Major depressive disorder, syndrome

Major depressive disorder is among the most common psychiatric syndromes affecting approximately one in four American women and one in ten American men during their lifetimes. Although the overall prevalence rates have stabilized, the average age of onset for the disorder has decidedly decreased. Numerous risk factors for depression have been identified and are listed in Table 3.3. 

Note Doses are provided as general guidelines only, and are not meant to be definitive. All doses must be individualized and monitored through appropriate clinical and/or laboratory means. ADHD, attention-deficit hyperactivity disorder bid, twice daily c, capsule CYP, cytochrome P450 EKG electrocardiogram FDA, Food and Drug Administration IM, intramuscular MDD, major depressive disorder OCD, obsessive-compulsive disorder PDD, pervasive developmental disorder qd, once daily qhs each bedtime qoWk, every other week t, tablet tid, three times daily TS, Tourette s syndrome WBC, white blood cell count. 

Major depressive disorder (MDD) can occur in children as young as 6 years of age. The diagnosis is based on the same criteria as in adults. These patients typically have a high familial loading for psychiatric disorders (110), with more than 70% of mothers having MDD, either pure or complicated by the presence of other psychiatric syndromes. Fathers, however, are more likely to have alcohol abuse or dependence, as opposed to MDD. Given this familial pattern, it is not surprising that many children and adolescents with MDD frequently also meet criteria for other psychiatric syndromes, particularly conduct and oppositional disorder ( 110). 

FIGURE 8-1. Anxiety and depression can be combined in a wide variety of syndromes. Generalized anxiety disorder (GAD) can overlap with major depressive disorder (MDD) to form mixed anxiety depression (MAD). Subsyndromal anxiety overlapping with subsyndromal depression to form subsyn-dromal mixed anxiety depression, sometimes also called anxious dysthymia. Major depressive disorder can also overlap with subsyndromal symptoms of anxiety to create anxious depression GAD can also overlap with symptoms of depression such as dysthymia to create GAD with depressive features. Thus, a spectrum of symptoms and disorders is possible, ranging from pure anxiety without depression, to various mixtures of each in varying intensities, to pure depression without anxiety. 

FIGURE 8—6. Subsyndromal mixed anxiety depression (MAD) may be an unstable psychological state, characterized by vulnerability under stress to decompensation to more severe psychiatric disorders, such as generalized anxiety disorder (GAD), full-syndrome MAD, or major depressive disorder (MDD). 

Affective disorders comprise the group of mental conditions that includes depression, bipolar syndrome (manic-depression), and several others that are characterized by a marked disturbance in a patient s mood.41 Patients with an affective disorder typically present with an inappropriate disposition, feeling unreasonably sad and discouraged (major depressive disorder) or fluctuating between periods of depression and excessive excitation and elation (bipolar disorder). 

The form of depression discussed previously is often referred to as major depressive disorder or unipolar depression, in contrast to bipolar or manic-depressive disorder. As these terms imply, bipolar syndrome is... 

Insomnias are a cause of sleep deprivation. As indicated, there is no uniform underlying problem related to the report of poor nocturnal sleep. Insomnias have been subdivided based on the timing of lack of sleep at sleep onset, during the night, or due to early-morning awakening (1). They have also been dissociated as part of a psychiatric syndrome, or independent from a psychiatric symptomatology such as major depressive disorder. The difficulty is that a patient with a psy-... 

A 38-year-old man with major depressive disorder and psychotic features developed rabbit syndrome after taking risperidone 4 mg/day and paroxetine 40 mg/ day for 4 months he was also taking simvastatin 10 mg/day, thiamine 100 mg/day, and folic acid 1 mg/ day (104). 

Tianeptine, (K5)-7-(3-chloro-6-methyl-6,ll-dihydrodibenzo[c/ [l,2]lhiazepin-ll-yl-amino)heptanoic acid 5, 5-dioxide, is an antidepressant effective against anxiety accompanying mood disorders. The drug is used primarily in the treatment of major depressive disorder, although it may also be used to treat asthma or irritable bowel syndrome. The TLC method was used to separate the photodegradation products of tianeptine [16] (Figure 14.13). 

Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X (2008) Interventions for enhancing medication adherence. Cochrtme Database Syst Rev 2 CD000011 Ho PM, Lambert-Kerzner A, Carey EP et ai (2014) Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge a randomized clinical tritil. JAMA Intern Med 174 186-193 Ho SC, Chong HY, Chaiyakunapruk N, Tangiisuran B, Jacob SA (2016) Clinical and economic impact of non-adherence to antidepressants in major depressive disorder a systematic review. J Affect Disord 193 1-10... 

Goodwin GM, Emsley R, Rembry S, Rouillon F. Agomelatine prevents relapse in patients with major depressive disorder without evidence of a discontinuation syndrome a 24-week randomized, doubleblind, placebo-controlled trial. J Clin Psychiatry 2009 70(8) 1128-37. 

The cause of most psychiatric disorders including depression remains unknown nevertheless, some diagnostic considerations are based on presumed causative factors. In these cases, the distinction from major depression is not based on the symptomatic presentation because there may be no symptomatic difference. The difference lies in the presence of an identifiable biological factor that is presumably causing the depressive syndrome. The causative differential of MDD includes a mood disorder due to a general medical condition in medically ill patients and a substance-induced mood disorder in patients using certain medications or substances of abuse. A comprehensive evaluation of depression must include consideration of potentially treatable causative factors. 

Recent evidence now indicates that social anxiety disorder, long overlooked in both routine clinical practice and the scientific literature, might be the third most common psychiatric syndrome, after major depression and alcohol dependence, with a lifetime prevalence of over 13%. Social anxiety disorder is only slightly more common among women than men. 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

The primary indication for ECT in adolescents is the short-term treatment of mood symptoms, depressive or manic (Walter et al., 1999). Mood symptoms in the course of major depression, psychotic depression, bipolar disorder, organic mood disorders, schizophrenia, and schizoaffective disorder respond well to ECT. Psychotic symptoms in mood disorders also respond well to ECT whereas the effectiveness of ECT in the treatment of psychotic symptoms in schizophrenia is doubtful. There are suggestions that other uncommon clinical conditions in adolescents such as catatonia and neuroleptic malignant syndrome also benefit from ECT. The effectiveness of ECT seems to lessen when there is a comorbid personality disorder or drug and/or alcohol problems. There are very few data about usefulness on prepubertal children. 

Grunhaus L Clinical and psychobiological characteristics of simultaneous panic disorder and major depression. Am J Psychiatry 145 1214-1221, 1988 Grunze H, Walden J, Wolf R, et al Combined treatment with lithium and nimodipine in a bipolar 1 manic syndrome. Prog Neuropsychopharmacol Biol Psychiatry 20 419-426, 1996... 

Given that the seat of hormonal modulation is in the limbic-hypothalamic-pituitary axis, endocrine changes serve as important correlates to major psychiatric disorders. These changes include basal hormone concentrations, as well as responses to pharmacological challenges. Equally important, endocrine disorders may present with psychiatric symptoms (e.g., manic symptoms in hyperthyroidism, severe depression in hypercortisol ism, psychotic symptoms associated with Cushing s syndrome). Commonly used neuroendocrine tests include the following. 

BPD is characterized by a pervasive pattern of unstable affect, stormy interpersonal relationships, and behavioral dyscontrol. An estimated 1% to 2% of the general population manifest this syndrome. It is also a co-morbid condition with major mood disorders (i.e., different studies estimate from 25% to 75% of these patients have a major depression and 5% to 20% a bipolar disorder). Furthermore, as many as 25% of bulimics may also suffer from BPD, and approximately 70% of BPD patients abuse alcohol or drugs. Self-mutilation, suicide attempts, and completed suicides are all too frequent. Indeed, it is estimated that 3% to 10% of these patients will take their own lives. 

It is also possible that there may not be a strict isomorphism between personality disorders and other diagnostic entities. Thus, a personality disorder may be a psychological condition that only exists in patients who have a major psychiatric disorder, such as schizophrenia, atypical depression, or social phobia. One example is mania, which can present with interpersonal behaviors such as attacking people s weaknesses, sensitivity to division, and manipulative behavior with staff. This syndrome disappears completely, however, when the patient undergoes treatment with a mood stabilizer. 

Complicating the proper assessment and, by implication, the most appropriate therapy for many patients, is the very real possibility of neuropsychiatric syndromes that may mimic classic psychiatric disorders, exacerbate them, or coexist with such disorders as major depression, panic attacks, and brief reactive psychosis. Thus, the CNS may be affected by various primary malignancies or secondary metastases cardiovascular disorders, leading to ischemic episodes or hemorrhagic events and several HIV-related complications. 

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