The document discusses several types of depression including major depressive disorder, dysthymic disorder, postpartum depression, seasonal affective disorder, and bipolar disorder. It then provides details on the prevalence, risk factors, causes, and screening tools for major depressive disorder. The remainder of the document discusses differential diagnoses, treatment options including pharmacotherapy and psychotherapy, specifics on different classes of antidepressants and their mechanisms of action, side effects, and drug interactions.

1. Babatunde Idowu Ogundipe M.D. M.P.H. December 2 2011 Comprehensive Clinical Services P.C.

8. http://getglue.com/books/lincolns_melancholy_how_depression_challenged_president_fueled_his_greatness/joshua_shenk readyshare.com

9. TABLE 1. Differential Diagnosis of Depressive Syndromes Depressive symptoms 1. Depressed mood 2. Decreased pleasure 3. Weight loss or weight gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or reduced energy 7. Preoccupation with feelings of worthlessness or guilt 8. Poor concentration or indecisiveness 9. Morbid or suicidal thoughts 10. Substantial social or occupational impairment Major depressive disorder Either 1 or 2; at least 4 items from 3-9 for at least 2 wk; Dysthymia 1; at least 2 items from 2-9 for at least 2 y; Adjustment disorder with depressed mood Identifiable stressor but symptoms out of proportion to what is expected Not enough symptoms to meet major depressive disorder criteria Substantial social or occupational impairment Stressor within 3 mo, impairment not longer than 6 mo Bereavement Specific stressor: death of a loved one Symptoms resemble major depressive disorder, but patient considers them appropriate Major depressive disorder diagnosis is not given unless symptoms persist longer than 2 mo or include guilt not related to the dead, a preoccupation with worthlessness, marked psychomotor retardation, suicidal ideation, and prolonged and marked functional impairment From Quick Reference to the Diagnostic Criteria From DSM-IV-TR,8 with permission. A Generalist’s Guide to Treating Patients With Depression With an Emphasis on Using Side Effects to Tailor Antidepressant Therapy

12. Dose (mg/d) Antidepressant Starting Therapeutic Maximum Selected first-generation antidepressants: Tricyclics Tertiary amine: Amitriptyline 25 50-200 300 Clomipramine (Anafranil) 25 50-200 300 Doxepin (Sinequan) 25 50-200 300 Imipramine (Tofranil) 25 50-200 300 Secondary amine: Desipramine (Norpramin) 25 50-200 300 Nortriptyline (Pamelor) 25 50-150 150 Selected second-generation antidepressants: SSRIs Citalopram (Celexa) 10 10-60 80 Escitalopram (Lexapro) 10 10-20 40 Fluoxetine (Prozac) 10 20-60 80 Paroxetine (Paxil) 10 20-50 60 Sertraline (Zoloft) 25 25-200 200 SNRIs Desvenlafaxine (Pristiq) 50 50-100 100 Duloxetine (Cymbalta) 30 30-90 120 Venlafaxine (Effexor XR) 37.5 37.5-375 Serotonin antagonist Mirtazapine (Remeron) 7.5 15-45 45 Norepinephrine and dopamine reuptake inhibitors Bupropion SR (Wellbutrin) 100 100-400 400 Bupropion XL (Wellbutrin) 150 150-450 450 SNRI = serotonin and norepinephrine reuptake inhibitor; SR = sustained release; SSRI = selective serotonin reuptake inhibitor; XL = extended release. All doses are for oral preparation taken once daily except for bupropion SR, which is taken twice daily, and venlafaxine (Effexor SR), which can be taken once a day or in divided doses . A Generalist’s Guide to Treating Patients With Depression With an Emphasis on Using Side Effects to Tailor Antidepressant Therapy

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28. SSRI Atypicals: MAOI’s: TCA’s: Sexual Dysfunction: Fluoxetine (if so switch to mirtazapine/bupropion(inc dopamine-sex fctn ) or decrease dose or add sildenafil) or buspirone Paroxetine(most of all SSRI’s). May be useful in men with premature ejaculation given delayed orgasm. Venlafaxine. yes Introduced in more sexually repressed 1950’s. yes. Weight Gain: Paroxetine(most of all SSRI’s ), citalopram, sertraline Fluoxetine  anorexia  weight loss. Escitalopram-weight neutral. Mirtazapine  increased appetite  increased weight. Bupropion  weight loss. yes Amitriptyline, Imipramine  weight increased after 6 months of use. Sedation: Paroxetine(most of all SSRI’s)-thus only one taken at night. Other SSRI’s energizing thus taken in morning. Bupropion  insomnia, may be beneficial in patient with lassitude . Mirtazapine-may be beneficial in patients with insomnia. Trazodone- insomnia (especially in early stages treatment can give in low dose to act as adjunct to another antidepressant). Amitriptyline. May be beneficial in patients with insomnia. Doxepin –high affinity for histamine receptor thus in low dose good for sleep induction Anticholinergic Venlafaxine. Amitriptyline with strongest anticholinergic effect Other: Bupropion  lowers seizure threshold . Venlafaxine  increased diastolic BP. Trazodone  priapism + postural hypotension. Tyramine-induced hypertensive crisis-aged cheeses & red wine. MAOI’s combined with SSRI’s, TCA’s, meperidine, fentanyl, or indirect sympathomimetics (i.e.OTC cold remedies) may  potentially fatal serotonin syndrome. Orthostatic hypotension, Cardiac conduction delays, overdose  fatal ventricular arrythmias