Mount Carmel Health Partners Clinical Guidelines Major Depression | Page 3

Depression Facts
• Approximately 20 million people in the United States suffer an episode of major depression each year.
• Women are twice as likely as men to suffer from depression.
• There are bidirectional relationships between depression and physical health.
• Healthcare costs are up to 50% higher for people age 65 and older who have depression.
• Other medical conditions and medication side effects can manifest depression-like symptoms and should be
ruled out (see Table 5).
The key objectives of treatment are:
• In the acute treatment phase: to achieve remission of
symptoms
• In the maintenance treatment phase: to prevent relapse
• To return the patient to previous level of occupational and
psychosocial function
Common Presentations
Patients do not always present with a chief complaint of sad
mood or anhedonia.
Common symptoms include:
• Multiple somatic complaints
• Work or relationship dysfunction
• Lack of attention to activities of daily living
• Appetite change, weight gain or loss
• Sleep disturbance
• Fatigue
• Cognitive complaints such as poor memory or difficulty
concentrating or making decisions
Common signs include:
• Multiple medical visits (more than five per year)
• Flattened affect
• Psychomotor retardation
• Poor grooming
• Poor adherence to physician’s recommendations
Risk Factors
Risk factors for major depression include:
• Family or personal history of major depression and/or substance
abuse
• Chronic medical illness, especially
- chronic pain
- myocardial infarction
- stroke
- diabetes mellitus
• Stressful life events that include loss (e.g., death of a loved one,
divorce)
• Physical trauma
• Major life changes (e.g., job change, financial difficulties)
• Domestic violence
• Advanced age
• Social isolation
Special Considerations
• Anticipatory guidance for patients who plan pregnancy
• Pregnancy
• Postpartum period (see the Edinburgh Postnatal Depression
Scale, page 6)
• LGBT individuals (Lesbian, gay, bisexual, transgender)
• Individuals with language barriers
Special Considerations (continue)
• Secondary/reversible causes
• vitamin deficiency
• thyroid
• nutritional deficiency
• other endocrine
• substance abuse (alcohol or drug)
• other co-morbidities: Parkinson, multiple sclerosis,
cancer, lupus)
Choice of an Initial Treatment Modality
The goal of acute phase treatment is remission of the major
depressive episode. Acute phase treatment may include:
• pharmacotherapy
• psychotherapy
• combination of medication and psychotherapy
Pharmacotherapy
Most antidepressant medications are equally effective. It is not
possible to predict an individual patient’s response to a particular
antidepressant. Therefore, the selection of the initial
antidepressant medication will be influenced by:
• Prior response to antidepressant medication (an agent that
was successful in the past is likely to be successful again)
• Potential side effects
• Pharmacological properties of the medication (e.g., half life,
drug interactions)
• Cost
As always, joint decision-making is appropriate.
Recommended for initial therapy:
• A selective serotonin reuptake inhibitor (SSRI)
• A serotonin norepinephrine reuptake inhibitor (SNRI)
• Mirtazapine
• Bupropion
Not recommended for initial therapy because of unfavorable side
effect profiles:
• Monoamine oxidase inhibitors (MAOIs)
• Tricyclic antidepressants (TCAs)
Dose Titration
Most often, antidepressant treatment is initiated with a low dose
of medication, then gradually increased until symptoms are
controlled or side effects supervene.
Maximum doses in the table are for reference only. Dosing
should be more conservative in older patients, patients with
comorbidities, or patients who take other medications.
The most common reasons for antidepressant failure are
inadequate dosing and inadequate duration of therapy.
Major Depression - 3