Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717
Depression
 
Etiology Monitoring
Epidemiology Prognosis
Diagnosis Prevention
Treatment Patient Education
General Information

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Specific Conditions/Diseases

 
Etiology
No evidence is cited. 

Epidemiology
No evidence is cited. 

Diagnosis
Clinical Diagnosis
Two simple clinical questions:
  • "During the past month, have you often been bothered by feeling down, depressed or hopeless?" and 
  • "During the past month, have you often been bothered by little interest or pleasure in doing things?" 
are a sensitive and quick method of detecting patients with major depression. The major clinical value of this tool is to exclude depression. A positive response to one of these questions should not be considered diagnostic, but needs confirmation with a more thorough investigation of depressive symptoms. For major depressive disorder, at least five of the following symptoms are present during the same time period, and at least one of the first two symptoms must be present. In addition, symptoms must be present most of the day, nearly daily, for at least 2 weeks. 
  • Depressed mood most of the day, nearly every day. 
  • Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day (as indicated either by subjective account or observation by others of apathy most of the time). 
  • Significant weight loss/gain. 
  • Insomnia/hypersomnia. 
  • Psychomotor agitation/retardation. 
  • Fatigue (loss of energy). 
  • Feelings of worthlessness (guilt). 
  • Impaired concentration (indecisiveness). 
  • Recurrent thoughts of death or suicide.
Additional diagnostic guidelines for mania, medical causes and other depressive symptoms are included.  In primary care patients, depression is frequently associated with somatiform disorder, panic disorder, eating disorders and alcohol abuse. The PRIME-MD screening instrument has been shown to be both sensitive and specific for diagnosing these disorders, but requires clinican time to administer. A patient-administered variation of PRIME-MD, entitled the "Patient Health Questionnaire," has been shown to be equally effective at diagnosing these conditions, and requires less clinician time.  Laboratory/X-ray Diagnosis
Among patients with major depression, psychotic depression is the subtype that is most closely associated with nonsuppression of cortisol on the dexamethasone suppression test (DST). Melancholic depression was not significantly associated with nonsuppression. In nonmelancholic outpatients with major depression, the occurrence of nonsuppression was low.
Treatment
Antidepressant medications
Medications have been shown to be effective in all forms of major depressive disorder. Barring contraindications to these agents, antidepressant medications are first-line treatments for major depressive disorder when: 
  • The depression is moderate to severe. 
  • There are psychotic, melancholic, or atypical (overeating, oversleeping, weight gain) symptom features. 
  • The patient requests medication. 
  • Psychotherapy by a trained, competent psychotherapist is not available. 
  • The patient has shown a prior positive response to medication. 
  • Maintenance treatment is planned.
Absence of these indicators does not predict medication failure. However, when these indications are present, there is high likelihood of a beneficial response to medication. (Strength of Evidence = A.) Tricyclic antidepressants (amitriptyline; clomipramine; desipramine; imipramine; nortriptyline) are no more effective than placebo in the treatment of depression in children and adolescents. They should not be used as a first line of treatment in this target group.  Tricyclic antidepressant (TCAs) medications are very slightly less well tolerated than selective serotonin re-uptake inhibitors (SSRIs).  For the majority of patients, starting with TCA's while maintaining a willingness to change medications if side effects are problematical remains a viable option. There is no difference in clinical outcomes between fluoxetine, desipramine, and imipramine when used for mild to moderate depression in adults diagnosed by family physicians.  The total cost of care for patients receiving fluoxetine is comparable to those given the other medications. The increased incidence of side effects in the TCA treated patients did not affect quality of life scores.  The tricyclic antidepressant imipramine is as cost-effective as or more cost-effective than the serotonin-specific reuptake inhibitor paroxetine.  Patients with long standing dysthymia not meeting the diagnosis of major depression may benefit from a trial of antidepressant medication. Although sertraline and imipramine produced similar clinical improvement, the higher rate of discontinuation secondary to adverse events seen with imipramine in this trial may make sertraline a better choice for patients able to afford a more costly medication.  There is evidence that extracts of hypericum (St. John's Wort) are more effective than placebo, and as effective as maprotiline, imipramine or amitryptiline, for the treatment of mild and moderately severe depressive disorders.  The objective of continuation treatment is to decrease the likelihood of relapse (a return of the current episode of depression). If patients respond to acute phase medication, it is generally continued at the same dosage for 4 to 9 months after return to the clinically well state. (Strength of Evidence = A.)  Psychotherapy
The likelihood that adjunctive therapy is indicated may be better gauged once the depressive syndrome has largely resolved with medication, since medication alone improves psychosocial difficulties in many patients. (Strength of Evidence = B.) Electroconvulsive therapy (ECT)
The indications for ECT in the treatment of severe depression are a depressive episode in which symptoms are intense, prolonged, and associated with severe vegetative symptoms and/or a marked functional impairment, the presence of psychotic symptoms, or failure to respond fully to several adequate trials of medication. (Strength of Evidence = A.)
Monitoring
No evidence is cited.

Prognosis
No evidence is cited. 

Prevention
No evidence is cited. 

Patient Education
The following patient education materials are consistent with the available evidence.
 Rev. 9/4/00

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