Comorbid Psychiatric Disorders with Major Depressive Disorder
The comorbidity of MDD and alcohol or other substance depend-ence requires careful attention to both diagnoses. The first pri-ority in treatment is abstinence from alcohol or substance use. Cooccurring addiction will complicate depressive disorders and increases risk for suicide. If detoxification from alcohol or other substance abuse is required, this should be undertaken before initiation of any somatic antidepressant therapy. Individuals who have a family history of depression or bipolar disorder are likely to require early initiation of appropriate mood disorder treatment following detoxification.
In individuals with OCD, lifetime risk of MDD approaches 70%. The use of higher dose SSRI treatment is often indicated to treat both conditions. Alternatively, the tricyclic antidepressant, clo-mipramine (Anafranil), may be effective for those individuals with both OCD and MDD who do not respond to SSRIs.
Lifetime risk of MDD approaches 50% in individuals with panic disorder. Because many of the SSRI and other antidepressants are effective treatments to treat panic as well as depression, these treatments have gained increasing popularity. One may continue to prescribe short-term courses of benzodiazepines, including lorazepam or clonazepam to alleviate acute symptoms of panic as low doses of antidepressant treatments are introduced into the treatment for comorbid panic and MDD. In addition, MAOIs con-tinue to be effective treatments for both panic and MDD.
Lifetime risk of MDD in individuals with generalized anxiety disorder (GAD) approaches 40%. New studies demonstrating ef-ficacy of venlafaxine as well as paroxetine make these effective interventions in situations in which an individual has both MDD and GAD.
An essential feature of PTSD is the vulnerability to the devel-opment of MDD. Recent studies (Friedman, 1998) demonstrate effectiveness in treating the core symptoms of PTSD as well as MDD. In addition, specific psychotherapy which addresses the core aspects of PTSD may be appropriate in individuals with co-morbid PTSD and MDD in order to minimize the vulnerability to depression because of persistent PTSD symptomatology.
When cognitive impairment is due to depressive disorder (as in “pseudodementia”), active treatment of depression may minimize associated cognitive difficulties. Many seniors evolve mild cogni-tive impairment and depression as early signs of dementia. Nev-ertheless, when MDD is mild it requires specific antidepressant treatment, or when severe or psychotic, electroconvulsive therapy.
The exacerbation of a persistent or chronic DD into a more severe depressive episode is termed “double depression”. Many treat-ments for MDD are also useful in DD. It is likely that SSRIs, newer antidepressants as well as tricyclic antidepressants are ef-fective for both DD and MDD. Specific forms of psychotherapy which are cognitive–behavioral have been investigated as effec-tive in addressing poor inter-episode recovery from MDD associ-ated with DD.
Increasing evidence of the cooccurrence of MDD with person-ality disorder with rates up to 40 to 50% in outpatient clinicssuggests incomplete response to antidepressants alone. Specific psychotherapy treatments which focus on maladaptive personal-ity traits may facilitate the ongoing response to antidepressant pharmacotherapy.