Michael Sean Stanley, MD Common Presentations in Primary Care: OHSU Department of [email protected] Anxiety OHSU Objectives

1) Understand the clinical presentation and approach to treatment of OHSUcommon psychiatric disorders. *Caveats

Psychiatric Diagnostics Which treatments are OHSUcan be frustrating. approved can be frustrating. Focus on big picture today, try FDA approved medications may not not to dwell on details. represent all medications with evidence for the treatment of psychiatric disorders. Common Presentations in Primary Care: Depression OHSU Test Yourself Which symptoms are most critical to the diagnosis of a ? OHSULow Motivation Suicidal Ideation Depressed Mood Test Yourself Which symptoms are most critical to the diagnosis of a major depressive episode? OHSULow Motivation Insomnia Suicidal Ideation Depressed Mood Case – Devon - Part 1 Major Depressive Disorder OHSU Case – Devon - Part 1 Major Depressive Disorder

25 yo female from Portland, in relationship with supportive partner, enjoys writing, running, going to new restaurants, currently in graduate school for MFA in creative writing. Family history notable for father with depression and hospitalizations, father attempted suicide when she was 17, but survived and has done well in treatment, and they are quite close. During period of heavy deadlines and crisis about whether to complete the MFA or try something “more practical” like law school, Devon experiences significant . After a number of weeks of feeling stressed, Devon experiences onset of more consistent sad mood, early morning waking, fatigue, and ruminative thoughts of being incapable. Over a few weeks, her symptoms begin to include more persistent decreased motivation for school or exercise, feeling slowed physically, decreased interest in OHSUeating although she is not malnourished, and fleeting thoughts that she would be better off not living, although she knows she could never do that to her family. Devon’s partner and father notice she is not her usual self, as they can’t seem to perk her up as they usually might, and begin to worry. Major Depressive Episode 2+ weeks of nearly every day… 5/9 of DSIGECAPS (must include one of *) Depressed Mood* Sleep Problems Interest Loss* Guilt/Worthlessness Energy Loss Concentration Problems Appetite/Weight changes /agitation OHSUSuicidal Ideation Causing functional impairment and not due to medical/substance cause. Appetite Change / Wt Change Sleep Change Psychomotor State Change Fatigue/Energy Loss Concentration Problems

(Illness Behavior)

Depressed Mood (sad, empty, hopeless) Decreased Interest/Pleasure OHSUSigns of limited drive resilience Guilt/Worthlessness Thoughts of Death / Suicide Turning on oneself Case – Devon – Part 2 Major Depressive Disorder

Devon, at the behest of her father and partner, see her father’s PCP, who asks Devon and her family what they’ve noticed recently, and gets a sense of Devon’s medical and history. The PCP has Devon complete a PHQ9 depression rating form (score 17 – mod-severe). Devon’s father also offers what has worked for his depression. Devon has never had a period of low mood so severe or persistent as this, although she has had some “disappointed times” in the past. She does not regularly drink or use drugs, and has generally been pretty healthy. She has not had hypo/manic episodes. She is a bit of a perfectionist, and can be self- critical, although it has not caused her problems in the past. The PCP orders labs to rule out medical contributors, discusses the diagnosis OHSUof Major Depressive Disorder, and discusses evidenced-supported interventions to treat MDD, including options such as cognitive-behavioral (CBT), SSRI medication, bright-, behavioral activation with moderate intensity exercise, avoidance of alcohol and drugs, and positive, strengths-focused social contacts with family and friends. 1 major depressive episode = major depressive disorder*

*unless: 1. Clear medical cause 2. Clear medication/substance use cause 3.OHSUHypomanic or manic episodes in past (=Bipolar DO) 4. sx more prominent (=Schizoaffective DO) Impacts of Major Depressive Disorder

Individual Impacts Family Impacts

Decreased Quality of Life Income Loss • Even up to 60% of remitted patients still have reduced QOL Increased days missed of work and decreased work performance Social Isolation Higher risk of developing chronic and neurodegenerative diseases Caregiver Burnout • CAD, DM, Parkinson’s, MCI, others Higher risk of worse outcomes with preexisting chronic and neurodegenerative diseases Familial Pessimism Higher all-cause mortality Increased Alcohol Abuse • 50-100% greater (ex 39% greater in cancer pts, 200% greater in DM females) Shorter life expectancy Divorce OHSU• 11-15 years shorter in males, 7-13 years shorter in females Higher incidence of suicide (27x greater in MDD than in Gen Pop) Decreased Bonding/attachment to children Higher risk of death to homicide (2.6x greater in MDD than in Gen Pop) Higher risk of death in accidents (2x greater in MDD than in Gen Pop) Impacts of Major Depressive Disorder OHSUFor 4 employers adapted from Loeppke RJ. Occup Environ Med, 2009. Major Depressive Disorder Brief Epidemiology: • Lifetime prevalence of MDD in US is 17% OHSU[2005] Major Depressive Disorder Course of illness over lifespan OHSU• First episode in teens-20s most often

Zisook S, et al. Effect of age at onset on the course of major depressive disorder. Am J Psychiatry. 2007 Oct;164(10):1539-46. Elevated Mood

18 yo Average Mood

2+ weeks 5/9 DSIGECAPS OHSUMDD How long to remission OHSU• Major depressive episodes may remit in <8 weeks, although median time to recovery is 20 weeks. Qaseem, et al. 2016. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians; Ann Intern Med. 2016;164(5):350-359. Major Depressive Disorder

1. Early episodes likely precipitated by life stressor 2. But after more episodes, subsequent episodes come more quickly and require OHSUless life stress to occur (accelerating susceptibility) Stressor Contribution to depression

SCORE HAS NO FACTOR IN WHETHER A STRESSOR CONTRIBUTES TO DEPRESSION.

Perceived lack of control over stressor or lack of support around stressor mediatesOHSU degree a stressor will lead to depression. Case – Devon – Part 3 Major Depressive Disorder

At her appointment with the PCP, Devon expresses concern about medications, as a friend close to her with a family history of severe mood disorders took fluoxetine and it caused her to not sleep for days and do risky things. She thus declines to start a medication at the current time, as she would like to try the non-pharmacological options first. She is not completely opposed to such medication in the future, as she knows they have helped her father in the past. The PCP writes a letter to support FMLA leave from her TA position, asks her to hold off on making big decisions about school for now, and OHSUpoints Devon to the Psychology Today Therapist Finder website that will help Devon find an in-network CBT therapist. They schedule to follow-up in 2 weeks to see how she is doing. Programmed Neuron- and Network-Level Stress Genetic Neurotransmitter- Changes OHSUResponse Level Changes Euthymia: Robust/Balanced/Responsive connections between critical parts: 1) GPS (Salience) 2) Gas/Brake (Central Executive) 3) Baseline Idle/Motor (Default Mode) OHSU Depression: Loss of balance and connections between critical parts: 1) Diminished GPS (Salience) – loss of response to external cues 2) Diminished Gas/Brake (Central Executive) – hard to make decisions 3) Increased Baseline Idle/Motor (Default Mode) - RUMINATION OHSU Case – Devon – Part 4 Major Depressive Disorder

2 weeks after the initial appt, Devon returns to the clinic for f/u. She has begun with her therapist, but her physical symptoms have not improved significantly so far. Devon agrees to start escitalopram, an SSRI available in generic form, to help assist her other treatments. She was cautioned that she may experience headache and stomach upset for the first few days, but was told it would likely remit, and was urged to continue the medication for at least a week. 4 weeks after the initial appt, Devon returns to the clinic for f/u. She reports that she is tolerating the medication, has noticed improvements in sleep and motivation, but doesn’t feel less depressed. She is recommended to continue her current treatments. 6 weeks after the initial appt, Devon returns to the clinic for f/u. She reports she no longer feels depressed mood, as if strong feelings “don’t stick anymore”, although she still maintains some residual feeling of being mildly slowed down, her appetite and concentration have not completely normalized, and she does not feel OHSUcompletely ready to return to school yet. PHQ9 is now 6. 12 weeks after the initial appt, Devon return to the clinic for f/u. She reports depression is in remission (PHQ9=1), she has returned to school with a slight change in perspective, which she realized was necessary through her psychotherapy. The PCP recommends remaining on the antidepressant medication for at least 12 months from the point of remission, at which time they can discuss possible trial taper of the medication. OHSU Mild Depression Moderate to Severe Depression Medications (see next slide) Monotherapy or Medications (see next slide) Monotherapy or Combined with therapy Combined Cognitive Behavioral Therapy Monotherapy or Cognitive Behavioral Therapy Adjunctive Combined with meds Interpersonal Therapy Monotherapy or Interpersonal Therapy Adjunctive Combined with meds Behavioral Activation Adjunctive Behavioral Activation Monotherapy or Combined with meds Exercise (30m mod intens 3x/wk) Adjunctive Exercise (30m mod intens Monotherapy or Light Therapy (am 30-60min qd) Adjunctive 3x/wk) Combined with meds/thx OHSUElectroconvulsive Therapy Monotherapy (*refractory, St. John’s Wort Monotherapy or suicidal, psychotic) Combined with therapy Transcranial Magnetic Stimulation Monotherapy (CANMAT Depression Guidelines, 2016) (*after 1 med failure) Medication SERT NET DAT M1 α1 H1 others

Citalopram +++ - - - + Norepinephrine Serotonin Escitalopram +++ - - - - Fluoxetine +++ + - + - - 5ht2c Amitriptyline Nortriptyline 2nd Gen APSX Paroxetine ++++ + - ++ - - Desipramine Paroxetine Imipramine Fluoxetine Sertraline ++++ + ++ + + - Mu-, k-opioid Venlafaxine Citalopram Venlafaxine ++ + Atomoxetine Escitalopram Duloxetine ++++ +++ + (ADHD tx) Duloxetine Sertraline Amitriptyline +++ ++ - ++ +++ ++++ Nortriptyline ++ +++ - ++ ++ +++

MAOIs Imipramine ++ ++ - ++ ++ +++ Desipramine + ++++ - ++ ++ ++

Trazodone + - - - ++ ++ 5ht2a Mirtazapine - - - + ++ ++++ 5ht2a & c Bupropion - ++ ++++ nicotinic OHSUMAOIs ↑↑ ↑↑ ↑↑ gaba 2nd Gen APSX ↑↑ ↓↓ var var var 5ht2a & c

Ki 0-1 = ++++ Ki 1-10 = +++ Ki 10-100 = ++ Ki 100-1000= + Dopamine Ki >1000 = - ↑↓ = Relative strength at neurotransmitter – not necessarily at receptor – not Ki FDA approved generic with good evidence for efficacy in Major Depressive Disorder

Medication Initial Dosing* Final Dosing* Anx Pain Sleep Other Benefits Interactions Adverse Effects Line** FDA aprvd

Citalopram 20mg qd 20-40mg qday x PMDD, OCD, PTSD - 1 x Escitalopram 10mg qd 10-20mg qday x PMDD, OCD, PTSD - 1 x Fluoxetine 20mg qam 20-80mg qday x PMDD, OCD, PTSD, Bulimia ++ 2d6, 2d19 + 1 x Paroxetine 20mg qd 20-50mg qday x PMDD, OCD, PTSD ++ 2d6 ++ 1 x Sertraline 50mg qd 50-200mg qday x PMDD, OCD, PTSD + 2d6 + 1 x Venlafaxine XR 37.5mg qd 75-225mg qday x x PMDD, OCD, PTSD ++, w/d 1 x Duloxetine 40mg qday 40-120mg qday x x + 2d6 +, w/d 1 x Amitriptyline 25mg qhs 50-150mg qhs or div x x x IBS, Migr ++ 2d6 +++ 2 x Nortriptyline 25mg qhs 75-150mg qhs or div x x x ++ 2d6 ++ 2 x Imipramine 25mg qhs 50-150mg qhs or div x x x ++ 2d6 +++ 2 x Desipramine 25mg qhs 100-200mg qhs or x x x ADHD ++ 2d6 ++ 2 x div Trazodone D: 150mg div D: 150-600mg div x x +, priap 2 x I: 50mg qhs I: 50-300mg qhs MirtazapineOHSU15mg qhs 15-45mg qhs x x PTSD ++ 1 x Bupropion XL 150mg qam 150-450mg qam ADHD, SAD, NicotineUD + 2d6 +, NO SEX Dysfxn 1 x MAOIs Several several x +++ +++, tyramine rxn 3 x

*Stahl’s Essential Psychopharmacology, Prescriber’s Guide, 5th Edition, 2014 **Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder Recommended Steps for Primary Care Pharmacotherapy for Major Depressive Disorder

Medication Med Step When Use Is Preferred

Escitalopram A Anxiety, PMDD, OCD, PTSD, elderly with complicated medical probs Sertraline B If Escitalopram doesn’t work, partial efficacy, or mild AEs, but no reasons to do below Venlafaxine ER B (*A) *If chronic pain comorbid, can try as step A Mirtazapine B (*A) *If insomnia, failure to thrive are prominent, can try as step A Bupropion XL B (*A) *If prominent lethargy, amotivation, psychomotor slowing, clearly established comorbid ADHD or SAD, or Nicotine Use Disorder (that patient desires to treat) are present, can try OHSUas step A

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder Antidepressant Pharmacotherapy in Primary Care Setting

Ketamine Aerobic Exercise

Norepinephrine Serotonin Chronic Dz Mgmt Glutamate

Dopamine Brain Derived Neurotrophic Factor  Inflammatory Factors

? OHSU? + Neurotrophism • Neuronal preservation Electro-convulsive • Synaptogenesis Electro-convulsive therapy (ECT) therapy (ECT) Case – Devon – Part 5 Major Depressive Disorder

13 years after her first episode of Major Depressive Disorder, Devon returns to the PCP with concern about depression. She is married, has two children, has been successful as a freelance writer and works with Write Around Portland which seeks to help persons from marginalized communities tell their life experiences through writing. She has been off of antidepressants for the last 12 years, having successfully slowly tapered off of her SSRI a year after her initial episode of depression. She has continued psychotherapy intermittently over the last decade, and has found it immensely supportive and helpful. She is returning now because her father, now in his early 70s, has been hospitalized for a prolonged severe depressive episode, and she OHSUfinds herself more stressed, waking early, and beginning to ruminate again on her familial depression despite continuing therapy, exercise, and good sleep hygiene for the last few weeks. She is concerned she may be slipping into another depressive episode. She requests to restart the SSRI medication she took in the past. Devon’s Friends (other common mood presentations)

Adam OHSULaurence Pressly Case – Adam Major Depressive Disorder – Depression with Atypical Features OHSU Case – Adam Major Depressive Disorder – Depression with Atypical Features

• 24 yo male, grew up in Portland, now living in Bend, unmarried, works for environmental non-profit. Self-identified introvert. Has a small group of good friends, one of whom is Devon’s partner. He enjoys reading and being in the outdoors with friends. • Family history of depression. No alcohol use, very rare cannabis <1x month. Periods of anxiety in the past, but has adapted his life to his anxiety. • Financial pressures at work, and possible implications for the non-profit. • Over course of a few weeks notices symptoms of decreased motivation, decreased energy, excessive eating (has gained 10 pounds in last month), sleeping 14 hours a day, at times feels “leaden” paralysis, where he feels he almost can’t move at all, concentration problems. OHSU• Reports to PCP with concern he has a medical condition. Doesn’t think it could be depression, because he can get excited for brief periods of time, for instance when a friend invited him to a ski movie screening. That said, he described feeling “rejected”, when the friend had to go home early, and soon after went back to his state of dysfunction. Case – Adam Major Depressive Disorder – Depression with Atypical Features

Symptom Atypical Depression Mood Unreactive Briefly reactive, sensitive to rejection Motivation/Interest Low Low Appetite Decreased Increased /Anxiety Slowed – leaden Energy Low Low Sleep Decreased (Insomnia) Increased () Guilt or Hope/Helplessness Present Present Concentration Low Low OHSUSuicidality May be Present May be Present Treatment (see prior discussion) MOAI antidepressants*

*Monoamine Oxidase Inhibitors – require washout of other antidepressants, and can cause hypertensive reaction when combined with other medications (antidepressants, opioids, decongestants, drugs of abuse), or fermented foods. Case – Adam Major Depressive Disorder – Depression with Atypical Features

• Adam’s PCP correctly recognized the possibility for depression, and recognized atypical features, and got labs to rule out other potential causes of depression. • They discussed treatments including Monoamine Oxidase Inhibitor antidepressants. But Adam was concerned about having to give up blue cheese to avoid the tyramine reaction, and ultimately elected to have a trial of sertraline, an SSRI, instead. • At 2 week follow-up, Adam reported stomach upset, , and no benefit for depression. He and PCP again discussed MAOI, but he again declined, and elected change to venlafaxine, an SNRI. • At 4 week follow-up, Adam reported headache, ongoing erectile dysfunction, more irritability, and still no benefit for depression. He and PCP again discussed MAOI, looked at actual recommendations re: tyramine diet, and realized he could actually have small amounts of blue cheese and cured meats while taking the medication, just needed to be cautious. Also discussed medications to avoid. He elected to start OHSUphenelzine, an MAOI, although was a little bummed he had to wait two weeks off of all antidepressants to start it. • At 8 week follow-up Adam was actually already feeling significant better, with less anxiety, more motivation, no more “leaden paralysis”. He was now actively working with his employer to find solutions to their financial challenges. Case – Laurence Major Depressive Disorder – Depression with Late Onset OHSU Case – Laurence Major Depressive Disorder – Depression with Late Onset

• 81 year old male, emeritus faculty in English at Portland college, widowed 3 years prior, after marriage of 49 years, has 3 children with whom he has good relationships and sees often. Was one of Devon’s graduate mentors. • No family history of depression, but significant family history of cardiovascular problems – father had strokes in 70s, brother died of MI at 68. • History of hypertension and hyperlipidemia, was a cigarette smoker for 20 years until his kids were at an impressionable age. Has enjoyed scotch in the past, but his family has never known him to overindulge, and currently drinks only rarely. • One of his daughters notices over the course of a few months that he seems to be more commonly dressed in his night clothes when she comes to visit during the day, that he doesn’t seem to be caring for himself or the family home as fastidiously as he was 6 months ago. At times he appears to take a longer time to respond to her in conversation. And most sadly, he seems to have lost the jovial, jocular character she’s OHSUalways known him to have. • She is worried about him, stays with him for a day or two, gets an urgent appointment with his PCP and takes him to the appointment where she expresses concern about her father. Laurence says “maybe I haven’t felt myself”, but denies gross sadness or suicidal thoughts. Case – Laurence Major Depressive Disorder – Depression with Late Onset OHSU Case – Laurence Major Depressive Disorder – Depression with Late Onset

• Laurence’s PCP checks labs, does a thorough physical and neurologic exam, which yields no causes or focal signs, although his blood pressure is mildly elevated. The PCP does a cognitive exam, showing slowed processing speed and problems with short term recall. • The PCP realizes that while Laurence has some signs of cognitive decline, he also has many signs of major depression – low energy, motivation, sleep changes, decline in appetite, change in affect - although he has never had this before. They discuss this possibility of geriatric “late-onset” depression, and decide to trial an SSRI, escitalopram, while Laurence waits to have an evaluation with a neurologist in the practice. • At 4 week follow-up, Laurence is improved in some ways (more animated affect, improved appetite and energy), although at repeat cognitive testing, he has continued to have some mild memory challenges, but seems to be more able to care for his OHSUbasic needs. • At 8 week follow-up, he continues to have cognitive challenges, but his mood is effectively back to normal. The family has made arrangements for Laurence to move in with one of the families, as they hope to help increase his stimulus and care without having him move to assisted living. Case – Pressly Premenstrual Dysphoric Disorder OHSU Case – Pressly Premenstrual Dysphoric Disorder

• Pressly is a 22 year old female, originally from California, currently living in Portland, going to college for architecture and design, where she has been honored for her work. Knows Devon from the gym they go to. • She is in solid relationship with a male partner, and she and her partner are experimenting with living together, and have been thinking about marriage and having a family. • She is generally healthy, rides her bike to school most days, avoids substances. • She has good friends, good relationships with her siblings, although strained relationship with her mother who she has butted heads with since her teens, and she often describes as “controlling” and “from the old country”. • She has no personal or family history of mental health disorders. OHSU• She is on no medications, having gone off OCPs about 3 months prior. She had been on the OCP regimen since age 17, and went off to “be more natural”. Case – Pressly Premenstrual Dysphoric Disorder • Pressly presents to the PCP at the student health center, reporting significant depression. • She reports that in the last few months of living with her partner, some relationship challenges have come up, and her partner has expressed concern that Pressly may “be Bipolar”, as Pressly’s mood, thoughts, and character seem to change so drastically for periods of time. • Pressly presents with a significantly labile mood, breaking into tears several times during the appointment, even at incongruous moments, discusses difficulties with her relationship and completing school work at certain times, and how sad and anxious it makes her feel that she can’t be a better partner or student. She talks about how difficult it is to figure out what to do to make things better. • Pressly denies psychosis, decreased need for sleep, grandiose or paranoid OHSUthoughts, risky behaviors, denies suicidal thoughts. She doesn’t exhibit pressured speech, flight of ideas, or agitation. • The PCP cannot be sure, but lets Pressly know she doesn’t likely have , states she thinks she most likely has major depression, and they agree to try sertraline, an SSRI, for her mood symptoms. Case – Pressly Premenstrual Dysphoric Disorder • At 1 week follow-up Pressly reports how “amazing” the medication worked, as her symptoms got much better within 2 days of taking the medication, and then resolved completely after 5 days. • The particularly savvy PCP knew SSRIs rarely work that quickly for Major Depressive Disorder, and asked whether the resolution of her symptoms coincided at all with menstrual changes. • Pressly reported that actually she began menstruation around the time the medication started working. • They discuss Pressly’s menstrual history, which did include particularly significant mood symptoms when she was a teen. Those sx resolved when started on OCPs at Planned Parenthood, which friends had recommended trying. They wonder together whether her symptoms might better be described by Premenstrual OHSUDysphoric Disorder. • They agree for Pressly to talk to her partner about when they first started noticing the symptoms getting worse, and for Pressly to track her menstrual and mood cycles to see if there is correlation. • They do decide to stay on the sertraline for the time being. Case – Pressly Premenstrual Dysphoric Disorder OHSU

https://womensmentalhealth.org/specialty-clinics/pms-and-pmdd/the-etiology-of-pmdd/ Case – Pressly Premenstrual Dysphoric Disorder

Has at least 5 of the following sx (must ! !!! !! include at least one from each pool) during final week before onset of meses;

• Decreased Interest in usual activities • Marked Affective Lability • Subjective difficulty in concentration • Marked irritability or anger • Lethargy/lack of energy • • Marked depressed mood or self- Marked change in appetite, overeating • Sleep changes deprecating thoughts • Sense of being overwhelemed or out of control • Marked anxiety or tension • Physical sx such as breast tenderness or swelling, joint or muscle pain, bloating, or wt gain.

Sx start to improve within a few days after the OHSUonset of menses, and become minimal or absent in the week postmenses.

• This process should be confirmed over at least two symptomatic cycles • Sx should be associated with clinically significant distress or functional impairment Case – Pressly Premenstrual Dysphoric Disorder OHSU

Am Fam Physician. 2016 Aug 1;94(3):236-240 Case – Pressly Premenstrual Dysphoric Disorder

• Pressly reports back to PCP three months later that she has noticed that her mood and anxiety do get much worse in the week prior to menstruation and resolve quickly afterwards. • They decided to change how she is using the sertraline and agree to have her take it just during last week of her cycle. • Pressly tries this, but has difficulty remembering to take the medication at the right times and suffers a few months when PMDD symptoms cause problems. • PCP recommends simply taking the sertraline daily, which is helpful in reducing PMDD, but causes significant libido problems in the weeks when she really doesn’t need to take it, which she would like to avoid. • PCP recommends a cycle tracking app, which reminds Pressly to take her sertraline for 10 days, starting at the approximate start date of her last cycle week. • This system works well throughout the remainder of school. OHSU• Pressly and her partner marry at the end of grad school, conceive, at which time Pressly quickly stops taking her sertraline without significant recurrence of mood sx during pregnancy. The couple move back to California to live closer to family when the baby comes. • The office receives a call for records on prior mental health medications when Pressly experiences . Test Yourself Again

1) Based on evidence, in what situation should PCPs more strongly recommend antidepressant pharmacotherapy over Cognitive-Behavioral Therapy? Moderate to Severe Major Depressive Episode 2) Cardiovascular risk factors are more predictive of which type of depression? Major Depression with Late Onset 3) How does the course of mood symptoms in PMDD differ from those in MDD? PMDD: Brief ~7-10 day course, starting in last week of cycle, ending abruptly around menstruation. MDD: 2+ weeks, slower onset, gradual recovery. OHSU4) Why are the following symptoms - mood is briefly reactive to positive stimuli, hyperphagia, hypersomnia, periods of “leaden paralysis” - important to recognize in a patient with depression? indicate likely Major Depression with Atypical Features  MAOI antidepressant a good choice. Common Presentations in Primary Care: Depression Summary

Major Depressive Disorder • of 2+ weeks of low mood or low motivation + other vegetative sx • Can cause profound life disruption • Treatment based on symptoms and severity • Mild depression  Antidepressant or CBT • Mod to Severe depression  Antidepressants first, then CBT • Refractory depression or w psychotic features  ECT • Depression with “atypical features” – wt gain, hypersomnia, reactive mood  MAOIs • Depression with late onset • Associated more with vascular risk factors OHSU• Less likely to resolve completely Premenstrual Dysphoric Disorder • Brief, recurrent, severe mood and physical sx – causing severe distress or dysfunction • occurring solely during last week of menstrual cycle with rapid resolution in first few days after menstruation OHSU