Major Depressive Disorder

“An Epidemic of Depression” by Wakefield and Horwitz (Psychiatric Times, November 2008, page 44) raised the issue that DSM does not take into account the context in which symptoms arise for the diagnosis of MDD. The authors opine that the diagnosis should require that symptoms be “excessive” or “unreasonable” relative to the context in which they arise, and that “the efficacy of these medications for the treatment of normal sadness is often overstated.”

To improve validity, we proposed extending the current MDD bereavement exclusion-which excludes “uncomplicated” (relatively brief, lacking certain severe symptoms) depressive bereavement from diagnosis-to also exclude uncomplicated reactions to other major stressors, such as romantic breakups, job loss, and serious medical diagnoses.

Social anxiety disorder (SAD), also referred to as social phobia, is a chronic and potentially disabling anxiety disorder characterized by the intense and persistent fear of being scrutinized or negatively evaluated by others. At its core, people with this disorder fear and/or avoid the scrutiny of others. Symptoms may occur only in circumscribed situations, such as a fear of speaking in formal or informal situations, or eating or drinking in front of others.

Acupuncture is associated with an increase in the level of neurobiologically active substances, such as endorphins and enkephalins. There are also data indicating that acupuncture induces the release of norepinephrine, serotonin, and dopamine.

For many antidepressants, the issue of brand-name versus generic has no practical significance. Elavil was first marketed almost a half century ago, and its patent has long expired. It lives on, however, but as generic amitriptyline. Today, only a few antidepressants are still fully protected by patents, namely, Cymbalta (2010), Lexapro (2012), and Pristiq (2022) for major depressive disorder (MDD); and Seroquel (2011) and Symbyax (2017) for bipolar depression.

Lecturing around the country has left us with the powerful impression that both psychiatrists and primary care physicians are hungry for new ways to think about and treat depression and the myriad symptoms and syndromes with which it is associated-including attention deficit disorder, insomnia, chronic pain conditions, substance abuse, and various states of disabling anxiety. Primary care physicians also seem especially excited to learn that depression is not just a psychiatric illness but a behavioral manifestation of underlying pathophysiological processes that promote most of the other conditions they struggle to treat-including cardiovascular disease, diabetes, cancer, and dementia.1,2

The assessment and treatment of psychiatric symptoms in persons with cognitive dysfunction are becoming increasingly important. Prevalence estimates of dementia in the United States range from 5% in those aged 71 to 79 years to 25% to 50% in those 90 or older.

Autism spectrum disorders (ASDs) are a group of 5 neuro developmental conditions (autism, Asperger syndrome, pervasive developmental disorder not otherwise specified [PDD-NOS], Rett syndrome, and disintegrative childhood disorder).1 Once thought to be rare, the incidence of these disorders is now estimated to be 1 in 150 children in the general population.2 Furthermore, the number of recognized cases has increased markedly in recent years.

Allegations of suppressed research, promotion of drugs for unapproved uses, payment of kickbacks to physicians, and ghostwriting of a major journal article surfaced recently when the Department of Justice unsealed a civil complaint against Forest Laboratories and Forest Pharmaceuticals, Inc.

Subjective complaints of impaired concentration, memory, and attention are common in people with major depressive disorder (MDD), and research shows that a variety of structural brain abnormalities are associated with MDD.1 These findings have intensified the interest in quantitative assessment of cognitive and neuropsychological performance in patients with mood disorders. Many studies that used standardized cognitive tests have found that mild cognitive abnormalities are associated with MDD and that these abnormalities are more pronounced in persons who have MDD with melancholic or psychotic features

Many people assume that it is the emotional and psychotic symptoms that make it difficult for a person with schizophrenia to function in everyday life. In fact, research indicates that cognitive impairment is a major reason why functional outcome is so poor.1

Generalized anxiety disorder (GAD) is a prevalent, chronic, debilitating mental illness associated with marked impairment in daily functioning.1 An ongoing evolution of the definition of GAD has resulted in a bifurcation of the historical anxiety neurosis designation.2 A diagnosis of GAD currently implies chronic, excessive worry lasting at least 6 months and 3 of the possible 6 somatic or psychological symptoms (restlessness, fatigue, muscle tension, irritability, difficulty concentrating, and sleep disturbance).3 GAD typically presents in an episodic pattern of moderate improvement or remission and relapse characterized by a chronic and complicated clinical course.

The cardiovascular properties of serotonin (5-HT) have been known for some time-its name reflects its presence in serum and its action in increasing vascular tone. Serotonergic medications are routinely used to treat depressive and anxiety disorders, and the association of depression with cardiovascular disease has become well established.2 Recent studies have confirmed the colloquial wisdom that anxiety (especially panic) and hypertension are linked.

The rationale for the use of anticonvulsants in anxiety disorders is supported by neurobiological underpinnings that make these compounds a likely alternative for short-term treatment.

It has been a relatively short time between clinical use of the term anxiety neurosis-which included worry, panic, and obsessions-and the advent of recent DSM-defined categorical diagnoses of panic disorder, generalized anxiety disorder, social anxiety disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. It seems that we have moved from a symptom-oriented approach in treating anxiety to a syndromal approach in which the patient has to accumulate enough symptoms and impairment to have a more definable illness or disorder.

Are serum concentrations of folate and vitamin B12 related to the onset of dementia? Can depression be prevented with folate, vitamin B12, and B6 supplementation? Two recent studies shed light on these questions.

Sildenafil (Viagra, Revatio) reduced antidepressant-associated sexual dysfunction in wom­en in a randomized controlled trial, which investigators characterize as the first conducted in women with this adverse drug effect.

Does adoption pose psychological risks? University of Minnesota researchers revisited this controversial issue recently and found that common DSM-IV childhood disorders are more prevalent in adoptees than nonadoptees.

An NIMH-sponsored study found that extending the duration of therapy for depressed adolescents increased the rate of response and decreased relapse rates relative to acute, short-term treatment.

Suicide risk assessment is a core competency that all psychiatrists must have.1 A competent suicide assessment identifies modifiable and treatable protective factors that inform patient treatment and safety management.2 Psychiatrists, unlike other medical specialists, do not often experience patient deaths, except by suicide. Patient suicide is an occupational hazard. A clinical axiom holds that there are 2 kinds of psychiatrists: those who have had patients commit suicide-and those who will.

Although most studies have focused on the risk of metabolic syndrome for patients with schizophrenia exposed to atypical antipsychotics, other psychiatric patients appear to be at risk for metabolic disturbances as well.7-9 Major depressive disorder (MDD) may be of particular interest because it is much more common than schizophrenia and is treated with a broad range of psychotropics.

Identifying and Reducing Professional Liability When Treating Older Adults, by Jacqueline M. Melonas, RN, MS, JD and Charles D. Cash, JD, LLM, ARM

A large percentage of youths use and abuse psychoactive substances. According to the 2007 Monitoring the Future (MTF) survey, the percentage of US adolescents who used illicit drugs or drank alcohol continued a decade-long drop, revealing that 19% of 8th grad­ers, more than 36% of 10th graders, and 47% of all 12th graders have taken an illicit drug (other than alcohol) during their lifetime.1 According to the National Survey on Drug Use and Health, the rate was 3.3% for misuse or nonmedical use of prescription drugs.2 The misuse of prescription drugs among adolescents was second only to marijuana use. In fact, prescription drugs increasingly have become a part of the repertoire of drug-using adolescents.

For some couples, the transition to parenthood is not filled with this rich mixture of great perplexity and great joy.

The substantial and often recurrent distress and impairment associated with major depressive disorder (MDD) in youth has prompted increased interest in the identification and dissemination of effective treatment models. Evidence supports the use of several antidepressant medications, specific psychotherapies, and, in the largest treatment study of depressed teenagers, the combination of fluoxetine and cognitive-behavioral therapy (CBT) as effective treatments.1-3 CBT is the most extensively tested psychosocial treatment for MDD in youth, with evidence from reviews and meta-analyses that supports its effectiveness in that population.3-5

The prospect of using computers to deliver psychotherapy has been intriguing a number of investigators who have been studying innovative methods of bringing technology into clinical practice.

Every life ends with death. For the elderly, death is the end of a long life that has been shaped by personal history and world events, various relationships, well-set personality characteristics and, of course, happenstance. Each of these, in addition to the specific circumstances that herald death, shapes the experience of dying in old age.

Suppose your new patient, Mr. Jones, tells you he is feeling “really down.” He meets all DSMIV symptomatic and duration criteria for a major depressive episode (MDE) after having lost his wife to cancer 2 weeks ago. Should you diagnose major depressive disorder?

Youths aged 6 to 16 years with any subtype of ADHD participated in the study. Comorbid bipolar disorder, pervasive developmental disorder, psychotic illness, anxiety disorders, and tic disorders were exclusionary criteria. Patients with other comorbid psychiatric disorders, including major depressive disorder, were allowed to participate if ADHD was the primary diagnosis.

Late-life depression is both underrecognized and undertreated, and the impact of medical comorbidity may mask depressive symptoms. Depression further complicates the prognosis of medical illness by increasing physical disability and decreasing motivation and adherence to prescribed medications and/or exercise or rehabilitation programs