Module: Pharmacotherapy III Module Coordinator: Dr. Arwa M. Amin Mostafa Academic Level: Postgraduate, Master of Pharmacy in Clinical Pharmacy School: Dubai Pharmacy College Year of first presented in Class: 2018 This presentation is for Educational purpose. It has no commercial value associated with it.

1. MAJOR DEPRESSIVE
DISORDER
ARWA M. AMIN MOSTAFA
Phd, M.Pharm Clinical Pharm, Dip. Management, BSc. Pharmacy

2. ARWA M. AMIN
WHAT WE ARE GOING TO DISCUSS TODAY?
• WHAT IS DEPRESSION?
• WHAT IS MAJOR DEPRESSIVE DISORDER (MDD)?
• WHAT IS THE ETIOLOGY OF MDD?
• WHAT ARE THE RISK FACTORS OF DEVELOPING MDD?
• WHAT IS THE PATHOPHYSIOLOGY OF MDD?
• HOW TO DIAGNOSE MDD?
• WHAT ARE THE GOALS OF MDD THERAPY?
• WHAT ARE THE NON-PHARMACOLOGICAL TREATMENT OF MDD?
• WHAT ARE THE PHARMACOLOGICAL TREATMENT OF MDD?
• HOW TO EVALUATE MDD THERAPY?

3. ARWA M. AMIN
DEPRESSION
• Depression is a mood disorder characterized by sadness,
hopeless and empty feeling.
• Depression may happen temporary in everyone’s life due to
stressful events such as loss of loved one or ending of
emotional relationship.
• Depression can happen as a side-effect of drug or due to
medical condition such as thyroid disorder.

4. ARWA M. AMIN
TYPES OF DEPRESSION
• Types of Depression:
• Major Depressive Disorder
• Clinical Depression (Severe Depression)
• Dysthymia (Mild Depression)
• Postpartum Depression
• 2 weeks to 6 months postpartum
• Bipolar Depression
• Patients with periods of Depression and Mania
• Seasonal Affective Disorder
• e.g. Seasonal/Winter Depression

5. ARWA M. AMIN
MAJOR DEPRESSIVE DISORDER (MDD)
• Major Depressive Disorder (MDD) or Clinical
Depression is a severe type of depression which
is characterized by persistent sadness,
hopelessness and loss of interest in activities.
• MDD has severe symptoms which mostly lead to
a significant impairment in daily life.

6. ARWA M. AMIN
ETIOLOGY OF MDD
• Major depressive disorder can happen due to unknown
cause
• Genetic factors
• Biological factors
• Hormonal Changes
• Environmental factors
• Emotional Trauma
• Lifestyle
• Concomitant Diseases
• Drug or Alcohol Intoxication
• Endogenous Biochemical Factors

7. ARWA M. AMIN
RISK FACTORS OF MDD
• Age:
• ↑↑ risk of MDD in 18 – 29 years old
• Common during Adolescence
• Associated with substance abuse and suicide attempts
• Sex: Women > Men
• Family History
• MDD & Suicide tend to occur within families
• Genetic Predisposition
• Gut microbiota Disturbances
• Autoimmune Disorders
• SLE
SLE: Systemic Lupus Erythematosus

8. ARWA M. AMIN
RISK FACTORS OF MDD
• Endocrinological factors
• Hypothyroidism
• Cushing’s Syndrome
• Poor Diabetes Management
• Neurodegenerative diseases
• AD & PD
• Cancer
• Hormonal Changes
• Post-Partum Depression
• Use of certain Medications
• E.g. Anticonvulsant, Antihypertensive, oral contraceptives, isotretinoin, interferon-
β1a. AD: Alzheimer Disease, PD: Parkinson’s disease

9. ARWA M. AMIN
RISK FACTORS OF MDD
• Un-healed Emotional Trauma or stressful event
• Post-traumatic stress disorder
• Death of loved ones
• Tragedies: Natural Calamities, Accidents, Rape, War, Kidnapping, Abuse
• Relationships Ending: Abandonment Grief, friendship ending, Divorce
• Changing Job or Financial Crises
• Drug Intoxication, Drug addiction
• It can also worsen depression symptoms
• Alcohol Intoxication
• It can also worsen depression symptoms
• Unhealthy Diet:
• Processed food, refined sugars

10. ARWA M. AMIN
Pathophysiology of MDD
• BIOGENIC-AMINE HYPOTHESIS
• POSTSYNAPTIC MONOAMINE RECEPTOR HYPOTHESIS
• DYSREGULATION HYPOTHESIS
• 5-HT/NOREPINEPHRINE LINK HYPOTHESIS
• THE ROLE OF DOPAMINE HYPOTHESIS
• NEUROTROPHIC FACTOR EXPRESSION

11. ARWA M. AMIN
Pathophysiology of MDD: Biogenic-amine Hypothesis
Biogenic-amine Hypothesis or Monoamine Theory
Reduction of monoamine Neurotransmitters levels in the brain may cause Depression
Norepinephrine (NE)
Serotonin 5-HT
Dopamine
Depression
Genetics
Environmental
factors
Lifestyle
Unknown
factors
Figure Source: http://www.completehealthdallas.com/Anti-DepressantsNaturalAlternativeDallas.html

12. ARWA M. AMIN
↑↑ Receptor Sensitivity to
Norepinephrine (NE)
↑↑ Receptor Sensitivity to
Serotonin 5-HT
Depression
Pathophysiology of MDD: Postsynaptic Monoamine Receptor Hypothesis
Postsynaptic Monoamine Receptor Hypothesis
•↑↑ Sensitivity to Monoamine
Neurotransmitters and Up-Regulation of
Postsynaptic receptors → Depression and
Suicides
•Desensitization or downregulation of
Norepinephrine or 5-HT1A receptors may
relate to onset of antidepressant effects
and tolerance to side-effect.Figure Source: https://basicmedicalkey.com/antidepressants-5/

13. ARWA M. AMIN
Norepinephrine (NE)
Serotonin 5-HT
Dopamine
Depression
Pathophysiology of MDD: Neurotransmitter Dysregulation Hypothesis
Neurotransmitter Dysregulation Hypothesis
• Failure of Homeostatic regulation of Neurotransmitter Systems.
• Effective Antidepressants may restore Efficient Regulation.
Homeostatic
Failure
Dysregulation

14. ARWA M. AMIN
Pathophysiology of MDD: 5-HT/Norepinephrine link Hypothesis
5-HT/Norepinephrine link Hypothesis
• 5-HT and Norepinephrine activities are
linked
• 5-HT and Norepinephrine play critical
role in pain perception
• Both the Serotonergic and
Noradrenergic systems are involved in
the antidepressant response.
Norepinephrine (NE)
Serotonin 5-HT
Descending
Modulatory pathways
Depression
e.g. Chronic
Pain Depression
Dysfunction
Or Modulation
Figure Source: Descending monoaminergic pain modulation Bidirectional control and clinical relevance, Descending
monoaminergic pain modulation Bidirectional control and clinical relevance http://n.neurology.org/content/71/3/217
http://n.neurology.org/content/71/3/217

15. ARWA M. AMIN
Pathophysiology of MDD: The Role of Dopamine Hypothesis
Dopaminergic
activity in the
Mesolimbic pathway
Depression
The Role of Dopamine Hypothesis
• Dysfunction of the Mesolimbic Dopamine
Pathway may cause Depression
• Depression may involve Hypoactivity of D1
receptor
• ↑↑ dopamine activity in the mesolimbic
pathway contributes to Antidepressant activity
Ac, nucleus accumbens;Am, amygdaloid nucleus;C, cerebellum;Hip, hippocampus;Hyp, hypothalamus;
LC, locus coeruleus;P, pituitary gland;SN, substantia nigra;Sep, septum;
Str, corpus striatum;VTA, ventral tegmental area.
Figure Source: http://slideplayer.com/slide/7321807/#

16. ARWA M. AMIN
Pathophysiology of MDD: Disruption of Neurotrophic factor Expression
• Disruption of Brain Derived Neurotrophic Factor (BDNF) expression in the
Hippocampus may be associated with depression
• BDNF is critical for Neurogenesis and neuronal plasticity
• Disruption in BDNF expression, caused by Epigenetic regulation processes,
stress, and/or reduced neuronal activity
Figure Source: http://austinpublishinggroup.com/pharmacology-therapeutics/fulltext/ajpt-v2-id1006.php

17. ARWA M. AMIN
Pathophysiology of MDD
The science of Depression
https://www.youtube.com/watch?v=GOK1tKFFIQI
https://www.youtube.com/watch?v=8SfOOsPwwsA

18. ARWA M. AMIN
CLINICAL PRESENTATION OF MDD
MDD Symptoms
Emotional Symptoms
• ↓↓ Ability to
experience
pleasure
• Sadness
• Crying
• Pessimism
• Anxiety
• Hopelessness
• Guilt
• Loss of interest in
usual activities
Cognitive Symptoms
• ↓↓ Ability to Concentrate
• Slowed thinking
• Poor memory for recent
events
• Confusion
• IndecisivenessPhysical Symptoms
• Fatigue
• Headache
• Pain
• Sleep disturbance
• ↓↑ Appetite
• Loss of sexual interest
• GI & CV Complaints
(palpitation)
Psychomotor Disturbances
• Psychomotor retardation
(Slowed Physical movement,
thought process and speech)
• Psychomotor Agitation

19. ARWA M. AMIN
MDD DIAGNOSIS
• MDD is diagnosed by the criteria of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) set by the American Psychiatric
Association.
• Family History
• Clinical examination
• Mental Status Examination
• Past Medical history
• Complete Medication Review(to rule out side-effect of drug)

20. ARWA M. AMIN
MDD DIAGNOSIS- DSM-5 CRITERIA
DSM-5 Criteria
Depressed Mood (Subjective or Observed)1
Loss of Interest or pleasure2
Change in weight or appetite3
Insomnia or Hypersomnia4
Psychomotor Retardation or Agitation (Observed)5
Loss of Energy or Fatigue6
Worthlessness or guilt7
Impaired concentration or indecisiveness8
Thoughts of death or suicidal ideation or suicide
attempts
9
DSM-5 criteria requires 5 or
more out of 9 signs and
symptoms in the same 2
weeks period (at least one of
the Depressed Mood or loss
of interest or pleasure).
Each of these symptoms
represents a change from
previous functioning
DSM-5: Diagnostic and Statistical Manual of Mental Disorders

21. ARWA M. AMIN
MDD DIAGNOSIS- DSM-5 CRITERIA
DSM-5 Criteria
Depressed Mood (Subjective or Observed)1
Loss of Interest or pleasure2
Change in weight or appetite3
Insomnia or Hypersomnia4
Psychomotor Retardation or Agitation (Observed)5
Loss of Energy or Fatigue6
Worthlessness or guilt7
Impaired concentration or indecisiveness8
Thoughts of death or suicidal ideation or suicide
attempts
9
• The symptoms cause
clinically significant
distress or impairment in
social, occupational, or
other important areas
of functioning.
• The episode is not
attributable to the
physiological effects of
a substance or to
another medical
condition.
DSM-5: Diagnostic and Statistical Manual of Mental Disorders

22. ARWA M. AMIN
SUICIDE AND DEPRESSION
SUCIDE is common in untreated MDD patients
Risk Factors of Suicide:
• Non-Religious > Religious
• Rich
• White > Black
• Relationships
• Single/divorced/widowed
• Age
• Teens and Elderly
• Suicide tend to occur within families
What is Depression?
https://www.youtube.com/watch?v=z-IR48Mb3W0

23. ARWA M. AMIN
MDD DIAGNOSIS –LABORATORY DATA
• Complete Blood Count with differential
• Thyroid panel (TSH, T3, T4)
• is it due to hypothyroidism?
• Serum electrolytes
• Serum B12
• Folate
• Liver function tests
• Novel Biomarkers are under validation to help in early diagnosis
of MDD

24. ARWA M. AMIN
CASE DISCUSSION
Mrs. GF is a 38-year-old woman who is referred by her
family Physician to an outpatient mental Health Clinic.
Her c/o feeling down and sad, with crying spells, trouble
sleeping, increased eating, depression, Impaired
concentration, and fatigue. She has not worked in over 2
months and has used up all of her work leaves. She went
through treatment for alcoholism over a year ago.

25. ARWA M. AMIN
CASE DISCUSSION
Things were going fairly well for her after her
treatment and she remarried approximately 8 months
ago. Arguments with her teenage Sons about family
issues and past incidents have made her increasingly
depressed over the last few months.
Both her sons moved out to live with their father. She
divorced the boys’ father after approximately 10
years of Marriage.

26. ARWA M. AMIN
CASE DISCUSSION
• Without a second income in the household, she
accumulated large credit card debts. She began
Drinking and soon developed a pattern of alcohol
abuse. Nevertheless of her second husband support,
she feels guilty about her failed previous marriage and
her sons, worries about her credit card debt, and has
become more despondent.

27. ARWA M. AMIN
CASE DISCUSSION
• She sought treatment for depression 3 months ago from
her family physician, who prescribed Mirtazapine.
• Her spirits have not improved, and she says the
medication made her gain weight. Despite not having
much of an appetite, reports eating more since taking
Mirtazapine. Because of vague references the physician
believed could possibly indicate Suicidal Ideas, she has
been referred for psychiatric Evaluation.

28. ARWA M. AMIN
CASE DISCUSSION
Family History
• A sister has Depression and Anxiety and she takes antidepressant
medication; G.F. doesn’t know the medication’s name.
• A second sister committed suicide.
Social History
• Reports heavy credit card debt. Attended church regularly in the past,
but not recently. Attends Alcoholics Anonymous weekly.
VS
• BP 132/78, P 88, RR 22, T 36.9°C; WT 187 LBS, HT 5'8''

29. ARWA M. AMIN
CASE DISCUSSION
Medications:
• Mirtazapine 30 mg PO at bed time
• Started at 15 mg at bed time, 3 months ago
• ST. John’s Wort 300 mg PO TID for the last 2 weeks
• Acetaminophen 1000 – 1500 mg PRN
Assessment:
MDD, single episode with melancholic features

30. ARWA M. AMIN
CASE DISCUSSION
What are the risk factors that may have lead to MDD in Mrs. GF?
• Woman
• Family History of Depression and suicide
• Alcohol Abuse
• Family and Social problems
• Financial problems

31. ARWA M. AMIN
CASE DISCUSSION
What are the signs and symptoms assessed the diagnosis of MDD
in Mrs. GF? Explain that using the DSM-5 Criteria.
• Depressed Mood: feeling down
and sad, with crying spells
• Loss of interest in previous
activities: she is on leave from her
work since 2 months.
• Trouble in sleeping.
• Despondent
• Impaired concentration
• Fatigue.
• Increased weight
• Guilt feeling: she blames her self
• Suicidal Ideas

32. ARWA M. AMIN
CASE DISCUSSION- DSM-5 CRITERIA
DSM-5 Criteria
Depressed Mood (Subjective or Observed)1
Loss of Interest or pleasure2
Change in weight or appetite3
Insomnia or Hypersomnia4
Psychomotor Retardation or Agitation (Observed)5
Loss of Energy or Fatigue6
Worthlessness or guilt7
Impaired concentration or indecisiveness8
Thoughts of death or suicidal ideation or
suicide attempts
9
Mrs. GF has > 5 signs and
symptoms of the DSM-5
criteria in the same 2 weeks
period (at least one of the
symptoms: Depressed Mood
or loss of interest or pleasure)
Each of these symptoms
represents a change from
previous functioning
DSM-5: Diagnostic and Statistical Manual of Mental Disorders
Explain Mrs. GF MDD Diagnosis based on the DSM-5 Criteria.

33. ARWA M. AMIN
MDD DIAGNOSIS- DSM-5 CRITERIA
• Mrs. GF symptoms caused clinically significant distress to her and
impairment in social (family issues) and occupational (she is not going
to work since 2 months).
• Her MDD episode is not attributable to the physiological effects of a
substance or to another medical condition.
Explain Mrs. GF MDD Diagnosis based on the DSM-5 Criteria.

34. ARWA M. AMIN
MDD THERAPEUTIC GOALS
What are the therapeutic Goals of MDD treatment?
• Reducing Depression symptoms.
• Prevent further Depressive Episodes.
• Facilitate return to premorbid functioning.
• Minimizing drug adverse effects.
• Ensure adherence to the prescribed regimen.

35. ARWA M. AMIN
CASE DISCUSSION
• What are the Non-pharmacological treatment options of MDD
that you can discuss with Mrs. GF and her family?

36. ARWA M. AMIN
NON-PHARMACOLOGICAL TREATMENT OF MDD
• Psychotherapy.
• First line in mild to moderate episodes
• Additive efficacy with antidepressants in
severe cases.
• May include:
• Counseling and motivating patient so
they can feel self-worth and
motivated.
• Educating patient how to cope with
emotional trauma and stressful events.
• Help patient to follow regular pattern
of sleep
• Cognitive and Behavioral Therapy

37. ARWA M. AMIN
NON-PHARMACOLOGICAL TREATMENT OF MDD
• Electroconvulsive Therapy (ECT)
• Can be considered when rapid response is
needed or medications are not tolerated
• Although considered safe it has some side
effects such as, confusion, memory loss,
cardiovascular complications
• Bright-light Therapy
• For Seasonal affective disorder
• Adjunctive therapy for MDD

38. ARWA M. AMIN
NON-PHARMACOLOGICAL TREATMENT OF MDD
• Lifestyle Changes
• Reduce Stressors
• Reduce or eliminate alcohol intake
• Diet
• Healthy Diet rich in Omega 3, Nuts and
vegetables.
• Mediterranean Diet
• Exercises and Sports
• Increase release of Endorphins → ↓↓ Depression

39. ARWA M. AMIN
CASE DISCUSSION
What are the pharmacological treatment options of MDD?
What are the common adverse drug effects of Antidepressant drugs?
What is the suitable MDD pharmacological treatment for Mrs. GF?

40. ARWA M. AMIN
PHARMACOLOGICAL THERAPY FOR MDD
SSRIs: Selective Serotonin Reuptake Inhibitors, SNERIs: Serotonin Norepinephrine reuptake inhibitors, NEDRIs: Norepinephrine and Dopamine reuptake inhibitors. 5-HT2A RA: 5-HT2A receptor
antagonists, MAOI: monoamine oxidase inhibitors, TCA: Tricyclic antidepressant, S- 2A: serotonin and 2 adrenergic antagonist
*Triazolopyridines: Trazodone, Nefazodone. **Aminoketone: Bupropion.
SSRIs
• Citalopram
• Escitalopram
• Sertraline
• Fluoxetine
• Paroxetine
• Fluvoxamine
SNERIs
• Desvenlafaxine
• Venlafaxine
• Duloxetine
TCAs
• Amitriptyline
• Imipramine
• Doxepine
• Desipramine
• Nortriptyline
S- 2A
• Mirtazapine
MDD Pharmacological
Therapy
5-HT2ARA*
• Trazodone
• Nefazodone
NEDRIs**
• Bupropion
MAOIs
• Phenelzine
• Tranylcypromine
• Selegeline

41. ARWA M. AMIN
ANTIDEPRESSANT DRUGS: MECHANISM OF ACTION

42. ARWA M. AMIN
Algorithm of treatment
of Uncomplicated MDD
Source: Major Depressive Disorder, Pharmacotherapy Handbook: A Pathophysiologic Approach, 9e, Citation: DiPiro JT, Talbert RL, Yee GC, Matzke
GR, Wells BG, Posey L. Pharmacotherapy: A Pathophysiologic Approach, 9e; 2015

43. ARWA M. AMIN
Drug Initiation and usual Doses of Frequently Prescribed Antidepressant drugs
Usual dose
Range (mg/day)
Initial Dose
(mg/day)
Antidepressant Drug
20 – 4020Citalopram
10 – 2010Escitalopram
20 – 6020Fluoxetine
50 – 20050Sertraline
20 – 6020Paroxetine
75 – 22537.5 - 75Venlafaxine
30 – 9030Duloxetine
100 – 30025Amitriptyline
15 – 4515Mirtazapine
Notes: Give elderly patients one half of the initial dose given to younger adults, and increase The dose more
slowly. The elderly may require 6 to 12 weeks of treatment to achieve The desired antidepressant response.

44. ARWA M. AMIN
MDD TREATMENT PHASES
Acute Phase
Goal: Remission
6 – 12 Weeks
Continuation Phase
Goal: Prevent Relapse
4 – 9 Months
Maintenance phase
Goal: Prevent Recurrence
of New episode of MDD
12 – 36 Months

45. ARWA M. AMIN
NOTES ON PHARMACOLOGICAL THERAPY OF MDD
• Antidepressant Response may delay (typically 2 – 4 weeks)
• 6-week trial of an antidepressant at maximum dosage before considering
switching.
• Educate patients and their families about the delay in response.
• Family history should be considered in the choice of antidepressant
treatment
• Response to Antidepressant is variable and is affected by genetic and
environmental factors
• Use combination therapy of ECT, antidepressant and antipsychotic in
psychotic depressed patients
ECT: Electroconvulsive Therapy

46. ARWA M. AMIN
• SSRIs are the FIRST LINE of MDD treatment due to their Relative Safety And
Tolerability.
• MAOIs in the Second Or Third Line of MDD treatment due to side effects,
food interaction and Drug-drug interactions:
• Serotonin syndrome (muscle rigidity, fever, seizures)
• Pain medications and SSRIs must be avoided
• MAO-A inhibitors interfere with tyramine
• ↑↑ tyramine levels → HTN crisis (advice: Restricted tyramine diet)
• MAOIs interact with certain drugs
SSRI: Selective Serotonin reuptake inhibitor, MAOI: monoamine oxidase enzyme inhibitors
MAOIs increase the concentrations of norepinephrine, 5-HT, and dopamine within the neuronal synapse through inhibition of monoamine oxidase (MAO).
NOTES ON PHARMACOLOGICAL THERAPY OF MDD

47. ARWA M. AMIN
PHARMACOLOGICAL THERAPY OF MDD
How should the patient be advised about the herbal therapy,
Saint John’s wort?
• St. John’s wort, is herbal medication which contains Hypericum
(Hyperforin and Hypericin).
• St. John’s wort can be used as antidepressant for Mild to
Moderate depression. However, it is associated with several
Drug–drug interactions.
• May ↓↓ the Efficacy of Warfarin, Theophylline, digoxin, HIV
drugs and anticonvulsants

48. ARWA M. AMIN
CASE DISCUSSION
What are the common adverse drug effects of Antidepressant drugs?

49. ARWA M. AMIN
Adverse drug effects (ADE) of Antidepressant drugs
• The FDA has established a link between Antidepressant use and suicidality (suicidal
thinking and behaviors) in children, adolescents, and young adults up to 24 years old.
• Common ADRs for SSRIs & SNERIs are insomnia, anxiety, serotonin syndrome, nausea,
sexual dysfunction.
Specific ADRAntidepressant Drug
QT interval prolongationCitalopram
AnorexiaFluoxetine
Anticholinergic effectsParoxetine
HyperlipidemiaDesvenlafaxine
Dose related HypertensionVenlafaxine
Weight GianMirtazapine
Liver ToxicityNefazodone
FDA: Food and Drug Administration

50. ARWA M. AMIN
Adverse drug effects (ADE) of Antidepressant drugs
Antidepressants Black Box Warning
All antidepressants carry a BLACK BOX Warning advising caution in using
antidepressants in children, adolescents, and young adults up to 24 years
old population.

51. ARWA M. AMIN
CASE DISCUSSION
What is the suitable MDD pharmacological treatment for Mrs. GF?

52. ARWA M. AMIN
CASE DISCUSSION
What is the suitable MDD pharmacological treatment for Mrs. GF?
• Since Mirtazapine didn’t improve Mrs. GF MDD symptoms, she should
discontinue it and be started on one of the SSRIs antidepressants. However,
family history of response (sister) to antidepressants should be taken into
consideration.
• Mrs. GF should be advised to follow non-pharmacological treatment with the
pharmacological treatment.
• Since Mrs. GF has a family history of Suicide (sister), she should be monitored
closely for any suicide thinking or behavior.
SSRIs: Selective Serotonin reuptake inhibitors

53. ARWA M. AMIN
PREGNANCY DEPRESSION TREATMENT
• Depression during pregnancy is associated with:
• Preterm delivery and/or
• Low birth weight
• Mild to Moderate Depression: Use Non-Pharmacological approach
• Severe Depression: Non-Pharmacological & Pharmacological
approaches.
• No class A or B Antidepressant drug.
• All are class C except Paroxetine which is class D
• Use of Antidepressant drugs should consider Risks and benefits.

54. ARWA M. AMIN
EVALUATION OF MDD THERAPY
• Monitor for suicidal ideation after initiation of any
antidepressant, especially in the first few weeks of
treatment.
• Monitor blood pressure of patients given venlafaxine.
• Monitor Plasma Concentrations of drugs.
• Order a pretreatment ECG before starting TCA therapy
and periodically after starting treatment.
• Use psychometric rating instruments to rapidly, and reliably
measure the nature and severity of depressive and
associated symptoms.

55. ARWA M. AMIN
EVALUATION OF MDD THERAPY
• Evaluate adverse effects, remission of target
symptoms, and changes in social or occupational
functioning.
• Assure regular monitoring for several months after
discontinuation of antidepressants.

56. ARWA M. AMIN
The more you know, the more
you realize how much you don’t
know - the less you know, the
more you think you know