Depressive Disorders - MSD Manual Professional Edition

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MedicalTopics&Chapters A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Professional / PsychiatricDisorders / MoodDisorders / ... / DepressiveDisorders / OTHERTOPICSINTHISCHAPTER OverviewofMoodDisorders BipolarDisorders DrugTreatmentofBipolarDisorders CyclothymicDisorder DepressiveDisorders DrugTreatmentofDepression DepressiveDisorders By WilliamCoryell ,MD,UniversityofIowaCarverCollegeofMedicine Lastfullreview/revisionAug2021|ContentlastmodifiedAug2021 ClickhereforPatientEducation Demoralizationandgrief Etiology SymptomsandSigns Diagnosis Treatment KeyPoints TopicResources 3DModels(0) Audios(0) Calculators(0) Images(0) LabTest(0) Tables(1) SomeCausesofSymptomsof... Videos(1) OverviewofDepression Depressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknownbutprobablyinvolvesheredity,changesinneurotransmitterlevels,alteredneuroendocrinefunction,andpsychosocialfactors.Diagnosisisbasedonhistory.Treatmentusuallyconsistsofdrugs,psychotherapy,orbothandsometimeselectroconvulsivetherapyorrapidtranscranialmagneticstimulation(rTMS).(SeealsoOverviewofMoodDisordersOverviewofMoodDisordersMooddisordersareemotionaldisturbancesconsistingofprolongedperiodsofexcessivesadness,excessivejoyousness,orboth.Mooddisorderscanoccurinchildrenandadolescents(seeDepressive...readmore.)Thetermdepressionisoftenusedtorefertoanyofseveraldepressivedisorders.SomeareclassifiedintheDiagnosticandStatisticalManualofMentalDisorders,FifthEdition(DSM-5)byspecificsymptoms:MajordepressivedisorderMajordepression(unipolardisorder)Depressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmore(oftencalledmajordepression)PersistentdepressivedisorderPersistentdepressivedisorderDepressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmore(dysthymia)OtherspecifiedorunspecifieddepressivedisorderOtherdepressivedisorderDepressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmoreOthersareclassifiedbyetiology:PremenstrualdysphoricdisorderPremenstrualdysphoricdisorderDepressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmoreDepressivedisorderduetoanothermedicalconditionSubstance/medication-induceddepressivedisorderDepressivedisordersoccuratanyagebuttypicallydevelopduringthemidteens,20s,or30s(seealsoDepressiveDisordersinChildrenandAdolescentsDepressiveDisordersinChildrenandAdolescentsDepressivedisordersarecharacterizedbysadnessorirritabilitythatissevereorpersistentenoughtointerferewithfunctioningorcauseconsiderabledistress.Diagnosisisbyhistoryand...readmore).Inprimarycaresettings,asmanyas30%ofpatientsreportdepressivesymptoms,but&lt10%havemajordepression.DemoralizationandgriefThetermdepressionisoftenusedtodescribethelowordiscouragedmoodthatresultsfromdisappointments(eg,financialcalamity,naturaldisaster,seriousillness)orlosses(eg,deathofalovedone).However,bettertermsforsuchmoodsaredemoralizationandgrief.Thenegativefeelingsofdemoralizationandgrief,unlikethoseofdepression,dothefollowing:OccurinwavesthattendtobetiedtothoughtsorremindersoftheincitingeventResolvewhencircumstancesoreventsimproveMaybeinterspersedwithperiodsofpositiveemotionandhumorArenotaccompaniedbypervasivefeelingsofworthlessnessandself-loathingThelowmoodusuallylastsdaysratherthanweeksormonths,andsuicidalthoughtsandprolongedlossoffunctionaremuchlesslikely.However,eventsandstressorsthatcausedemoralizationandgriefcanalsoprecipitateamajordepressiveepisodeMajordepression(unipolardisorder)Depressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmore,particularlyinvulnerablepeople(eg,thosewithapasthistoryorfamilyhistoryofmajordepression).Inasmallbutsubstantialnumberofpatients,griefmaybecomepersistentanddisabling.ThisconditionistermedprolongedgriefdisorderProlongedgriefdisorderDepressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmoreandmayrequirespecificallytargetedtreatment.EtiologyofDepressiveDisordersExactcauseofdepressivedisordersisunknown,butgeneticandenvironmentalfactorscontribute.Heredityaccountsforabouthalfoftheetiology(lesssoinlate-onsetdepression).Thus,depressionismorecommonamong1st-degreerelativesofdepressedpatients,andconcordancebetweenidenticaltwinsishigh.Also,geneticfactorsprobablyinfluencethedevelopmentofdepressiveresponsestoadverseevents.Othertheoriesfocusonchangesinneurotransmitterlevels,includingabnormalregulationofcholinergic,catecholaminergic(noradrenergicordopaminergic),glutamatergic,andserotonergic(5-hydroxytryptamine)neurotransmission(1EtiologyreferenceDepressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmore).Neuroendocrinedysregulationmaybeafactor,withparticularemphasison3axes:hypothalamic-pituitary-adrenal,hypothalamic-pituitary-thyroid,andhypothalamic-pituitary-growthhormone.Psychosocialfactorsalsoseemtobeinvolved.Majorlifestresses,especiallyseparationsandlosses,commonlyprecedeepisodesofmajordepression;however,sucheventsdonotusuallycauselasting,severedepressionexceptinpeoplepredisposedtoamooddisorder.Peoplewhohavehadanepisodeofmajordepressionareathigherriskofsubsequentepisodes.Peoplewhoarelessresilientand/orwhohaveanxioustendenciesmaybemorelikelytodevelopadepressivedisorder.Suchpeopleoftendonotdevelopthesocialskillstoadjusttolifepressures.Thepresenceofothermentaldisordersincreasesrisksformajordepressivedisorder.Womenareathigherrisk,butnotheoryexplainswhy.Possiblefactorsincludethefollowing:GreaterexposuretoorheightenedresponsetodailystressesHigherlevelsofmonoamineoxidase(theenzymethatdegradesneurotransmittersconsideredimportantformood)HigherratesofthyroiddysfunctionEndocrinechangesthatoccurwithmenstruationandatmenopauseInperipartum-onsetdepression,symptomsdevelopduringpregnancyorwithin4weeksafterdelivery(postpartumdepressionPostpartumDepressionPostpartumdepressionisdepressivesymptomsthatlast>2weeksafterdeliveryandmeetcriteriaformajordepression.Postpartumdepressionoccursin10to15%ofwomenafterdelivery.Although...readmore);endocrinechangeshavebeenimplicated,butthespecificcauseisunknown.Inseasonalaffectivedisorder,symptomsdevelopinaseasonalpattern,typicallyduringautumnorwinter;thedisordertendstooccurinclimateswithlongorseverewinters.Depressivesymptomsordisordersmayaccompanyvariousphysicaldisorders,includingthyroiddisordersOverviewofThyroidFunctionThethyroidgland,locatedintheanteriorneckjustbelowthecricoidcartilage,consistsof2lobesconnectedbyanisthmus.Follicularcellsintheglandproducethe2mainthyroidhormones...readmore,adrenalglanddisordersOverviewofAdrenalFunctionTheadrenalglands,locatedonthecephaladportionofeachkidney(seefigureAdrenalglands),consistofaCortexMedullaTheadrenalcortexandadrenalmedullaeachhaveseparateendocrine...readmore,benignandmalignantbraintumorsOverviewofIntracranialTumorsIntracranialtumorsmayinvolvethebrainorotherstructures(eg,cranialnerves,meninges).Thetumorsusuallydevelopduringearlyormiddleadulthoodbutmaydevelopatanyage;theyare...readmore,strokeOverviewofStrokeStrokesareaheterogeneousgroupofdisordersinvolvingsudden,focalinterruptionofcerebralbloodflowthatcausesneurologicdeficit.StrokescanbeIschemic(80%),typicallyresulting...readmore,AIDSHumanImmunodeficiencyVirus(HIV)InfectionHumanimmunodeficiencyvirus(HIV)infectionresultsfrom1of2similarretroviruses(HIV-1andHIV-2)thatdestroyCD4+lymphocytesandimpaircell-mediatedimmunity,increasingriskofcertain...readmore,ParkinsondiseaseParkinsonDiseaseParkinsondiseaseisaslowlyprogressive,degenerativedisordercharacterizedbyrestingtremor,stiffness(rigidity),slowanddecreasedmovement(bradykinesia),andeventuallygaitand/or...readmore,andmultiplesclerosisMultipleSclerosis(MS)Multiplesclerosis(MS)ischaracterizedbydisseminatedpatchesofdemyelinationinthebrainandspinalcord.Commonsymptomsincludevisualandoculomotorabnormalities,paresthesias,weakness...readmore(seetableSomeCausesofSymptomsofDepressionandManiaSomeCausesofSymptomsofDepressionandMania*).Certaindrugs,suchascorticosteroids,somebeta-blockers,interferon,andreserpine,canalsoresultindepressivedisorders.Abuseofsomerecreationaldrugs(eg,alcoholAlcoholToxicityandWithdrawalAlcohol(ethanol)isacentralnervoussystemdepressant.Largeamountsconsumedrapidlycancauserespiratorydepression,coma,anddeath.Largeamountschronicallyconsumeddamagetheliver...readmore,amphetaminesAmphetaminesAmphetaminesaresympathomimeticdrugswithcentralnervoussystemstimulantandeuphoriantpropertieswhosetoxicadverseeffectsincludedelirium,hypertension,seizures,andhyperthermia...readmore)canleadtooraccompanydepression.Toxiceffectsorwithdrawalofdrugsmaycausetransientdepressivesymptoms.TableEtiologyreference1.GhasemiM,PhillipsC,FahimiA,etal:MechanismsofactionandclinicalefficacyofNMDAreceptormodulatorsinmooddisorders.NeurosciBiobehavRev80:555-572,2017.doi:10.1016/j.neubiorev.2017.07.002SymptomsandSignsofDepressiveDisordersDepressioncausescognitive,psychomotor,andothertypesofdysfunction(eg,poorconcentration,fatigue,lossofsexualdesire,lossofinterestorpleasureinnearlyallactivitiesthatwerepreviouslyenjoyed,sleepdisturbances),aswellasadepressedmood.PeoplewithadepressivedisorderfrequentlyhavethoughtsofsuicideSuicidalBehaviorSuicideisdeathcausedbyanintentionalactofself-harmthatisdesignedtobelethal.Suicidalbehaviorencompassesaspectrumofbehaviorfromsuicideattemptandpreparatorybehaviors...readmoreandmayattemptsuicide.Othermentalsymptomsordisorders(eg,anxietyOverviewofAnxietyDisordersEveryoneperiodicallyexperiencesfearandanxiety.Fearisanemotional,physical,andbehavioralresponsetoanimmediatelyrecognizableexternalthreat(eg,anintruder,acarspinningon...readmoreandpanicattacksPanicAttacksandPanicDisorderApanicattackisthesuddenonsetofadiscrete,briefperiodofintensediscomfort,anxiety,orfearaccompaniedbysomaticand/orcognitivesymptoms.Panicdisorderisoccurrenceofrepeated...readmore)commonlycoexist,sometimescomplicatingdiagnosisandtreatment.Patientswithallformsofdepressionaremorelikelytoabusealcoholorotherrecreationaldrugsinanattempttoself-treatsleepdisturbancesoranxietysymptoms;however,depressionisalesscommoncauseofalcoholicusedisorderandothersubstanceusedisordersthanwasoncethought.Patientsarealsomorelikelytobecomeheavysmokersandtoneglecttheirhealth,increasingtheriskofdevelopmentorprogressionofotherdisorders(eg,chronicobstructivepulmonarydiseaseChronicObstructivePulmonaryDisease(COPD)Chronicobstructivepulmonarydisease(COPD)isairflowlimitationcausedbyaninflammatoryresponsetoinhaledtoxins,oftencigarettesmoke.Alpha-1antitrypsindeficiencyandvariousoccupational...readmore[COPD]).Depressionmayreduceprotectiveimmuneresponses.Depressionincreasesriskofcardiovasculardisorders,myocardialinfarctionsAcuteMyocardialInfarction(MI)Acutemyocardialinfarctionismyocardialnecrosisresultingfromacuteobstructionofacoronaryartery.Symptomsincludechestdiscomfortwithorwithoutdyspnea,nausea,and/ordiaphoresis...readmore(MIs),andstrokeOverviewofStrokeStrokesareaheterogeneousgroupofdisordersinvolvingsudden,focalinterruptionofcerebralbloodflowthatcausesneurologicdeficit.StrokescanbeIschemic(80%),typicallyresulting...readmore,perhapsbecauseindepression,cytokinesandfactorsthatincreasebloodclottingareelevatedandheartratevariabilityisdecreased—allpotentialriskfactorsforcardiovasculardisorders.Majordepression(unipolardisorder)Patientsmayappearmiserable,withtearfuleyes,furrowedbrows,down-turnedcornersofthemouth,slumpedposture,pooreyecontact,lackoffacialexpression,littlebodymovement,andspeechchanges(eg,softvoice,lackofprosody,useofmonosyllabicwords).AppearancemaybeconfusedwithParkinsondiseaseParkinsonDiseaseParkinsondiseaseisaslowlyprogressive,degenerativedisordercharacterizedbyrestingtremor,stiffness(rigidity),slowanddecreasedmovement(bradykinesia),andeventuallygaitand/or...readmore.Insomepatients,depressedmoodissodeepthattearsdryup;theyreportthattheyareunabletoexperienceusualemotionsandfeelthattheworldhasbecomecolorlessandlifeless.Nutritionmaybeseverelyimpaired,requiringimmediateintervention.Somedepressedpatientsneglectpersonalhygieneoreventheirchildren,otherlovedones,orpets.Fordiagnosisofmajordepression,≥5ofthefollowingmusthavebeenpresentnearlyeverydayduringthesame2-weekperiod,andoneofthemmustbedepressedmoodorlossofinterestorpleasure:DepressedmoodmostofthedayMarkedlydiminishedinterestorpleasureinalloralmostallactivitiesformostofthedaySignificant(>5%)weightgainorlossordecreasedorincreasedappetiteInsomnia(oftensleep-maintenanceinsomnia)orhypersomniaPsychomotoragitationorretardationobservedbyothers(notself-reported)FatigueorlossofenergyFeelingsofworthlessnessorexcessiveorinappropriateguiltDiminishedabilitytothinkorconcentrateorindecisivenessRecurrentthoughtsofdeathorsuicide,asuicideattempt,oraspecificplanforcommittingsuicidePersistentdepressivedisorderDepressivesymptomsthatpersistfor≥2yearswithoutremissionareclassifiedaspersistentdepressivedisorder(PDD),acategorythatconsolidatesdisordersformerlytermedchronicmajordepressivedisorderanddysthymicdisorder.Symptomstypicallybegininsidiouslyduringadolescenceandmaypersistformanyyearsordecades.Thenumberofsymptomsoftenfluctuatesaboveandbelowthethresholdformajordepressiveepisode.Affectedpatientsmaybehabituallygloomy,pessimistic,humorless,passive,lethargic,introverted,hypercriticalofselfandothers,andcomplaining.PatientswithPDDarealsomorelikelytohaveunderlyinganxietydisordersOverviewofAnxietyDisordersEveryoneperiodicallyexperiencesfearandanxiety.Fearisanemotional,physical,andbehavioralresponsetoanimmediatelyrecognizableexternalthreat(eg,anintruder,acarspinningon...readmore,substanceusedisordersSubstanceUseDisordersSubstanceusedisordersareatypeofsubstance-relateddisorderthatinvolveapathologicpatternofbehaviorsinwhichpatientscontinuetouseasubstancedespiteexperiencingsignificant...readmore,orpersonality(ie,borderlinepersonality)disordersOverviewofPersonalityDisordersPersonalitydisordersingeneralarepervasive,enduringpatternsofthinking,perceiving,reacting,andrelatingthatcausesignificantdistressorfunctionalimpairment.Personalitydisorders...readmore.Fordiagnosisofpersistentdepressivedisorder,patientsmusthavehadadepressedmoodformostofthedayformoredaysthannotfor≥2yearsplus≥2ofthefollowing:PoorappetiteorovereatingInsomniaorhypersomniaLowenergyorfatigueLowself-esteemPoorconcentrationordifficultymakingdecisionsFeelingsofhopelessnessPremenstrualdysphoricdisorderPremenstrualdysphoricdisorderinvolvesmoodandanxietysymptomsthatareclearlyrelatedtothemenstrualcycle,withonsetduringthepremenstrualphaseandasymptom-freeintervalaftermenstruation.Symptomsmustbepresentduringmostmenstrualcyclesduringthepastyear.ManifestationsaresimilartothoseofpremenstrualsyndromePremenstrualSyndrome(PMS)Premenstrualsyndrome(PMS)isarecurrentluteal-phasedisordercharacterizedbyirritability,anxiety,emotionallability,depression,edema,breastpain,andheadaches,occurringduringthe...readmorebutaremoresevere,causingclinicallysignificantdistressand/ormarkedimpairmentofsocialoroccupationalfunctioning.Thedisordermaybeginanytimeaftermenarche;itmayworsenasmenopauseapproachesbutceasesaftermenopause.Prevalenceisestimatedat2to6%ofmenstruatingwomeninagiven12-monthinterval.Fordiagnosisofpremenstrualdysphoricdisorder,patientsmusthave≥5symptomsduringtheweekbeforemenstruation.Symptomsmustbegintoremitwithinafewdaysafteronsetofmensesandbecomeminimalorabsentintheweekaftermenstruation.Symptomsmustinclude≥1ofthefollowing:Markedmoodswings(eg,suddenlyfeelingsadortearful)MarkedirritabilityorangerorincreasedinterpersonalconflictsMarkeddepressedmood,feelingsofhopelessness,orself-deprecatingthoughtsMarkedanxiety,tension,oranon-edgefeelingInaddition,≥1ofthefollowingmustbepresent:DecreasedinterestinusualactivitiesDifficultyconcentratingLowenergyorfatigueMarkedchangeinappetite,overeating,orspecificfoodcravingsHypersomniaorinsomniaFeelingoverwhelmedoroutofcontrolPhysicalsymptomssuchasbreasttendernessorswelling,jointormusclepain,afeelingofbeingbloated,andweightgainProlongedgriefdisorderProlongedgriefispersistentsadnessfollowingthelossofalovedone.Itisdistinctfromdepressioninthatthesadnessrelatestothespecificlossratherthanthemoregeneralfeelingsoffailureassociatedwithdepression.Incontrasttonormalgriefthisconditionmaybehighlydisablingandrequiretherapyspecificallydesignedforprolongedgriefdisorder.Prolongedgriefisconsideredpresentwhenthegriefresponse(typifiedbypersistentlongingoryearningand/orpreoccupationwiththedeceased)lastsayearorlongerandispersistent,pervasive,andexceedingculturalnorms.Italsomustbeaccompaniedby≥3ofthefollowingforthelastmonthtoadegreethatcausesdistressordisability:DisbeliefIntenseemotionalpainFeelingofidentityconfusionAvoidanceofremindersofthelossFeelingsofnumbnessIntenselonelinessFeelingsofmeaninglessnessDifficultyengaginginongoinglifeSomeusefulscreeningtoolsincludetheInventoryofComplicatedGriefandtheBriefGriefQuestionnaire.OtherdepressivedisorderClustersofsymptomswithcharacteristicsofadepressivedisorderthatdonotmeetthefullcriteriaforotherdepressivedisordersbutthatcauseclinicallysignificantdistressorimpairmentoffunctioningareclassifiedasotherdepressive(specifiedorunspecified)disorder.Includedarerecurrentperiodsofdysphoriawith≥4otherdepressivesymptomsthatlast&lt2weeksinpeoplewhohavenevermetcriteriaforanothermooddisorder(eg,recurrentbriefdepression)anddepressiveperiodsthatlastlongerbutthatincludeinsufficientsymptomsfordiagnosisofanotherdepressivedisorder.SpecifiersMajordepressionandpersistentdepressivedisordermayincludeoneormorespecifiersthatdescribeadditionalmanifestationsduringadepressiveepisode:Anxiousdistress:Patientsfeeltenseandunusuallyrestless;theyhavedifficultyconcentratingbecausetheyworryorfearthatsomethingawfulmayhappen,ortheyfeelthattheymaylosecontrolofthemselves.Mixedfeatures:Patientsalsohave≥3manicorhypomanicsymptoms(eg,elevatedmood,grandiosity,greatertalkativenessthanusual,flightofideas,decreasedsleep).PatientswhohavethistypeofdepressionareatincreasedriskofdevelopingbipolardisorderBipolarDisordersBipolardisordersarecharacterizedbyepisodesofmaniaanddepression,whichmayalternate,althoughmanypatientshaveapredominanceofoneortheother.Exactcauseisunknown,butheredity...readmore.Melancholic:Patientshavelostpleasureinnearlyallactivitiesordonotrespondtousuallypleasurablestimuli.Theymaybedespondentanddespairing,feelexcessiveorinappropriateguilt,orhaveearlymorningawakenings,markedpsychomotorretardationoragitation,andsignificantanorexiaorweightloss.Atypical:Patients'moodtemporarilybrightensinresponsetopositiveevents(eg,avisitfromchildren).Theyalsohave≥2ofthefollowing:overreactiontoperceivedcriticismorrejection,feelingsofleadenparalysis(aheavyorweighted-downfeeling,usuallyintheextremities),weightgainorincreasedappetite,andhypersomnia.Psychotic:Patientshavedelusionsand/orhallucinations.Delusionsofteninvolvehavingcommittedunpardonablesinsorcrimes,harboringincurableorshamefuldisorders,orbeingpersecuted.Hallucinationsmaybeauditory(eg,hearingaccusatoryorcondemningvoices)orvisual.Ifonlyvoicesaredescribed,carefulconsiderationshouldbegiventowhetherthevoicesrepresenttruehallucinations.Catatonic:Patientshaveseverepsychomotorretardation,engageinexcessivepurposelessactivity,and/orwithdraw;somepatientsgrimaceandmimicspeech(echolalia)ormovement(echopraxia).Peripartumonset:Onsetisduringpregnancyorinthe4weeksafterdelivery.Psychoticfeaturesmaybepresent;infanticideisoftenassociatedwithpsychoticepisodesinvolvingcommandhallucinationstokilltheinfantordelusionsthattheinfantispossessed.Seasonalpattern:Episodesoccurataparticulartimeofyear,mostoftenfallorwinter.DiagnosisofDepressiveDisordersClinicalcriteria(DSM-5)Completebloodcount(CBC),electrolytes,andthyroid-stimulatinghormone(TSH),vitaminB12,andfolatelevelstoruleoutphysicaldisordersthatcancausedepressionDiagnosisofdepressivedisordersisbasedonidentificationofthesymptomsandsignsandtheclinicalcriteriadescribedabove.Specificclosed-endedquestionshelpdeterminewhetherpatientshavethesymptomsrequiredbyDSM-5criteriafordiagnosisofmajordepression.Tohelpdifferentiatedepressivedisordersfromordinarymoodvariations,theremustbesignificantdistressorimpairmentinsocial,occupational,orotherimportantareasoffunctioning.Severityisdeterminedbythedegreeofpainanddisability(physical,social,occupational)andbydurationofsymptoms.Aphysicianshouldgentlybutdirectlyaskpatientsaboutanythoughtsandplanstoharmthemselvesorothers,anypreviousthreatsofand/orattemptsatsuicideSuicidalBehaviorSuicideisdeathcausedbyanintentionalactofself-harmthatisdesignedtobelethal.Suicidalbehaviorencompassesaspectrumofbehaviorfromsuicideattemptandpreparatorybehaviors...readmore,andotherriskfactors.Psychosisandcatatoniaindicateseveredepression.Melancholicfeaturesindicatesevereormoderatedepression.Coexistingphysicalconditions,substanceusedisordersSubstanceUseDisordersSubstanceusedisordersareatypeofsubstance-relateddisorderthatinvolveapathologicpatternofbehaviorsinwhichpatientscontinuetouseasubstancedespiteexperiencingsignificant...readmore,andanxietydisordersOverviewofAnxietyDisordersEveryoneperiodicallyexperiencesfearandanxiety.Fearisanemotional,physical,andbehavioralresponsetoanimmediatelyrecognizableexternalthreat(eg,anintruder,acarspinningon...readmoremayaddtoseverity.DifferentialdiagnosisDepressivedisordersmustbedistinguishedfromdemoralizationandgrief.Othermentaldisorders(eg,anxietydisordersOverviewofAnxietyDisordersEveryoneperiodicallyexperiencesfearandanxiety.Fearisanemotional,physical,andbehavioralresponsetoanimmediatelyrecognizableexternalthreat(eg,anintruder,acarspinningon...readmore)canmimicorobscurethediagnosisofdepression.Sometimesmorethanonedisorderispresent.Majordepression(unipolardisorder)mustbedistinguishedfrombipolardisorderBipolarDisordersBipolardisordersarecharacterizedbyepisodesofmaniaanddepression,whichmayalternate,althoughmanypatientshaveapredominanceofoneortheother.Exactcauseisunknown,butheredity...readmore.Inolderpatients,depressioncanmanifestasdementiaofdepression(formerlycalledpseudodementia),whichcausesmanyofthesymptomsandsignsofdementiaDementiaDementiaischronic,global,usuallyirreversibledeteriorationofcognition.Diagnosisisclinical;laboratoryandimagingtestsareusuallyusedtoidentifytreatablecauses.Treatmentis...readmoresuchaspsychomotorretardationanddecreasedconcentration.However,earlydementiamaycausedepression.Ingeneral,whenthediagnosisisuncertain,treatmentofadepressivedisordershouldbetried.Differentiatingchronicdepressivedisorders,suchasdysthymia,fromsubstanceusedisordersSubstanceUseDisordersSubstanceusedisordersareatypeofsubstance-relateddisorderthatinvolveapathologicpatternofbehaviorsinwhichpatientscontinuetouseasubstancedespiteexperiencingsignificant...readmoremaybedifficult,particularlybecausetheycancoexistandmaycontributetoeachother.Physicaldisordersmustalsobeexcludedasacauseofdepressivesymptoms.HypothyroidismHypothyroidismHypothyroidismisthyroidhormonedeficiency.Itisdiagnosedbyclinicalfeaturessuchasatypicalfacialappearance,hoarseslowspeech,anddryskinandbylowlevelsofthyroidhormones...readmoreoftencausessymptomsofdepressionandiscommon,particularlyamongolderpatients.ParkinsondiseaseParkinsonDiseaseParkinsondiseaseisaslowlyprogressive,degenerativedisordercharacterizedbyrestingtremor,stiffness(rigidity),slowanddecreasedmovement(bradykinesia),andeventuallygaitand/or...readmore,inparticular,maymanifestwithsymptomsthatmimicdepression(eg,lossofenergy,lackofexpression,paucityofmovement).AthoroughneurologicexaminationIntroductiontotheNeurologicExaminationTheneurologicexaminationbeginswithcarefulobservationofthepatiententeringtheexaminationareaandcontinuesduringhistorytaking.Thepatientshouldbeassistedaslittleaspossible...readmoreisneededtoexcludethisdisorder.ScreeningSeveralbriefquestionnairesareavailableforscreeningfordepression.Theyhelpelicitsomedepressivesymptomsbutcannotbeusedalonefordiagnosis.However,manyofthesetoolsareusefulinidentifyingat-riskpeoplewhoneedmoredetailedevaluation.SomeofthemorewidelyusedscreeningtoolsincludethePatientHealthQuestionnaire-9(PHQ-9)andtheBeckDepressionInventory(BDI).TestingNolaboratoryfindingsarepathognomonicfordepressivedisorders.However,laboratorytestingisnecessarytoexcludephysicalconditionsthatcancausedepression(seetableSomeCausesofDepressionSomeCausesofSymptomsofDepressionandMania*).Testsincludecompletebloodcount,thyroid-stimulatinghormonelevels,androutineelectrolyte,vitaminB12,andfolatelevelsand,inoldermen,testosteronelevels.Testingforillicitdruguseissometimesappropriate.TreatmentofDepressiveDisordersSupportPsychotherapyDrugs(SeealsoDrugTreatmentofDepressionDrugTreatmentofDepressionSeveraldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmore.)Symptomsmayremitspontaneously,particularlywhentheyaremildorofshortduration.Milddepressionmaybetreatedwithgeneralsupportandpsychotherapy.Moderatetoseveredepressionistreatedwithdrugs,psychotherapy,orbothandsometimeselectroconvulsivetherapyElectroconvulsivetherapy(ECT)Depressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmore.Somepatientsrequireacombinationofdrugs.Improvementmaynotbeapparentuntilafter1to4weeksofdrugtreatment.Depression,especiallyinpatientswhohavehad>1episode,islikelytorecur;therefore,severecasesoftenwarrantlong-termmaintenancedrugtherapy.Mostpeoplewithdepressionaretreatedasoutpatients.Patientswithsignificantsuicidalideation,particularlywhenfamilysupportislacking,requirehospitalization,asdothosewithpsychoticsymptomsorphysicaldebilitation.InpatientswithsubstanceusedisordersSubstanceUseDisordersSubstanceusedisordersareatypeofsubstance-relateddisorderthatinvolveapathologicpatternofbehaviorsinwhichpatientscontinuetouseasubstancedespiteexperiencingsignificant...readmore,depressivesymptomsoftenresolvewithinafewmonthsofstoppingsubstanceuse.Antidepressanttreatmentismuchlesslikelytobeeffectivewhilesubstanceusecontinues.Ifaphysicaldisorderordrugtoxicitycouldbethecause,treatmentisdirectedfirstattheunderlyingdisorder.However,ifthediagnosisisindoubtorifsymptomsaredisablingorincludesuicidalideationorhopelessness,atherapeutictrialwithanantidepressantoramood-stabilizingdrugmayhelp.Prolongedgriefdisordermaybenefitfrompsychotherapyspecificallytailoredtothisdisorder.InitialsupportUntildefiniteimprovementbegins,aphysicianmayneedtoseepatientsweeklyorbiweeklytoprovidesupportandeducationandtomonitorprogress.Telephonecallsmaysupplementofficevisits.Patientsandlovedonesmaybeworriedorembarrassedabouttheideaofhavingamentaldisorder.Thephysiciancanhelpbyexplainingthatdepressionisaseriousmedicaldisordercausedbybiologicdisturbancesandrequiresspecifictreatmentandthattheprognosiswithtreatmentisgood.Patientsandlovedonesshouldbereassuredthatdepressiondoesnotreflectacharacterflaw(eg,laziness,weakness).Tellingpatientsthatthepathtorecoveryoftenfluctuateshelpsthemputfeelingsofhopelessnessinperspectiveandimprovesadherence.Encouragingpatientstograduallyincreasesimpleactivities(eg,takingwalks,exercisingregularly)andsocialinteractionsmustbebalancedwithacknowledgingtheirdesiretoavoidactivities.Thephysiciancansuggestthatpatientsavoidself-blameandexplainthatdarkthoughtsarepartofthedisorderandwillgoaway.PsychotherapyNumerouscontrolledtrialshaveshownthatpsychotherapy,particularlycognitive-behavioraltherapyandinterpersonaltherapy,iseffectiveinpatientswithmajordepressivedisorder,bothtotreatacutesymptomsandtodecreasethelikelihoodofrelapse.Patientswithmilddepressiontendtohavebetteroutcomesthanthosewithmoreseveredepression,butthemagnitudeofimprovementisgreaterinthosewithmoreseveredepression.DrugtherapyfordepressionSeveraldrugclassesanddrugscanbeusedtotreatdepression:SelectiveserotoninreuptakeinhibitorsSelectiveSerotoninReuptakeInhibitors(SSRIs)Severaldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmore(SSRIs)SerotoninmodulatorsModulators(5-HT2Blockers)Severaldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmore(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitorsSerotonin-NorepinephrineReuptakeInhibitorsSeveraldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmoreNorepinephrine-dopaminereuptakeinhibitorNorepinephrine-DopamineReuptakeInhibitorSeveraldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmoreHeterocyclicantidepressantsHeterocyclicAntidepressantsSeveraldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmoreMonoamineoxidaseinhibitorsMonoamineOxidaseInhibitors(MAOIs)Severaldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmore(MAOIs)MelatonergicantidepressantMelatonergicAntidepressantSeveraldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmoreKetamine-likedrugsKetamine-likeDrugsSeveraldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmoreChoiceofdrugDrugChoiceandAdministrationofAntidepressantsSeveraldrugclassesanddrugscanbeusedtotreatdepression:Selectiveserotoninreuptakeinhibitors(SSRIs)Serotoninmodulators(5-HT2blockers)Serotonin-norepinephrinereuptakeinhibitors...readmoremaybeguidedbypastresponsetoaspecificantidepressant.Otherwise,SSRIsareoftentheinitialdrugsofchoice.AlthoughthedifferentSSRIsareequallyeffectivefortypicalcases,certainpropertiesofthedrugsmakethemmoreorlessappropriateforcertainpatients(seetableAntidepressants).Electroconvulsivetherapy(ECT)ECTinvolvestheelectricalinductionofaseizureundercontrolledconditions.Itsmechanismofactionisuncertainbuttheproductionofseizureactivityappearstobeintegraltoitsantidepressanteffects.ModernECT,deliveredunderheavysedation/generalanesthesia,istypicallywelltoleratedbutconfusionandmemoryimpairmentmayoccuracutely.Muchofthisimprovesandisresolvedby6monthsfollowingacourseofECT,butretrogradeamnesiamaypersistforthelongterm.ThisisparticularlysoformemoriesfromtheseveralmonthsprecedingECT.Patientswithbaselinecognitivedeficits,thosereceivingbilateraltreatments,olderpatients,andpatientsreceivinglithiumareathigherriskformemoryimpairmentandconfusion.ThefollowingareoftentreatedwithECTifdrugsareineffective:SeveresuicidaldepressionDepressionwithagitationorpsychomotorretardationDelusionaldepressionDepressionduringpregnancyPatientswhohavestoppedeatingmayneedECTtopreventdeath.ECTisparticularlyeffectiveforpsychoticdepression.Responseto6to10ECTtreatmentsisusuallydramaticandmaybelifesaving.RelapseafterECTiscommon,anddrugtherapyisoftenmaintainedafterECTisstopped.PhototherapyPhototherapyisbestknownforitseffectsonseasonaldepressionbutappearstobeequallyeffectivefornonseasonaldepression.Treatmentcanbeprovidedathomewithaspeciallightunitthatprovides2500to10,000luxatadistanceof30to60cmthatpatientslookatfor30to60minutes/day(longerwithalessintenselightsource).Inpatientswhogotosleeplateatnightandriselateinthemorning,phototherapyismosteffectiveinthemorning,sometimessupplementedwith5to10minutesofexposurebetween3PMand7PM.Forpatientswhogotosleepandriseearly,phototherapyismosteffectivebetween3PMand7PM.OthertherapiesPsychostimulants(eg,dextroamphetamine,methylphenidate)aresometimesused,oftenwithantidepressants.Anumberofcontrolledtrialssupporttheiruseindepressivedisorders(1TreatmentreferencesDepressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmore).Medicinalherbsareusedbysomepatients.St.John’swortSt.John’sWortTheflowersofSt.John’swort(Hypericumperforatum)(SJW)containitsbiologicallyactiveingredients,hypericinandhyperforin.SJWmayincreasecentralnervoussystemserotoninand...readmoremaybeeffectiveformilddepression,althoughdataarecontradictory.St.John’swortmayinteractwithotherantidepressantsandotherdrugs.Someplacebo-controlledstudiesofomega-3supplementation,usedasaugmentationorasmonotherapy,havesuggestedthateicosapentaenoicacid1to2gonceadayhasusefulantidepressanteffects.Vagusnervestimulationinvolvesintermittentlystimulatingthevagusnerveviaanimplantedpulsegenerator.Itmaybeusefulfordepressionrefractorytoothertreatmentsbutusuallytakes3to6monthstobeeffective.Theuseofrepetitivetranscranialmagneticstimulation(rTMS)fortheacutetreatmentofmajordepressivedisorderhassubstantialsupportfromcontrolledtrials.Low-frequencyrTMSmaybeappliedtotherightdorsolateralprefrontalcortex(DLPC),andhigh-frequencyrTMScanbeappliedtotheleftDLPC.Themostcommonadverseeffectsareheadachesandscalpdiscomfort;bothoccurmoreoftenwhenhigh-frequencyratherthanlow-frequencyrTMSisused.Deepbrainstimulationusingimplantedelectrodesthattargetthesubgenualcingulateortheanteriorventralinternalcapsule/ventralstriatumhashadpromisingresultsinuncontrolledcaseseries(2TreatmentreferencesDepressivedisordersarecharacterizedbysadnesssevereenoughorpersistentenoughtointerferewithfunctionandoftenbydecreasedinterestorpleasureinactivities.Exactcauseisunknown...readmore).Controlledtrialsareunderway.Supportgroups(eg,theDepressionandBipolarSupportAlliance[DBSA])canhelppatientsbyprovidingaforumtosharetheircommonexperiencesandfeelings.Treatmentreferences1.McIntyreRS,Leey,ZhouAJ,etal:Theefficacyofpsychostimulantsinmajordepressiveepisodes:Asystematicreviewandmeta-analysis.JClinPscyhopharmacol37(4):412-418,2017.doi:10.1097/JCP.00000000000007232.BergfeldIO,MantioneM,HoogendoornMLC,etal:Deepbrainstimulationoftheventralanteriorlimboftheinternalcapsulefortreatment-resistantdepression:Arandomizedclinicaltrial.JAMAPsychiatry73(5):456-64,2016.doi:10.1001/jamapsychiatry.2016.0152KeyPointsDepressionisacommondisorderthatinvolvesdepressedmoodand/ornear-completelossofinterestorpleasureinactivitiesthatwerepreviouslyenjoyed;somatic(eg,weightchange,sleepdisturbance)andcognitivemanifestations(eg,difficultyconcentrating)arecommon.Depressionmaymarkedlyimpairtheabilitytofunctionatworkandtointeractsocially;riskofsuicideissignificant.Sometimesdepressivesymptomsarecausedbyphysicaldisorders(eg,thyroidoradrenalglanddisorders,benignormalignantbraintumors,stroke,AIDS,Parkinsondisease,multiplesclerosis)oruseofcertaindrugs(eg,corticosteroids,somebeta-blockers,interferon,somerecreationaldrugs).Diagnosisisbasedonclinicalcriteria;physicaldisordersmustberuledoutbyclinicalevaluationandselectedtesting(eg,CBC;electrolyte,TSH,B12andfolatelevels).Treatmentinvolvespsychotherapyandusuallydrugs;SSRIsareusuallytriedfirst,andiftheyareineffective,otherdrugsthataffectserotonin,norepinephrineand/ordopaminemaybetried. ClickhereforPatientEducation NOTE: ThisistheProfessionalVersion. CONSUMERS: ClickherefortheConsumerVersion Copyright©2022Merck&Co.,Inc.,Rahway,NJ,USAanditsaffiliates.Allrightsreserved. CyclothymicDisorder WasThisPageHelpful? Yes No DrugTreatmentofDepression Testyourknowledge TakeaQuiz!  BroughttoyoubyMerck&Co,Inc.,Rahway,NJ,USA(knownasMSDoutsidetheUSandCanada)— dedicatedtousingleading-edgesciencetosaveandimprovelivesaroundtheworld.LearnmoreabouttheMSDManualsandourcommitmenttoGlobalMedicalKnowledge. About Disclaimer Permissions Privacy CookieSettings Termsofuse Licensing ContactUs VeterinaryManual ThissitecomplieswiththeHONcodestandardfortrustworthyhealthinformation:verifyhere. Copyright©2022Merck&Co.,Inc.,Rahway,NJ,USAanditsaffiliates.Allrightsreserved. TOP