Medical Pharmacology: Drugs Used to Manage Depression

Differential Diagnosis II:¹⁰⁵

Major endogenous depression vs. Bipolar disorder:¹⁰⁵

A diagnosis and appropriate management of depression depends on identifying and possibly ruling out other mental disorders which present symptoms comparable to depression.
- With multiple disorders, i.e. psychiatric comorbidity, effective management of depression may be associated with improvement in the other disorder.
  - The presence of the secondary disorder may itself require modification of the management approach.

**"Personal Reflections on Manic-Depressive Illness"¹⁰⁶**

Attribution: Jamison K "Personal Reflections on Manic-Depressive Illness," https://www.youtube.com/watch?v=CxRLap9xLag ResearchChannel YouTube Channel: https://www.youtube.com/channel/UCMi6tHz2CmTA6IRaKr3ppRQ

Distinguishing between bipolar depression and major endogenous depression is an important differential diagnostic issue.¹⁰⁵
- Clinical signs and symptoms of these two disorders appear the same; however, the differential depends on the answer to one question.
  - That question is whether or not the patient previously experienced clinical mania or hypomania.¹⁰⁵
    - Common presentations of a manic episode include:
      - Elated or irritable mood
      - Poor judgment in interpersonal circumstances, sexual circumstances or financial situations
      - Racing thoughts, and
      - Excessive energy.
  - Hypomania present similarly but with less intensity than is typically not disruptive of normal activities.¹⁰⁵
    - Elucidation of mania or hypomania history of may require asking questions concerning personal or family history of mania/hypomania/bipolar disorder and specifically inquiring of the patient whether racing thoughts, reduced need for sleep, notably high-energy or unusually poor judgment have been experienced.
    - These presentations would have to be judged out of character relative to usual behavior.

Depression and Anxiety¹⁰⁵
- Anxiety may frequently co-occur with depression. If anxiety is primary, depression may be present and in those cases in which the anxiety disorder appears dominant, a depressive component may also be present.
  - In the outpatient setting common anxiety disorders include:
    - Posttraumatic stress disorder (PTSD)
    - Generalized anxiety disorder (GAD)
    - Panic disorder (PD), and
    - Obsessive-compulsive disorder (OCD).
  - In generalized anxiety disorder as well as in the other presentations, the anxiety may prove disabling. Management of major depression by medication may also alleviate anxiety symptoms.
Depression in association with somatoform disorders¹⁰⁵
- Depression may present with somatic complaints and such somatoform disorders may provide a diagnostic challenge, differentiating between depressive disorder and the somatic, unexplained medical symptom.
  - Somatoform disorders appear more difficult to treat, compared to depression.
    - With respect to medical management, depression is often treated aggressively; whereas, somatoform illness may be more appropriately managed in a conservative way.
    - Unexplained somatic complaints may be associated with depression about half the time.
    - Effective management of major depression in these patients typically ameliorates the somatoform presentation.
Depression and substance abuse¹⁰⁵
- Individuals exhibiting alcohol dependence as well as dependence on other substances may also present with endogenous depression. In the diagnostic process, patients are evaluated for substance use/abuse disorders.
- With continuing substance use, management of major depression must be approached with caution. However, effective management of major depression may alleviate an alcohol problem.
Depression and dementia¹⁰⁵
- Dementia, presenting in early stages, may be difficult to separate from a presentation of depression.
  - Reversible cognitive impairment may accompany depression, since depression itself may be associated with memory difficulties, difficulties in decision-making, reduced concentration, difficulty planning and organizing and difficulty in initiation of tasks.
  - With effective management of depression, these presentations may resolve.
    - However, if these presentations were associated principally with dementia, progression is more likely.
    - Given at least an early diagnostic uncertainty, treatment of depression, using both counseling and antidepressant medication, may be appropriate with con current and continuing evaluation of cognitive symptoms.
- Microvascular cerebrovascular ischemia may result in a late-onset depression.
  - Symptoms of vascular depression may include mild-to-moderate cognitive deficits especially in certain memory tasks which require attention and concentration in addition to diminished executive function.
  - This type of late-onset vascular depression is more resistant to contemporary antidepressant medications.

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