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20.11.2014

Major depressive disorder diagnostic criteria dsm-iv-tr, sleepless movie trailer - For You

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Depression and anxiety disorders are the most prevalent psychiatric disorders seen in the primary care setting. Mood and anxiety disorders are the most common psychiatric disorders in the community and in primary care settings.1 This educational review is designed to be an evidence-based reference for primary care clinicians using psychiatric medication to treat patients with these conditions. There are many good reasons for the recent proliferation of evidence-based guidelines for psychiatric disorders. Depression should be diagnosed using specific diagnostic criteria, such as those outlined in the Diagnostic and Statisical Manual of Mental Disorders, Fourth Edition, Text-Revision, (DSM-IV-TR) (Table 1). The differential diagnosis of depression includes not only other psychiatric disorders, but also mood disorders due to general medical conditions and substance-induced mood disorders.
Depression may be complicated in several ways, impacting decisions about pharmacotherapy and other interventions. Melancholic features of depression include loss of pleasure in activities, lack of reactivity to pleasurable stimuli, and various neurovegetative symptoms such as exacerbation of depression in the morning, early-morning awakening, and significant weight loss.
Clinicians should be alert for psychotic symptoms in depression, as these are sometimes subtle.
Atypical features of depression include mood reactivity, as well as neurovegetative symptoms of reversed polarity (ie, increased rather than decreased sleep and appetite), severe lack of energy or leaden feelings in the limbs (leaden paralysis), and pathologic sensitivity to interpersonal rejection. A detailed history of substance abuse is essential in patients with depression because of the frequent comorbidity of these disorders. Depression during pregnancy should be treated with nonpharmacotherapeutic interventions when possible. Depression during lactation should be treated with nonpharmacotherapeutic interventions when possible.
Although antidepressants may be useful,88 additional interventions, such as psychotherapy, may be crucial in patients with depression and comorbid personality disorders.
Depressed patients who fail to respond to medication should be thoroughly reassessed for an underlying medical disorder.
Some medications may be particularly useful in cases of depression that do not respond to one or more antidepressants. Particular attention should be paid to the evaluation of symptoms that are chosen as targets for pharmacotherapy and to symptoms that may point to the presence of other psychiatric disorders. It is also necessary to rule out the presence of comorbid psychiatric and medical disorders. Research indicates that GAD in the elderly is not uncommon and is often accompanied by depression.101 Given the possibility of accumulation of the drug and consequent adverse effects, such as motor vehicle accidents, falls, and fractures, benzodiazepines (particularly in high doses or those with long half-lives) should be prescribed only with great caution in this population. As noted earlier, there is a high rate of comorbidity among GAD, other anxiety disorders, and mood disorders.
Clinicians need to be aware of the multiple interactions between medications used in the treatment of GAD and the treatment of other disorders, as well as of the impact of the medication’s adverse effects on medical disorders.
It is important to establish whether comorbid mood or other anxiety disorders are present.
In the presence of active alcohol or substance use, it may be necessary to shift the emphasis of treatment toward a substance use disorder as the primary diagnosis, with the anxiety as a secondary problem. Although antidepressants may be useful, additional interventions, such as psychotherapy, may be helpful in patients with chronic anxiety and comorbid personality disorder.
In some cases, a diagnosis of an adjustment disorder with anxious features may be more accurate than that of GAD, and a psychotherapeutic approach therefore indicated.
In such cases, following some of the strategies that have proven useful in the treatment of resistant depression is suggested.
Panic disorder, social anxiety disorder (social phobia), and PTSD are all anxiety disorders and are among the most common of the psychiatric disorders.1 Each is characterized by panic attacks or hyperarousal and by underdiagnosis or misdiagnosis as physical illness in primary care settings. The role of psychotherapy in the treatment of panic disorder, social anxiety disorder, and PTSD must be emphasized.119 Cognitive-behavioral therapy can augment the anxiolytic effects of medication, is essential in reducing avoidance behaviors (eg, agoraphobia, avoidance of social situations), and may be important in ultimately allowing medication discontinuation. Panic attacks in panic disorder and PTSD (Tables 5, 6) may be spontaneous or may be cued by exposure to stimuli previously associated with a panic attack (eg, a confined space), while panic attacks in social phobia (Table 7) are cued by feared social situations (eg, public speaking).
Panic attacks may occur in other psychiatric disorders, such as depression, specific phobias, OCD, and substance use disorders. Panic disorder, social anxiety disorder, and PTSD may be complicated in several ways, impacting decisions about pharmacotherapy.
Patients with anxiety disorders often have comorbid depression, but this usually also responds to first-line anti-anxiety treatments such as the SSRIs. Alcohol and other substance use disorders are associated with exacerbation of anxiety disorders. Clinicians need to be aware of the multiple interactions between medications used in the treatment of the anxiety disorders and other medications, as well as of the impact of medication adverse effects on medical disorders. In Algorithm 3, SSRIs or venlafaxine are suggested as the first-line treatment of panic disorder, social anxiety disorder, and PTSD.


Panic disorder also responds to the TCAs and to certain other antidepressants (but not all).
Social anxiety disorder does not respond to the TCAs (with the possible exception of clomipramine, a predominantly serotonergic TCA), and these agents should not be used as first-line treatments of this disorder. There are few studies showing that any one SSRI is superior to another in the treatment of anxiety disorders. Important aspects of psychoeducation regarding the SSRIs and SNRIs include the fact that these are not addictive, that despite being termed antidepressants they are highly effective in anxiety disorders, that side effects are typically transient, that therapeutic response is relatively slow in onset, and that if one agent does not work another should be tried.
High-potency benzodiazepines (alprazolam, clonazepam) have also been shown to be effective in the treatment of panic disorder and social anxiety disorder. Although β-blockers are often prescribed by primary care practitioners for anxiety symptoms, there is not sufficient evidence to include them as a first-line medication for panic disorder, generalized social anxiety disorder, or PTSD. In panic disorder, high-potency benzodiazepines have been anecdotally described as useful in treatment-resistant panic disorder,136 and these agents (particularly slow-release agents or those with a longer half-life) may be expected to reduce anxiety secondary to antidepressants and to combat the primary disorder. In social anxiety disorder, given its efficacy as monotherapy, augmentation with clonazepam is a theoretical consideration.141 Nevertheless, this again runs the risk of benzodiazepine dependence.
When anxiety disorders do not respond to a clinical trial of optimal dose and duration, it is useful to reassess a number of factors. The algorithms included here cover the major mood and anxiety disorders, namely major depressive disorder (MDD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), and social anxiety disorder. Nevertheless, there is increasing recognition that dysthymia also responds to standard antidepressant treatments.21,22 This disorder, which is characterized by chronic depressive symptoms, has significant associated morbidity when left untreated.
A range of practical questionnaires that incorporate these criteria are available to help clinicians identify and diagnose patients with major depression.27,28 Particular attention should be paid to symptoms that are chosen as targets for pharmacotherapy, which include mood symptoms, associated symptoms (such as pain), and disability. There is some evidence that TCAs and venlafaxine may be more effective than selective serotonin reuptake inhibitors (SSRIs) in patients with depression accompanied by melancholic features34 and in possibly related subgroups, such as in-patients with depression,35,36 although not all data is consistent.37 Certainly the presence of melancholic features in depression predicts a poor response to nonsomatic interventions. Depression with psychotic features is associated with increased risk for suicide and recurrent depression. Depressed patients with comorbid substance use disorders are more likely to require hospitalization, more likely to attempt suicide, and less likely to comply with treatment. Increasingly, the literature is emphasizing not only significant reduction in depressive symptoms, but also the value of aiming for near-complete remission of symptoms. Guidelines for maintenance therapy of depression have become increasingly conservative, favoring longer courses of medication, in view of the safety of modern antidepressants and the likelihood of additional episodes of depression in patients with repeated episodes.77,78 It is reasonable to continue medication for at least 1 year before gradual tapering, and to continue for even longer in patients with a risk of recurrence. Even among responders, residual symptoms of depression are common, and, as noted earlier, are associated with greater likelihood of relapse.
While improvement in depressive symptoms may reduce maladaptive behavior in patients with comorbid personality disorder, there are other patients (eg, those with borderline personality disorder) in whom the personality disorder itself may need to be a major target of treatment. Apathy has been reported as an adverse event of some antidepressants, and may masquerade as depression. In particular, there is increasing evidence that patients with GAD and mixed anxiety-depression frequently present in primary care settings,100 and the DSM-IV-TR now provides fairly user-friendly criteria for the diagnosis of GAD (Table 3). Mood disorders, such as depression and dysthymia, and other anxiety disorders are common in patients with GAD. GAD will often respond to the antidepressants that are used as first-line medication in these disorders and these agents should therefore be initially prescribed.
Nevertheless, the high comorbidity of symptoms of depression in GAD, and the significant difficulties experienced by many patients during benzodiazepine withdrawal, constitute a strong argument against their use. Disadvantages include a lack of efficacy against the depressive symptoms often found in GAD and a lack of efficacy in some trials. Indeed, guidelines for maintenance therapy of GAD emphasize the safety of modern agents, the likelihood of additional episodes of illness in patients with repeated past episodes, and the theoretical possibility that appropriate treatment may prevent the onset of secondary disorders.106 Such guidelines have become increasingly conservative, favoring longer courses of medication.
Augmentation offers the advantage of retaining any possible gains from the first agent, but the potential disadvantages of polypharmacy (more side effects and drug interactions).81 Given the literature on combining SSRIs with buspirone in the treatment of refractory depression, this strategy perhaps deserves consideration in GAD patients with partial response. For example, comorbid dysthymia may not respond to buspirone alone, comorbid social anxiety disorder is unlikely to respond to a TCA (other than clomipramine), and comorbid hypochondriasis may require high doses of serotonin reuptake inhibitors. While improvement in anxiety symptoms may reduce maladaptive behavior in patients with comorbid personality disorder, there are other patients (eg, those with borderline personality disorder) in whom the personality disorder itself may need to be a major target of treatment. A range of different medical disorders may lead to chronic anxiety, including endocrine disorders (eg, hyperthyroidism), respiratory disorders (eg, chronic obstructive pulmonary disorders), cardiac disorders (eg, congestive heart failure) and others. In addition, psychoeducation of both patient and family is crucial in the treatment of anxiety disorders. Although there is less data on the treatment of children and adolescents with these disorders, what does exist suggests that a similar approach may be useful in some younger patients.120,121 Specialist consultation may, however, be indicated in such cases. Panic disorder, social anxiety disorder, and PTSD may all be associated with other psychiatric symptoms, particularly depressive and substance abuse symptoms, which therefore also deserve particular attention.
The possible association between panic disorder and increased risk of suicide, for example, needs to be taken seriously.


However, there is some evidence (albeit controversial) that TCAs and venlafaxine may be more effective than SSRIs in patients with depression accompanied by melancholic features34 and in possibly related subgroups, such as in-patients with depression,35,36 although not all data is consistent.37 Interestingly, clomipramine is a TCA with properties that overlap with the SSRIs in that it is relatively selective for the serotonin system. Anxiety disorders may lead to use of alcohol and other substances in order to self-medicate anxiety.
Fortunately, certain SSRIs have relatively few interactions with other medications, and the SSRIs as a class are well tolerated in most medical disorders. Dose-response relationship of the SSRIs has not been as well studied in the anxiety disorders as in depression. Guidelines for maintenance therapy of anxiety disorders have become increasingly conservative, favoring longer courses of medication, in view of the safety of modern antidepressants and the likelihood of relapse in patients with an untreated chronic illness. It aims to provide a concise, logical, and user-friendly approach to the pharmacotherapy of depression and anxiety disorders in the primary care context. Classical monoamine oxidase inhibitors (MAOIs) are more effective than TCAs in atypical depression.40 However, in view of the inconvenience caused by dietary and other restrictions when using these MAOIs, SSRIs may be considered a first-line class of medication41 (despite the fact that not all studies of these agents in this subgroup have been positive).
A depressed patient with a history of any cardiac disorder should be monitored for the emergence of cardiac symptoms, electrocardiogram (EG) changes, and orthostatic blood-pressure decrements. It may be useful to have the patient complete a rating scale of depression (Table 2) to help quantify response to medication.
Risk factors for recurrence include history of multiple episodes, persistent dysthymic symptoms after recovery from MDD, and comorbid psychiatric and medical disorders. Given that GAD often presents with somatic symptoms and comorbid psychiatric disorders, the diagnosis is frequently overlooked.
It is possible that the situation in GAD mirrors that in depression, where less severe forms of the disorder respond equally well to pharmacotherapy and to psychotherapy. In addition, attention should be paid to the possibility of comorbid somatization disorder or substance abuse, dependence, or withdrawal.
Similarly, in patients with chronic anxiety and comorbid personality disorder (eg, borderline personality disorder), antidepressants may be particularly useful. Excluding important comorbid psychiatric disorders is perhaps the most important step in the evaluation and management of refractory GAD.
Melancholic features of depression include loss of pleasure in activities, lack of reactivity to pleasurable stimuli, and various neurovegetative symptoms, such as exacerbation of depression in the morning, early-morning awakening, and significant weight loss.
Thus, although it is generally advisable to detoxify patients prior to beginning pharmacotherapy, in some cases such pharmacotherapy is an integral part of the treatment of the secondary substance use disorder.102 There is some evidence that the SSRIs in particular may be useful as a primary treatment of alcohol dependence.
No matter which antidepressant is used in the treatment of panic disorder, however, it is crucial to initiate treatment with very low doses (eg, fluoxetine 5 mg or imipramine 10 mg) in order to prevent early exacerbation of panic attacks. Some authors have suggested that high-potency benzodiazepines qualify as first-line monotherapies in panic disorder and social anxiety disorder, but others have emphasized the potential problems of long-term treatment. In panic disorder, social anxiety disorder, and PTSD it is not unreasonable to continue medication for at least a year before gradual tapering.126-128,133 Cognitive-behavioral therapy may be useful prior to beginning and during medication withdrawal in order to maintain gains, although more research on the optimal combination and sequencing of pharmacotherapy and psychotherapy in these disorders is needed. The anticonvulsant gabapentin has shown some efficacy as monotherapy in panic disorder,137 does not have dependence potential, and is another theoretical possibility for use as an augmenting agent. The anticonvulsant gabapentin also showed some efficacy as monotherapy in social anxiety disorder,142 does not have dependence potential, and is another theoretical possibility for use as an augmenting agent.
It is particularly important to exclude a history of mania or hypomania in patients with a family history of bipolar disorder. ECT may be used in selected cases, or in patients in whom depression is complicated by psychotic features, as it is both safe and effective in depression during pregnancy. In addition to monitoring depression symptoms, it is important to ascertain overall change in objective disability and subject well-being (ie, quality of life).
On the other hand, improvements in the nosology and treatment of GAD now make it useful to establish whether diagnostic criteria for this disorder are met.
A compromise position is that short-term augmentation of antidepressant agents with benzodiazepines may be useful in rapidly stabilizing symptoms, and should therefore be considered in panic disorder132 and perhaps social anxiety disorder, particularly when high levels of anxiety threaten to disrupt ongoing pharmacotherapy. Nevertheless, there is a paucity of research on augmentation strategies in social anxiety disorder. On the other hand, a positive family history of depression, a history of depression preceding alcohol or other substance use, or a history of major depression during periods of sobriety raises the possibility that early intervention with antidepressants may be useful.
Certainly, the lowest effective antidepressant dose of an SSRI may not be sufficient for some patients with panic disorder, social anxiety disorder, and PTSD.
In patients with depression and comorbid OCD, it is advisable to use a serotonergic medication (ie, clomipramine or an SSRI).
In patients with depression and comorbid social anxiety disorder, SSRIs and venlafaxine, rather than TCAs, would be favored as first-line agents.



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