Depression for USMLE Step 3 / COMLEX-USA Level 3
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Major Depressive Disorder (MDD)
- Diagnostic Criteria:
- Depressed mood or loss of interest/pleasure in daily activities for more than two weeks.
- Accompanied by additional symptoms such as significant weight change, sleep disturbances, fatigue, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, recurrent thoughts of death or suicidal ideation.
- Management:
- Pharmacological: SSRIs are first-line treatment. Alternatives include SNRIs, atypical antidepressants, and, for resistant cases, TCAs or MAOIs. See this tutorial for a review of Antidepressants
- Psychotherapy: Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are effective, especially in conjunction with pharmacotherapy.
- Continuity of Care: Regular follow-ups to monitor treatment response and adjust medications as needed.
- Management of Treatment-Resistant Depression: Consideration of adjunctive therapies, including atypical antipsychotics, ketamine, or electroconvulsive therapy (ECT).
Dysthymia (Persistent Depressive Disorder)
- Characteristics:
- Chronic depression that persists for at least two years in adults (one year in children and adolescents).
- Symptoms may be less severe than major depression but are more persistent.
- Treatment:
- Often requires long-term, sometimes lifelong, treatment including medications and psychotherapy.
Adjustment Disorder with Depressed Mood
- Features:
- Emotional and behavioral symptoms developing in response to an identifiable stressor and occurring within three months of the stressor.
- Management:
- Typically, symptoms resolve with time; however, short-term psychotherapy and occasionally antidepressants are used if symptoms are severe or persistent.
Seasonal Affective Disorder (SAD)
- Presentation:
- Episodes of depression occurring at a specific time of year, usually winter, when there is less natural sunlight.
- Treatment:
- Light therapy is the primary treatment.
- If additional intervention is needed, SSRIs or CBT are effective.
Bipolar Disorder (Depression Phase)
- Importance:
- Distinguishing between bipolar depression and MDD is critical as treatment differs significantly.
- Management:
- Mood stabilizers (e.g., lithium, valproate) and atypical antipsychotics. Antidepressants are used cautiously due to the risk of inducing mania.
Treatment Considerations for Complex Cases
- Integrated Care: Coordination with primary care providers and mental health specialists to manage comorbid conditions and optimize overall health.
- Chronic Management: Ongoing assessment of medication efficacy and side effects, potential for psychotherapy, and lifestyle modifications.
- Risk Management: Assessment of suicide risk and implementation of safety plans as needed.
High-Yield Points for Step 3
- Clinical Decision Making: Applying clinical guidelines to manage acute episodes and make long-term treatment plans.
- Interdisciplinary Approach: Utilizing a team-based approach to manage and coordinate care for complex psychiatric conditions.
- Ethical and Legal Considerations: Managing consent, confidentiality, and treatment decisions, especially in cases involving involuntary treatment or high-risk behaviors.