Major depressive disorders documenting

Well accepted for use in schizophrenia and bipolar disorder, including difficult cases Documented utility in treatment-refractory cases, especially at higher doses Documented efficacy as augmenting agent to SSRIs (especially fluoxetine) in nonpsychotic treatment-resistant major depressive disorder Documented efficacy in bipolar depression, especially in combination with fluoxetine... 

GAD is distinct from major depressive disorder with anxiety in that the drugs which are well documented to treat major depressive disorder with anxiety are not necessarily also well documented to treat GAD. 

When documenting major depressive disorder (described in Table 4.1), the DSM-IV (American Psychiatric Association, 1994) establishes diagnostic codes. If a client is diagnosed with major depressive disorder (single episode or recurrent), the following coding scheme needs to outlined ... 

The anxiety disorders are common and surprisingly disabling conditions. Studies on the health economics of generalized anxiety disorder, panic disorder, social anxiety disorders and obsessive compulsive disorder document the cost to the individual and to society. Attention has focused on the major psychiatric disorders such as depression, schizophrenia and the dementias. Studies suggest that many anxiety disorders are of early onset and too often chronic they are quite common and impose a heavy burden on society. More studies will be needed to discern the fine grain in the survey material and to identify more precisely the location and type of societal costs. These factors will vary from country to country, from district to district, between men and women and between various age groups. 

Both genetic and nongenetic factors play roles in the transmission of mood disorders. The familial nature of mood disorders is well established. Studies over the past 20 years have consistently documented higher rates of mood disorder in the relatives of individuals with major depression and bipolar disorder than in relatives of healthy controls [6,7], The familial aggregation of mood disorders is the outcome of both genetic and environmental factors. 

There is no doubt that IL-6 is involved in the modulation of the HPA axis and increased availability of 11 6 in the hypothalamus is associated with increased HPA activity (Plata-Salaman, 1991). Ac tivation of the HPA axis is one of the best-documented changes in major depression (Roy et al., 1987). Stress acts as a predisposing factor for MD, an increased susceptibility to stress has repeatedly been described in patients with MD, even prior to their first exacerbation of the disorder and psychosocial stressors frequently precede the onset of MD. Additionally, an altered HPA axis physiology and dysfunctions of the extrahypo-thalamic CRH system have been consistently found in subjects with MD (Hasler et al., 2004). Several studies demonstrate that MD patients exhibit higher baseline cortisol levels or at least much higher cortisol levels during the recovery period after psychological stress (Burke et al., 2005). 

When symptoms of major depression and psychosis coexist, medication treatment is always warranted. (Often hospitalization, ECT, or both may also be necessary.) Psychotically depressed patients do not respond to psychotherapy alone, and they represent a very high suicide risk when actively psychotic. It has been firmly documented that treatment with antidepressants alone is not very effective (only 25 percent). Likewise, treatment with antipsychotics alone produce disappointing results (35 percent effective). However, combined antidepressant-antipsychotic treatment is significantly more effective (60 to 70 percent). Electroconvulsive treatment is really the gold standard in the treatment of psychotic mood disorders (90 percent effective). (See chapters 14 and 17, on treatment with antidepressants and antipsychotics, respectively.)... 

Few studies have prospectively documented the degree of functional impairment before or after specific treatments or have evaluated the pharmacoeconomic differences in treatments for premenstrual and perimenopausal disorders. Data on the economic burden (i.e., health care utilization, related costs, and the loss of productivity) from different menstrual-related disorders are still lacking. Several PMDD studies have reported greater improvement in psychosocial functioning and work capacity with SRls compared with placebo. In all studies, the degree of functional impairment was substantial at baseline and similar to that seen in studies of major depression. The functional improvement correlated with the improvement in premenstrual symptoms and was evident by the second cycle of treatment. 

The critical defining feature that can help the clinician be more certain of a borderline diagnosis is the history. As noted in chapter 4, many individuals may transiently experience borderline characteristics while in the throes of a major Axis I disorder (for example, a depression), only to recompensate when the Axis I problem resolves. A more definitive diagnosis of borderline disorder emerges when there is a well-documented history of ego impairment dating back to adolescence or early adulthood—"stable instability."... 

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