From the Guidelines
The medical workup of depression should begin with a comprehensive clinical assessment, including a detailed history, physical examination, and screening tools like the Patient Health Questionnaire-9 (PHQ-9) or Beck Depression Inventory, as recommended by the American College of Physicians 1. The initial evaluation aims to confirm the diagnosis of major depressive disorder (MDD) and rule out other medical conditions that can mimic depression.
- Key components of the clinical assessment include:
- Detailed psychiatric history
- Physical examination
- Screening for substance use and other psychiatric disorders
- Assessment of functional capacity and quality of life
- Laboratory tests should be guided by the clinical presentation and may include:
- Complete blood count
- Comprehensive metabolic panel
- Thyroid function tests (TSH, free T4)
- Vitamin B12, folate, and vitamin D levels
- Inflammatory markers (CRP, ESR) if indicated
- HbA1c for diabetes screening
- Urine drug screen if substance use is suspected
- Neuroimaging (MRI or CT) is generally not indicated unless there are neurological symptoms or signs, as the evidence does not support its routine use in the diagnosis of MDD 1.
- An electrocardiogram (ECG) may be necessary before starting certain antidepressants, particularly tricyclics, to assess cardiovascular risk.
- The workup should also include assessment for bipolar disorder, anxiety disorders, substance use disorders, and personality disorders, as these comorbidities affect treatment approach and prognosis.
- A thorough evaluation is essential because many medical conditions can present with depressive symptoms, including hypothyroidism, anemia, vitamin deficiencies, and neurological disorders, and identifying and addressing these underlying conditions can resolve depressive symptoms without psychiatric medication 1.
From the FDA Drug Label
14 CLINICAL STUDIES
The efficacy of bupropion in the treatment of major depressive disorder was established with the immediate-release formulation of bupropion hydrochloride in two 4-week, placebo-controlled trials in adult inpatients with MDD and in one 6-week, placebo-controlled trial in adult outpatients with MDD
The trial demonstrated the efficacy of bupropion as measured by the Hamilton Depression Rating Scale (HAMD) total score, the HAMD depressed mood item (item 1), and the Clinical Global Impressions-Severity Scale (CGI-S)
The medical work up of depression, as it pertains to the use of bupropion, involves assessing the patient's symptoms using various scales such as:
- Hamilton Depression Rating Scale (HAMD): to measure the severity of depressive symptoms
- Clinical Global Impressions-Severity Scale (CGI-S): to assess the severity of the patient's condition
- Montgomery-Asberg Depression Rating Scale (MADRS): to evaluate the severity of depressive symptoms
- Clinical Global Impressions-Improvement Scale (CGI-I): to assess the patient's improvement over time
These assessments are crucial in determining the efficacy of bupropion in treating major depressive disorder (MDD) 2.
From the Research
Medical Workup of Depression
The medical workup of depression involves a comprehensive evaluation of the patient's symptoms, medical history, and treatment options.
- The primary mechanism of action of selective serotonin reuptake inhibitors (SSRIs) is to inhibit presynaptic reuptake of serotonin at the serotonin transporter, subsequently increasing serotonin at the postsynaptic membrane in the serotonergic synapse 3.
- SSRIs are a group of structurally unrelated molecules that share a similar mechanism of action, but each has unique pharmacokinetics, pharmacodynamics, and side effect profiles 3, 4.
Treatment Options
Treatment options for depression include:
- Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, citalopram, escitalopram, paroxetine, sertraline, and fluvoxamine 3, 5, 6, 4, 7.
- The aim of treatment is to educate clinicians on potential adverse effects of SSRIs and to factor in the potential treatment effects, adverse effects, and dangers of the illness to be treated 3.
- Initiating treatment with SSRIs at doses higher than those typically used in clinical trials/settings is associated with higher response rates but also higher rates of discontinuation due to intolerance 5.
Dose-Response Effects
Dose-response effects of SSRIs for the treatment of depression include:
- Standard daily doses of SSRIs provide a favourable balance between efficacy, acceptability, and tolerability 7.
- Higher than standard daily doses are associated with higher dropout rates and a greater incidence of adverse drug effects, such as nausea, sexual dysfunction, fatigue, and anxiety 7.
- The majority of reviews indicate that individual SSRIs and SSRI class demonstrate flat dose-response effects, with standard doses being optimal for efficacy 7.