Symptoms depressive disorders

Third, only 31% of those patients presenting with major depressive disorder symptoms but making no medication-related request were prescribed an antidepressant, and only 56% received some form of minimally acceptable care, whereas minimally acceptable treatment was received by 90% making a brand-specific request, and 98% a general request, which supports the notion that DTCA mitigates undertreatment of major depressive disorder. 

Potential drug interaction between sertraline and St. John s wort cannot be ruled out in one case that experienced manic depressive disorder symptoms one to two weeks after St. John s wort was started into sertraline therapy. The patient was treated with an antipsychotic and has had no problems after discontinuing St. John s wort and decreasing the sertraline dose. 

In summary, research on the use of antidepressants to treat cannabis dependence, particularly among individuals with comorbid major depressive disorder, although limited, offers a promising avenue for the development of pharmacological aids to assist in the treatment of cannabis withdrawal. There are clear parallels between this literature and the existing research on the use of antidepressants in the treatment of alcohol dependence comorbid with major depressive disorder (see Chapter 1, Medications to Treat Co-occurring Psychiatric Symptoms or Disorders in Alcoholic Patients). 

Identify symptoms and clinical features of major depressive disorder. 

Although ADHD generally is considered a childhood disorder, symptoms can persist into adolescence and adulthood. The prevalence of adulthood ADHD is estimated to be 4%, with 60% of adults having manifested symptoms of ADHD from childhood.8,9 Further, problems associated with ADHD (e.g., social, marital, academic, career, anxiety, depression, smoking, and substance-abuse problems) increase with the transition of patients into adulthood. 

The classic symptoms of depression are listed in Table 12.1, which is based on DSM-IV criteria. For a diagnosis of major depressive disorder, most of these symptoms must be present, including the first two (APA, 2000). These symptoms should be of sufficient intensity and chronic duration (at least 2 weeks) to cause clinically significant distress and impairment in social or economic functioning. However, they should not be a result of another psychiatric or somatic illness, nor of drug misuse or bereavement. For a diagnosis of mania, the symptoms are a mirror image of those for depression (Table... 

Major depressive disorder causes the following mood symptoms ... 

The positive symptoms are the most responsive to antipsychotic medications, such as chlorpromazine or halo-peridol. Initially, these drugs were thought to be specific for schizophrenia. However, psychosis is not unique to schizophrenia, and frequently occurs in bipolar disorder and in severe major depressive disorder in which paranoid delusions and auditory hallucinations are not uncommon (see Ch. 55). Furthermore, in spite of early hopes based on the efficacy of antipsychotic drugs in treating the positive symptoms, few patients are restored to their previous level of function with the typical antipsychotic medications [2]. 

The typical antipsychotic drugs, which for 50 years have been the mainstay of treatment of schizophrenia, as well as of psychosis that occurs secondary to bipolar disorder and major depressive disorder, affect primarily the positive symptoms[10]. The behavioral symptoms, such as agitation or profound withdrawal, that accompany psychosis, respond to the antipsychotic drugs within a period of hours to days after the initiation of treatment. The cognitive aspects of psychosis, such as the delusions and hallucinations, however, tend to resolve more slowly. In fact, for many patients the hallucinations and delusions may persist but lose their emotional salience and intrusiveness. The positive symptoms tend to wax and wane over time, are exacerbated by stress, and generally become less prominent as the patient becomes older. 

The essential feature of major depressive disorder is a clinical course that is characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes. Dysthymic disorder is a chronic disturbance of mood involving depressed mood and at least two other symptoms, and it is generally less severe than major depressive disorder. This chapter focuses exclusively on the diagnosis and treatment of major depressive disorder. 

Major depression is characterized by one or more episodes of major depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (Table 70-1). Symptoms must have been present nearly every day for at least 2 weeks. Patients with major depressive disorder may have one or more recurrent episodes of major depression during their lifetime. 

As the first SNRI drug approved, venlafaxine has become one of the first-line choices for depression and anxiety disorder [45,46]. An active metabolite, desvenlafaxine (19), is also under clinical development for the treatment of major depressive disorders [47], Preclinical studies also indicate that 19 may be effective in relieving vasomotor symptoms associated with menopause (e.g., hot flushes and night sweats) [47,48]. Desvenlafaxine is reported to be in clinical development for the treatment of fibromyalgia and neuropathic pain, as well as vasomotor symptoms associated with menopause [68]. 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

The mood disorders were once called affective disorders and are grouped into two main categories unipolar and bipolar. The unipolar depressive disorders include major depressive disorder and dysthymic disorder the bipolar disorders include bipolar 1, bipolar II, bipolar not otherwise specified, and cyclothymic disorder. Other mood disorders are substance-induced mood disorders and mood disorders due to a general medical condition. In addition, mood disturbance commonly occurs as a symptom in other psychiatric disorders including dementia, post-traumatic stress disorder, substance abuse disorders, and schizophrenia. 

Major Depressive Disorder (MDD) with Atypicai Features. The anhedonia of MDD is often manifested by social withdrawal. In contrast to social anxiety disorder, the social withdrawal of MDD is desired by the patient, at least during the major depressive episode, and does not persist when the episode remits. Atypical depression is characterized by another symptom reminiscent of social anxiety disorder—a longstanding pattern of sensitivity to interpersonal rejection. The interpersonal sensitivity associated with atypical depression is often characterized by stormy relationships and overly emotional responses to perceived slights. Such social lability is seldom observed in patients with social anxiety disorder. 

Major Depressive Disorder. The symptoms of depression can overlap with many of the avoidant/numbing or hyperarousal symptoms of PTSD. For example, those with either disorder can experience insomnia, poor concentration, irritability, diminished interest in activities, or a restricted range of affect. Furthermore, comor-bid depression is very common among those with PTSD. 

Appropriate management of AN also requires the early detection and treatment of any comorbid psychiatric disorders. The most common comorbid conditions associated with AN are major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and substance use disorders. At the time of presentation, over 50% of AN patients also fulfill criteria for MDD however, accurate diagnosis of depression in these patients is complicated by the fact that prolonged starvation often produces a mood disturbance and neurovegetative symptoms identical to MDD. If MDD appears to be comorbid with AN at the time of presentation, there is debate as to whether it is more prudent to withhold treatment of the depression until weight restoration has been initiated. If the depression persists despite refeeding, then treatment of the depression is likely warranted. 

In addition to having a certain number of these symptoms, DSM-IV also requires that the illness be evident before age 7 and that it be seen in at least two settings (nsually school, work, or home). The age of onset is important. Many adults, for example, with major depressive disorder will have symptoms of ADHD, and perhaps even score high on standardized ADHD scales. One does not, however, develop ADHD at 20, 30, or 40 years of age. 

Major Depressive Disorder with Psychotic Features. One severe subtype of depression is characterized by both depressive and psychotic symptoms. Unless a longitudinal history is available, it can be difficult to distinguish a patient with a psychotic depression from a depressed patient who has a comorbid Cluster A personality disorder. Some qualitative features may be helpful, but these are not wholly reliable. The most prominent psychotic symptoms of a psychotic depression tend to be delusions and auditory hallucinations, but these sometimes present in an attenuated form more reminiscent of Cluster A symptoms. 

These patients will often present with complaints of depressed mood or anxiety. The depression frequently takes the form of dysthymic disorder although these patients are at increased risk for major depressive disorder as well. Anxiety is often a symptom of the personality disorder itself, though comorbid Axis 1 anxiety disorders are occasionally present. Similar to the other personality disorders, there is a differential diagnosis that should be considered in patients who have a Cluster C personality disorder. 

In Huntington s chorea, tetrabenazine is used to control movement disorders. It probably causes a depletion of nerve endings of dopamine. However, it has a useful action in only a proportion of patients and its use may be limited by the development of depression, a symptom that may already be present due to the underlying disease itself. 

Amoxapine Relief of depressive symptoms in patients with neurotic or reactive depressive disorders and endogenous and psychotic depression depression accompanied by anxiety or agitation. 

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