uestion: The patient is depressed and pharmacotherapy is indicated. You have ruled out medical causes of this depression, or treated the possible medical causes and the symptoms remain. This patient meets DSM-IV criteria for:

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IMPORTANT COMMENTS: THIS ENTIRE ALGORITHM REQUIRES THAT USERS EMPLOY CRITERIA-BASED DSM-IV DIAGNOSES FOR DEPRESSIVE DISORDERS AND ASSOCIATED COMORBID CONDITIONS. THE RECOMMENDATIONS RELATE TO THESE DIAGNOSES ONLY. SIGNIFICANT INACCURACIES WILL OCCUR IF THE DIAGNOSIS IS INCORRECT. Although the validity of the DSM diagnostic categories has not been established, the categories possess high utility because of the quantity and quality of the scientific literature that has accumulated regarding treatment response, course, and related information regarding these categories.² Clinicians intent on applying evidence-based medicine principles to their clinical decision-making must start by making a diagnosis utilizing these criteria. Rival definitions of a disorder (e.g. from ICD-10) may be used if research has shown that the definition describes an almost identical population, or if there is independent research regarding the course/outcome with the other definition.

If you are unsure about which DSM-IV diagnosis best describes the patient, follow the algorithm answering the questions appropriately for each possible diagnosis. You will receive recommendations for treatment. Compare the recommendations for each diagnostic possibility. There may be a treatment option that covers both diagnoses. This might be the treatment of choice that "covers" the diagnostic ambiguity.

The presence of a general medical condition or history of a substance abuse problem comorbid with and secondary to the depression would not preclude following the treatment guidelines of this algorithm. The general medical condition or substance abuse problem should usually receive specific treatment first, however.³ Generally, the patient should be abstinent from substances for a minimum of one week.² Occasionally, it may be helpful to use pharmacotherapy for depression even while the substance abuse continues in an active phase (eg - in alcoholism (4)).

Considerations that go into choosing pharmacotherapy and other treatments for depression in the elderly are essentially the same as for younger patients.(5) Lower doses of the agents selected are usually required, and sensitivity to particular side effects may be greater or vary with the individual. The medical differential diagnosis should be pursued with the usual or greater scrupulousness. The diagnostic criteria according to DSM-IV are the same, but the elderly typically display more vegetative signs and cognitive disturbance than younger patients.

References for this Help section:

¹Subsyndromal Depressive Syndrome, or Depression NOS in DSM-4, is a major public health problem that produces significant functional impairment. See Judd LL. Socioeconomic burden of subsyndromal depressive syndrome and major depression in a sample of the general population. Am J Psychiatry 1996;153:1411-1417.

²Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003;160:4-12.

³ American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000: 157:4 Supplement, p. 15-18.

(4)Mason BJ, Kocsis JH, Ritvo EC, Cutler RB. A double-blind, placebo-controlled trial of desipramine for primary alcohol dependency stratified in the presence or absence of major depression. JAMA March 13, 1996;275(10):761-767.

(5)Roy-Byrne PP, Pages KP, Russo JE, et al. Nefazodone treatment of major depression in alcohol-dependent patients: a double-blind, placebo-controlled trial. J Clin Psychopharmacol 2000;20:129-136.