Depression for the American Board of Internal Medicine (ABIM) Exam

Diagnostic Criteria:

• Presence of five or more of the following symptoms during a 2-week period, with at least one of the symptoms being either depressed mood or loss of interest or pleasure:
• Depressed mood most of the day, nearly every day.
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day.
• Significant weight loss when not dieting or weight gain, or decrease or increase in appetite.
• Insomnia or hypersomnia nearly every day.
• Psychomotor agitation or retardation nearly every day.
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt.
• Diminished ability to think or concentrate, or indecisiveness.
• Recurrent thoughts of death, suicidal ideation without a specific plan, or a suicide attempt.

See this tutorial for a review of Antidepressants Management:

• Pharmacological: SSRIs are first-line treatment options. Other options include SNRIs, bupropion, and tricyclic antidepressants. See this tutorial for a review of Antidepressants
• Psychotherapy: Cognitive Behavioral Therapy (CBT), Interpersonal Therapy (IPT), and other evidence-based psychotherapies.
• Lifestyle Modifications: Encouraging regular exercise, healthy diet, and adequate sleep.

• Characteristics:
• Depressed mood for most of the day, for more days than not, for at least two years.
• Presence of two (or more) of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness.
• Treatment:
• Similar to MDD, often requires long-term treatment strategies including medications and psychotherapy.

• Features:
• Emotional or behavioral symptoms in response to an identifiable stressor occurring within three months of the onset of the stressor.
• Symptoms are out of proportion to the severity of the stressor and cause significant impairment in social, occupational, or other important areas of functioning.
• Management:
• Often time-limited; treatment focuses on support, psychotherapy, and managing stress.

• Clinical Presentation:
• Recurrent episodes of depression that typically begin in late fall and winter and remit in the spring and summer.
• Treatment:
• Light therapy, SSRIs, and behavioral therapy.

• Common Comorbidities: Anxiety disorders, substance abuse, cardiovascular diseases.
• Management Considerations: Integrated approach to treat depression and comorbid conditions simultaneously, adjusting medications and monitoring interactions.

• SSRIs: Sexual dysfunction, gastrointestinal disturbances, and weight changes.
• SNRIs: Similar to SSRIs with additional risks of increased blood pressure.
• Atypical Antidepressants: May include drowsiness, weight gain, and metabolic changes.

• Elderly Patients: Increased sensitivity to side effects of medications, risk of drug interactions, and potential for exacerbation of comorbid medical conditions.
• Suicide Risk: Assessment and management of suicide risk are crucial, particularly at the start of treatment or during dosage adjustments.

• Diagnostic Criteria: Mastery of DSM-5 criteria for depression and differential diagnosis.
• Pharmacological Management: Understanding the indications, mechanisms, and side effects of antidepressants.
• Integration of Care: Coordinating mental and physical health care, especially in patients with multiple comorbidities.
• Ethical and Legal Issues: Managing issues related to consent, confidentiality, and treatment decisions in depressed patients.