Whether treating a newly diagnosed patient with depression or a patient with treatment-resistant depression, this is the source to have right at your fingertips.'
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This chapter discusses models of unipolar mood disorder that incorporate both current neuroscience and clinical research. Severe major depressive disorder (MDD) is associated with higher basal cortisol secretion and higher peak levels, as well as dexamethasone resistance, indicating failure of feedback inhibition at both the higher stimulated cortisol levels and the lower resting cortisol levels. Post-traumatic stress disorder (PTSD) is associated with lower basal cortisol and increased glucocorticoid receptor (GCR) expression, indicating that the response to stress can be different in different disorders. The fundamental concept of the gene-environment interaction model is that whether a result of genes or early environmental trauma, or both, early life stress results in functional and structural changes in the brain that confer a life-long hyperactive stress response mediated by the hypothalamic pituitary adrenal (HPA) axis. Direct genetic effects or purely environmental effects may result in depressions.
This chapter deals with the diagnosis of mood disorders. The adoption of a lumping strategy for mood disorders, particularly for classifying depressive disorders, reflects the perspective of depression as a unitary construct that represents a final common pathway derived from a variety of etiological and pathophysiological sources, which accounts for the shared clinical features seen in the heterogeneous groups of depressive disorders. A diagnosis of a major depressive episode (MDE) is made by recognizing the characteristic syndrome of symptoms that cluster together during the same period of time. The hallmark of manic and hypomanic episodes is a discrete period of abnormally elevated, euphoric, expansive, or irritable mood that persists for at least a week in the case of mania or at least 4 days in the case of hypomania. Major depressive disorder is characterized by one or more major depressive episodes.
Chronic depression and dysthymia are even more likely to co-exist with anxiety disorders; indeed, some authors argue that dysthymic disorder (DD) is less common in a pure form than in a mixed depression, anxiety co-morbidity, for which the term cothymia has been proposed. Attention deficit hyperactivity disorder (ADHD) is an under-recognized problem in adults and is a common complicating factor in depression. People with depression have more Axis II disorders (most commonly dependent, avoidant, histrionic, or borderline personality disorder) than the general population. Individuals with chronic depression have more co-morbid Axis II disorders than do individuals with episodic major depression. Chronic depression, regardless of severity level, is associated with considerable functional impairment and morbidity. Chronic low-grade depression causes significant impairment and suffering. Dysthymia can be conceptualized as a prodromal disorder, since nearly all individuals with DD will at some point experience a full-blown major depressive episode.
Diagnosis of major depressive disorder is entirely clinical at present, and based on criteria such as DSM-IV. The classes of medications include antidepressants, selective serotonin reuptake inhibitors (SSRIs), older dual-action reuptake inhibitors, newer dual-action antidepressants, norepinephrine reuptake inhibitors (NRIs) and monoamine oxidase inhibitors. Successful treatment of major depression may require a multi-modal approach including pharmacotherapy, education, and psychotherapy. Patient response to treatment needs systematic monitoring, not only to improve compliance, but to make sound decisions about the need to raise the dose to achieve an optimal antidepressant effect and to monitor side effects. A history of episodes lasting more than 6 months require longer continuation treatment of up to 12 months, and generally continuation treatment will be longer for psychotic depression. Antidepressant and adjunctive pharmacological agents allow successful acute treatment and prevention of future episodes of major depression in most patients.
Pathologic rejection sensitivity is the most common feature of depression with atypical features. While monoamine oxidase inhibitors (MAOI) studies suggested that MAOIs might be useful first-line agents in treatment of depression with atypical features, dietary restrictions, high rates of side effects, such as weight gain and sexual dysfunction, and significant drug-drug interactions make MAOIs less attractive in practice. Hence, the advent of the more user-friendly selective serotonin reuptake inhibitors (SSRIs) had significant appeal. The literature is clear that phenelzine is a superior choice over imipramine for the treatment of depression with atypical features, particularly if onset is early and the course is very chronic. Prior to starting an MAOI, the patient must be educated about the content of and rationale for the tyramine-free diet and dangerous medications, such as SRIs and meperidine. The selegiline patch has the side effects of other MAOIs.
Multiple studies have demonstrated that psychotic major depression (MDpsy) occurs more frequently in bipolar than in unipolar depression. Most MDpsy patients receive acute treatment on inpatient services. Management begins with establishing the diagnosis. DSM-IV recognizes that depression may occur during the prodromal, active, and residual phases of schizophrenia, and limits MDpsy to patients whose episodes of psychosis occur exclusively during episodes of major depressive disorder (MDD). An appropriate goal of acute treatment is to achieve both the remission of major depression and the resolution of delusional ideas. Remarkably little systematic data is available to guide continuation treatment to prevent relapses in the 4-6 months following remission and no studies are available on the prevention of recurrences after 6 months. The outcomes of untreated or inadequately treated MDpsy are poor, with high rates of suicide attempts, recurrences, and residual disability.
Studies including patients with depression in the course of bipolar disorder I or II indicate lithium's effectiveness in the treatment and prevention of bipolar depression. A handful of studies have focused on the use of antidepressants as maintenance treatment for bipolar patients. Long-standing concerns that antidepressant treatment of bipolar depression may induce a switch to mania, an onset of rapid cycling, or treatment resistance. This chapter lists out various antidepressants that include quetiapine, lamotrigine, olanzapine/fluoxetine, aripiprazole, ziprasidone, risperidone, carbamazepine and valproate. The other treatments for bipolar depression include electroconvulsive therapy, deep brain stimulation and transcranial magnetic stimulation. As a secondary strategy, based on existing data, it seems reasonable to use antidepressants in combination with a mood stabilizer, with attention paid to possible emergence of manic/hypomanic symptoms. Despite widespread usage, the efficacy of lamotrigine for either acute or maintenance treatment of bipolar depression remains in question.
Eleven drugs are approved by the US Food and Drug Administration (FDA) for acute mania. For bipolar maintenance, only lithium, aripiprazole, olanzapine, lamotrigine, and adjunctive quetiapine are FDA approved. The standard medications for acute mania include monotherapy and combined therapy. The standard medications for maintenance include lithium, valproate, carbamazepine and second-generation antipsychotics (SGAs). The other established acute and maintenance treatments include benzodiazepines, electroconvulsive therapy (ECT), clozapine and experimental antimanic treatments. All of the medications reviewed have potentially serious adverse consequences that obligate careful pretreatment and ongoing monitoring, and that call for personalized treatment selection. The traditional mood stabilizers, lithium, valproate, and carbamazepine, are teratogenic, particularly in the first trimester, although the risk of cardiovascular malformation with lithium is thought by some to have been over-estimated. In general first-generation antipsychotics (FGAs), SGAs, and, if necessary ECT, are preferred for mania in pregnancy.
The mainstay of treatment for late-life depression is antidepressant medication, although recently there have been some psychotherapies that have been developed specifically for the older patient, e.g. problem solving therapy, that have proved effective. Although tricyclic antidepressants (TCAs) are used much less frequently in younger patients, they still have a very important role in the treatment of late-life depression. The selective serotonin reuptake inhibitors (SSRIs) are the most prescribed class of antidepressants for late-life depression. Given the number of patients with late-life depression who do not respond to a trial of an antidepressant there is considerable opportunity to study augmentation strategies. This chapter discusses dysthymic disorder and sub-syndromal depressive disorder, which is a heterogenous group of milder forms of depression. In patients with depression and cognitive impairment, there is a need to understand pathophysiology, determine early prognostic indicators, and develop optimal treatment strategies.
This chapter reviews how concepts of chronic depression have evolved in modern psychiatry. It describes the evaluation of patients who present with depressive symptoms that are 2 years or longer in duration. The chapter also reviews the evidence base for the management of these conditions, and presents an illustrative case. Chronic forms of depression were shown to be responsive to a variety of antidepressant medications, first in open-label and subsequently in a placebo-controlled trial. Half of the studies included patients with double depression and the remaining studies enrolled only patients with pure dysthymia. For patients who do remit or have a significant response to medication, psychotherapy, or combined treatment, the treating clinician is faced with the question of how to optimally treat the patient to maintain a robust and durable recovery. A significant body of work suggests that continuing the medication or psychotherapy are both effective relapse-prevention strategies.
This chapter reviews the developmental epidemiology, and determinants of course and outcome of pediatric depression. Early-onset depression conveys significantly increased risk, compared to later-onset depression for the development of bipolar spectrum disorder. Parents have a right to know the goals and progress of treatment. A high proportion of clinically referred youth with mood disorders have clinically significant suicidal ideation or behavior. Multi-family psychoeducation and family-based attachment therapy show promise in randomized clinical trials. Two selective serotonin reuptake inhibitors, fluoxetine and escitalopram are approved for use in adolescent depression by the Federal Drug Administration (FDA); fluoxetine is also approved for use in preadolescent patients. Patients with co-morbid anxiety or obsessive compulsive disorder (OCD) can usually be treated with the same antidepressant as that used for the depression, although higher dosages may be needed to treat anxiety or OCD.
This chapter reviews the diagnostic features of pediatric bipolar disorder (BPD) patients, co-morbidity, and the evidence for various medications, including complementary treatments, and offers a treatment algorithm. Co-morbid disorders are the rule rather than the exception among children and adolescents with BPD. Lithium is the only mood stabilizer approved by the United States Food and Drug Administration (FDA) for use in the treatment of mania in adolescents. Valproic acid (VPA) is a chemical compound that has found clinical use as an anticonvulsant and mood stabilizer. Treatment of bipolar depression (BD) can be complicated because of the often necessary use of combinations of medications, including antidepressants, that may induce mania, hypomania, or rapid cycling. It is important for clinicians to be familiar with complementary and alternative medicine (CAM) and integrative therapies for bipolar disorder, as parents may well be using them for their affected children, with or without informing the clinician.
Depression secondary to medical illness is an appropriate diagnosis when the physiological effects of the illness on the brain directly result in depressive symptoms. Several medical disorders are associated with depressive symptoms in this way. Occult hypothyroidism exemplifies disorders in which recognition and treatment of the underlying condition may alleviate depression symptoms. In addition to organic causes of depression in the medically ill, other relevant factors to consider and explore with patients include: the meaning of the illness to the patient, the patient's causal attributions about illness, distorted cognitions or maladaptive behavioral responses to illness, coping mechanisms, and strengths or weaknesses which may be imbedded in patients' premorbid personality traits and style. When rapid improvement of depressive symptoms is the goal, psychostimulants have been useful in patients with advanced cancer. The suggestion that antidepressants increase the risk of cancer has been refuted.