ITEMS IN AFP WITH MESH TERM:
Depression in Children and Adolescents - Article
ABSTRACT: Depression among children and adolescents is common but frequently unrecognized. It affects 2 percent of prepubertal children and 5 to 8 percent of adolescents. The clinical spectrum of the disease can range from simple sadness to a major depressive or bipolar disorder. Risk factors include a family history of depression and poor school performance. Evaluation should include a complete medical assessment to rule out underlying medical causes. A structured clinical interview and various rating scales such as the Pediatric Symptom Checklist are helpful in determining whether a child or adolescent is depressed. Evidence-based treatment guidelines from the literature are limited. Psychotherapy appears to be useful in most children and adolescents with mild to moderate depression. Tricyclic antidepressants and selective serotonin reuptake inhibitors are medical therapies that have been studied on a limited basis. The latter agents are better tolerated but not necessarily more efficacious. Because the risk of school failure and suicide is quite high in depressed children and adolescents, prompt referral or close collaboration with a mental health professional is often necessary.
ABSTRACT: Traditionally, psychiatric medications were withheld during pregnancy because of fear of teratogenic and other effects. The emergence of evidence of the safety of most commonly used psychiatric medications, the availability of this information in the form of online databases, and the documentation of the adverse effects of untreated maternal mental illness have all increased the comfort of physicians and patients with respect to the use of psychiatric medications during pregnancy. The tricyclic antidepressants and fluoxetine (Prozac) appear to be free of teratogenic effects, and emerging data support similar safety profiles for the other selective serotonin reuptake inhibitors. The mood stabilizers appear to be teratogenic. With the exception of the known risk for depression to worsen in the postpartum period, there is little consistent evidence of the effects of pregnancy on the natural history of mental illness. Decisions regarding the use of psychiatric medications should be individualized, and the most important factor is usually the patient's level of functioning in the past when she was not taking medications.
ABSTRACT: Depression is a common psychiatric disorder in children, adolescents, adults, and the elderly. Primary care physicians, not mental health professionals, treat the majority of patients with symptoms of depression. Persons who are depressed have feelings of sadness, loneliness, irritability, worthlessness, hopelessness, agitation, and guilt that may be accompanied by an array of physical symptoms. A diagnosis of major depression requires that symptoms be present for two weeks or longer. Identifying patients with depression can be difficult in busy primary care settings where time is limited, but certain depression screening measures may help physicians diagnose the disorder. Patients who score above the predetermined cut-off levels on the screening measures should be interviewed more specifically for a diagnosis of a depressive disorder and treated within the primary care physician's scope of practice or referred to a mental health subspecialist as clinically indicated. Targeted screening in high-risk patients such as those with chronic diseases, pain, unexplained symptoms, stressful home environments, or social isolation, and those who are postnatal or elderly may provide an alternative approach to identifying patients with depression.
ABSTRACT: A number of antidepressants have emerged in the U.S. market in the past two decades. Selective serotonin reuptake inhibitors have become the drugs of choice in the treatment of depression, and they are also effective in the treatment of obsessive-compulsive disorder, panic disorder, and social phobia. New indications for selective serotonin reuptake inhibitors include post-traumatic stress disorder, premenstrual dysphoric disorder, and generalized anxiety disorder. Extended-release venlafaxine has recently been approved by the U.S. Food and Drug Administration for the treatment of generalized anxiety disorder. Mirtazapine, which is unrelated to the selective serotonin reuptake inhibitors, is unique in its action--stimulating the release of norepinephrine and serotonin. The choice of antidepressant drug depends on the agent's pharmacologic profile, secondary actions, and tolerability. Sexual dysfunction related to the use of antidepressants may be addressed by reducing the dosage, switching to another agent, or adding another drug to overcome the sexual side effects. Augmentation with lithium or triiodothyronine may be useful in patients who are partially or totally resistant to antidepressant treatment. Finally, tapering antidepressant medication may help to avoid discontinuation syndrome or antidepressant withdrawal.
ABSTRACT: Depression in elderly persons is widespread, often undiagnosed, and usually untreated. The current system of care is fragmented and inadequate, and staff at residential and other facilities often are ill-equipped to recognize and treat patients with depression. Because there is no reliable diagnostic test, a careful clinical evaluation is essential. Depressive illness in later life should be treated with antidepressants that are appropriate for use in geriatric patients. A comprehensive, multidisciplinary approach, including consideration of electroconvulsive treatment in some cases, is important. The overall long-term prognosis for elderly depressed patients is good.
ABSTRACT: Family physicians must decide how to screen for depression or dementia and which patients to screen. Mental health questionnaires can be helpful. In practice-based screening, questionnaires are administered to all patients, regardless of risk status. In case-finding screening, questionnaires are administered only when depression or dementia is suspected. The 2002 U.S. Preventive Services Task Force report recommends screening adults for depression to improve detection and patient outcomes but does not suggest the use of any particular screening instrument. Serial or sequential testing with the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 is a good strategy for detecting major depressive episodes in primary care settings. The Patient Health Questionnaire-2 consists of two questions that assess the presence of anhedonia and dysphoria. If a patient answers "yes" to either question, the more specific Patient Health Questionnaire-9 is administered to assess the severity of depressive symptoms and to ascertain the presence of major depressive episode. The Patient Health Questionnaire-9 also can be used to monitor symptom severity and treatment response. The 2003 U.S. Preventive Services Task Force report does not recommend for or against routine screening for dementia in older adults. However, the report does assert that cognitive function should be assessed when impairment is suspected. The Folstein Mini-Mental State Examination and the Functional Activities Questionnaire are suggested tools. The Clock Drawing Test also has been shown to be useful in primary care settings.
Childhood and Adolescent Depression - Article
ABSTRACT: Major depression affects 3 to 5 percent of children and adolescents. Depression negatively impacts growth and development, school performance, and peer or family relationships and may lead to suicide. Biomedical and psychosocial risk factors include a family history of depression, female sex, childhood abuse or neglect, stressful life events, and chronic illness. Diagnostic criteria for depression in children and adolescents are essentially the same as those for adults; however, symptom expression may vary with developmental stage, and some children and adolescents may have difficulty identifying and describing internal mood states. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies. Current literature supports use of cognitive behavior therapy for mild to moderate childhood depression. If cognitive behavior therapy is unavailable, an antidepressant may be considered. Antidepressants, preferably in conjunction with cognitive behavior therapy, may be considered for severe depression. Tricyclic antidepressants generally are ineffective and may have serious adverse effects. Evidence for the effectiveness of selective serotonin reuptake inhibitors is limited. Fluoxetine is approved for the treatment of depression in children eight to 17 years of age. All antidepressants have a black box warning because of the risk of suicidal behavior. If an antidepressant is warranted, the risk/benefit ratio should be evaluated, the parent or guardian should be educated about the risks, and the patient should be monitored closely (i.e., weekly for the first month and every other week during the second month) for treatment-emergent suicidality. Before an antidepressant is initiated, a safety plan should be in place. This includes an agreement with the patient and the family that the patient will be kept safe and will contact a responsible adult if suicidal urges are too strong, and assurance of the availability of the treating physician or proxy 24 hours a day to manage emergencies.
ABSTRACT: Major depression is a common and treatable disease. Many patients benefit from pharmacologic treatment and, because there is little variation in antidepressant effectiveness, medication choices should be made based on patient characteristics, safety, and anticipated side effects. Most patients respond favorably to treatment, but many do not have complete symptom relief. Changing medications or augmenting with a second medication is helpful for some partial or nonresponders. All antidepressants are capable of producing harmful side effects, and some are particularly prone to dangerous drug-drug interactions. The risk of suicide is always a concern in depression and this risk is not necessarily reduced by the use of antidepressants. Some persons may have an increase in suicidal thoughts with antidepressant treatment. Close follow-up is required when initiating therapy and adjusting dosages.
Mirtazapine: A Newer Antidepressant - Article
ABSTRACT: Mirtazapine is a newer antidepressant that exhibits both noradrenergic and serotonergic activity. It is at least as effective as the older antidepressants for treating mild to severe depression. Sedation is the most common side effect. Although agranulocytosis is the most serious side effect, it is rare (approximately one in 1,000) and usually reversible when the medication is stopped. Mirtazapine is relatively safe in overdose. Many clinicians consider mirtazapine a second-line or even third-line antidepressant to be used when older antidepressants are not tolerated or are ineffective. Physicians who are concerned about the risks of elevated lipid levels and agranulocytosis may choose to reserve mirtazapine as a third-line choice. It is particularly useful in patients who experience sexual side effects from other antidepressants. Mirtazapine is also a good choice in depressed patients with significant anxiety or insomnia. Although mirtazapine has been used successfully in Europe for a number of years, its place in the care of patients with depression in the United States has not yet been established.
ABSTRACT: Women experience depression twice as often as men. The diagnostic criteria for depression are the same for both sexes, but women with depression more frequently experience guilt, anxiety, increased appetite and sleep, weight gain and comorbid eating disorders. Women may achieve higher plasma concentrations of antidepressants and thus may require lower dosages of these medications. Depending on the patient's age, the potential effects of antidepressants on a fetus or neonate may need to be considered. Research indicates no increased teratogenic risk from in utero exposure to selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. SSRIs are effective in treating premenstrual dysphoric disorder and many comorbid conditions associated with depression in women. Psychotherapy may be used alone in women with mild to moderate depression, or it may be used adjunctively with antidepressant drug therapy. Women who have severe depression accompanied by active suicidal thoughts or plans should usually be managed in conjunction with a psychiatrist.