Depression for USMLE Step 2 / COMLEX-USA Level 2
Major Depressive Disorder (MDD)
- Diagnostic Criteria:
- Presence of five or more symptoms during the same 2-week period, with at least one of the symptoms being either depressed mood or loss of interest or pleasure.
- Symptoms include significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, recurrent thoughts of death or suicide.
- Management:
- Pharmacotherapy: SSRIs are first-line. Other options include SNRIs, bupropion, and tricyclic antidepressants for more resistant cases. See this tutorial for a review of Antidepressants
- Psychotherapy: Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are effective.
- Combined Therapy: Often, a combination of medication and psychotherapy is most effective.
Dysthymia (Persistent Depressive Disorder)
- Features:
- Chronic depressive symptoms lasting at least two years.
- Less severe than major depression but more persistent.
- Treatment:
- Similar to MDD, often involving long-term treatment strategies.
Adjustment Disorder with Depressed Mood
- Diagnosis:
- Development of emotional or behavioral symptoms in response to an identifiable stressor, occurring within three months of the onset of the stressor.
- Symptoms are clinically significant as evidenced by marked distress or significant impairment in social, occupational, or other important areas of functioning.
- Management:
- Focus on short-term therapy and support, addressing the stressor directly.
Seasonal Affective Disorder (SAD)
- Clinical Presentation:
- Recurrent episodes of depression that typically occur during the fall or winter and remit in the spring.
- Treatment:
- Light therapy is the cornerstone of treatment.
- Supplemental treatment may include SSRIs or cognitive-behavioral therapy tailored for SAD.
Bipolar Disorder (Depressive Phase)
- Consideration:
- Differentiating between bipolar depression and MDD is crucial due to differences in treatment.
- Treatment:
- Mood stabilizers (e.g., lithium, valproate) and atypical antipsychotics are used. Use of antidepressants without mood stabilizers is avoided to prevent triggering manic episodes.
Treatment Considerations
- Medication Side Effects: Monitoring for side effects such as sexual dysfunction with SSRIs, hypertension with SNRIs, or sedation with mirtazapine.
- Suicide Risk Assessment: Always assess for the severity of suicidal ideation, plans, and means.
High-Yield Points for Step 2
- Clinical Diagnosis and Differential: Ability to diagnose based on DSM-5 criteria and differentiate from other mood disorders or medical conditions mimicking depression.
- Pharmacological Management: Understanding first-line treatments and tailoring therapy based on patient history and symptomatology.
- Psychotherapeutic Interventions: Knowing when to refer for psychotherapy and the types of therapies beneficial for different forms of depression.