Depression for the American Board of Internal Medicine (ABIM) Exam
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Major Depressive Disorder (MDD)
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.
- 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.
Persistent Depressive Disorder (Dysthymia)
- 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.
Adjustment Disorder with Depressed Mood
- 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.
Seasonal Affective Disorder (SAD)
- 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.
Comorbid Conditions
- Common Comorbidities: Anxiety disorders, substance abuse, cardiovascular diseases.
- Management Considerations: Integrated approach to treat depression and comorbid conditions simultaneously, adjusting medications and monitoring interactions.
Medication Side Effects
- 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.
Special Considerations
- 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.
High-Yield Topics for ABIM Exam
- 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.