Major
Depressive Episode
Depression, which
affects people of all ages, income, race, and cultures, is a disturbance
of mood and is characterized by a loss of interest or pleasure in
normal everyday activities. People who are depressed may feel "down
in the dumps" for weeks, months, or even years at a time.
in the same 2 weeks, the patient has had 5 or more of the following
symptoms, which are a definite change from usual functioning. Either
depressed mood or decreased interest or pleasure must be one of the
five:
Mood. For most
of nearly every day, the patient reports depressed mood or appears
depressed to others.
Interests. For most of nearly every day, interest or pleasure is
markedly decreased in nearly all activities (noted by the patient
or by others).
Eating and weight. Although not dieting, there is a marked loss
or gain of weight (such as five percent in one month) or appetite
is markedly decreased or increased nearly every day.
Sleep. Nearly every day the patient sleeps excessively or not enough.
Motor activity. Nearly every day others can see that the patient's
activity is agitated or retarded.
Fatigue. Nearly every day there is fatigue or loss of energy.
Self-worth. Nearly every day the patient feels worthless or inappropriately
guilty. These feelings are not just about being sick; they may be
delusional.
Concentration. Noted by the patient or by others, nearly every day
the patient is indecisive or has trouble thinking or concentrating.
Death. The patient has had repeated thoughts about death (other
than the fear of dying), suicide (with or without a plan) or
has made a suicide attempt.
These symptoms cause clinically important distress or impair work,
social or personal functioning.
They don't fulfill criteria for Mixed
Episode
This disorder is not directly caused by a general medical condition
or the use of substances, including prescription medications.
Unless the symptoms
are severe (defined as severely impaired functioning, severe preoccupation
with worthlessness, ideas of suicide,
delusions or hallucinations or psychomotor retardation), the episode
has not begun within two months of the loss of a loved one.
Use the following
codes (including Chronic) for the current or most recent
Major Depressive Episode in Major Depressive, Bipolar
I or Bipolar II Disorders.
Fifth Digit
Severity Code for Major Depressive Episode.
.1 Mild. Symptoms
barely meet criteria for major depression and result in little distress
or interference with the patient's ability to work, study or socialize.
.2 Moderate. Intermediate
between Mild and Severe.
.3 Severe without
Psychotic Features. The number of symptoms well exceeds the minimum
for diagnosis, and they markedly interfere with patient's work, social
or personal functioning.
.4 With Psychotic
Features. The patient has delusions or hallucinations, which may be
mood-congruent or mood-incongruent. Specify, if possible:
Severe With
Mood-congruent Psychotic Features. The content of the patient's
delusions or hallucinations is completely consistent with the typical
themes of depression: death, disease, guilt, nihilism, personal
inadequacy or punishment that is deserved.
Severe With
Mood-incongruent Psychotic Features. The content of the patient's
delusions or hallucinations is not consistent with the typical themes
of depression. Mood incongruent themes include delusions of control,
persecution, thought broadcasting and thought insertion.
.5 In Partial
Remission. Use this code for patients who formerly met full criteria
for Major Depressive Episode and now either (1) have fewer than five
symptoms or (2) have had no symptoms for less than two months.
.6 In Full Remission.
The patient has had no material evidence of Major Depressive Episode
during the past 2 months.
.0 Unspecified.
Chronicity Specifier:
Chronic. All the criteria for a Major Depressive Episode have been
met without interruption for the previous 2 years or longer.
Psychomotor Agitation
and Psychomotor Retardation
Psychomotor agitation and retardation occur in depression, producing
states of over activity and under activity respectively. Agitation and
retardation can lead to impaired cognition, judgment, reason, and decision
making, which often further isolates depressed people and prolongs symptoms.
Psychomotor agitation can also lead to generalized restlessness.
Motor agitation
is rarer than motor retardation and is often occurs in the elderly.
Over activity in this sense does not mean mania. The agitated state
in major depressive disorder should not be confused with the manic
episode that occurs in bipolar disorder, when mood is temporarily
elevated by a transient sense of hope and elation.
Psychomotor activities
are the physical gestures that result from mental processes and are
a product of the psyche. Many psychomotor behaviors associated with
mental disorder affect impulses, cravings, instincts, and wishes.
The spectrum of agitated behavior includes the following:
Incoherent conversation
Expansive gesturing
Pacing and hair twirling
Psychomotor retardation manifests as a slowing of coordination, speech,
and impaired articulation. In this state, a person appears sluggish
and seems hesitant or confused in speech and intention.
Essentially
Features:
Physical illness,
alcohol, medication, or street drug use.
Normal
bereavement.
Bipolar Disorder
Mood-incongruent
psychosis (e.g., Schizoaffective Disorder, Schizophrenia, Schizophreniform
Disorder, Delusional Disorder,
or Psychotic Disorder Not Otherwise Specified).
Major
Depressive Disorder causes the following mood
symptoms:
Abnormal depressed mood:
Sadness
is usually a normal reaction to loss. However, in Major Depressive
Disorder, sadness is abnormal because it:
Persists continuously
for at least 2 weeks.
Causes marked functional impairment.
Causes disabling physical symptoms (e.g., disturbances in sleep,
appetite, weight, energy, and psychomotor activity).
Causes disabling psychological symptoms (e.g., apathy, morbid
preoccupation with worthlessness, suicidal ideation, or psychotic
symptoms).
The
sadness in this disorder is often described as a depressed, hopeless,
discouraged, "down in the dumps," "blah," or
empty. This sadness may be denied at first. Many complain of bodily
aches and pains, rather than admitting to their true feelings of
sadness.
Abnormal loss of interest and pleasure mood:
The loss of
interest and pleasure in this disorder is a reduced capacity to
experience pleasure which in its most extreme form is called anhedonia.
The resulting
lack of motivation can be quite crippling.
Abnormal irritable mood:
This disorder
may present primarily with irritable, rather than depressed or apathetic
mood. This is not officially recognized yet for adults, but it is
recognized for children and adolescents.
Unfortunately,
irritable depressed individuals often alienate their loved ones
with their cranky mood and constant criticisms.
Major Depressive Disorder causes the following physical
symptoms:
Abnormal appetite:
Most depressed patients experience loss of appetite and weight loss.
The opposite, excessive eating and weight gain, occurs in a minority
of depressed patients. Changes in weight can be significant.
Abnormal sleep:
Most depressed patients experience difficulty falling asleep, frequent
awakenings during the night or very early morning awakening. The
opposite, excessive sleeping, occurs in a minority of depressed
patients.
Fatigue or loss
of energy: Profound fatigue and lack of energy usually is very prominent
and disabling.
Agitation or
slowing: Psychomotor retardation (an actual physical slowing of
speech, movement and thinking) or psychomotor agitation (observable
pacing and physical restlessness) often are present in severe Major
Depressive Disorder.
Major
Depressive Disorder causes the following cognitive
symptoms:
Abnormal
self-reproach or inappropriate guilt:
This disorder
usually causes a marked lowering of self-esteem and self-confidence
with increased thoughts of pessimism, hopelessness, and helplessness.
In the extreme, the person may feel excessively and unreasonably
guilty.
The "negative
thinking" caused by depression can become extremely dangerous
as it can eventually lead to extremely self-defeating or suicidal
behavior.
Abnormal
poor concentration or indecisiveness:
Poor concentration
is often an early symptom of this disorder. The depressed person
quickly becomes mentally fatigued when asked to read, study, or
solve complicated problems.
Marked forgetfulness
often accompanies this disorder. As it worsens, this memory loss
can be easily mistaken for early senility (dementia).
Abnormal morbid thoughts of death (not just fear of dying) or suicide:
The symptom
most highly correlated with suicidal behavior in depression is hopelessness
Associated Features
and Comorbitity
Anxiety:
80 to 90% of
individuals with Major Depressive
Disorder also have anxiety symptoms (e.g., anxiety, obsessive
preoccupations, panic attacks, phobias, and excessive health concerns).
Separation
Anxiety may be prominent in children.
About one third
of individuals with Major Depressive
Disorder also have a full-blown anxiety disorder (usually either
Panic Disorder, Obsessive-Compulsive
Disorder, or Social Phobia).
Anxiety in a
person with major depression leads to a poorer response to treatment,
poorer social and work function, greater likelihood of chronicity
and an increased risk of suicidal behavior.
Eating
Disorders:
Individuals
with Anorexia Nervosa and Bulimia
Nervosa often develop Major Depressive
Disorder.
Psychosis:
Mood congruent
delusions or hallucinations may accompany severe Major
Depressive Disorder.
Substance
Abuse:
The combination
of Major Depressive Disorder
and substance
abuse is common (especially Alcohol and Cocaine).
Alcohol or street
drugs are often mistakenly used as a remedy for depression. However,
this abuse of alcohol or street drugs actually worsens Major
Depressive Disorder.
Depression may
also be a consequence of drug or alcohol withdrawal and is commonly
seen after cocaine and amphetamine use.
Medical
Illness:
25% of individuals
with severe, chronic medical illness (e.g., diabetes, myocardial
infarction, carcinomas, stroke) develop depression.
About 5% of
individuals initially diagnosed as having Major Depressive Disorder
subsequently are found to have another medical illness which was
the cause of their depression.
Medical conditions
often causing depression are:
Endocrine
disorders: hypothyroidism, hyperparathyroidism, Cushing's disease,
and diabetes mellitus.
Neurological disorders: multiple sclerosis, Parkinson's
Disease, migraine, various forms of epilepsy, encephalitis,
brain tumors.
Medications: many medications can cause depression, especially
antihypertensive agents such as calcium channel blockers, beta
blockers, analgesics and some anti-migraine medications.
Mortality:
Up to 15% of patients with severe Major
Depressive Disorder die by suicide.
Over age 55, there is a fourfold increase in death rate.
Premorbid
History: 10-25% of patients with Major Depressive Disorder have preexisting
Dysthymic Disorder. These "double
depressions" (i.e., Dysthymia
+ Major Depressive Disorder) have
a poorer prognosis.
Gender:
Males and females are equally affected by Major
Depressive Disorder prior to puberty. After puberty, this disorder
is twice as common in females as in males. The highest rates for this
disorder are in the 25- to 44-year-old age group.
Prevalence:
The lifetime risk for Major Depressive
Disorder is 10% to 25% for women and from 5% to 12% for men. At
any point in time, 5% to 9% of women and 2% to 3% of men suffer from
this disorder. Prevalence is unrelated to ethnicity, education, income,
or marital status.
Onset:
Average age at onset is 25, but this disorder may begin at any age.
Psychological
stress: Stress appears to play a prominent role in triggering the
first 1-2 episodes of this disorder, but not in subsequent episodes.
Duration:
An average episode lasts about 9 months.
Course:
Course is variable. Some people have isolated episodes that are separated
by many years, whereas others have clusters of episodes, and still
others have increasingly frequent episodes as they grow older. About
20% of individuals with this disorder have a chronic course.
Recurrence:
The risk of recurrence is about 70% at 5 year follow up and at least
80% at 8 year follow-up. After the first episode of Major
Depressive Disorder, there is a 50%-60% chance of having a second
episode, and a 5-10% chance of having a Manic
Episode (i.e., developing Bipolar
I Disorder). After the second episode, there is a 70% chance of
having a third. After the third episode, there a 90% chance of having
a fourth.
The greater number of previous episodes is an important risk factor
for recurrence.
Recovery:
For patients with severe Major Depressive
Disorder, 76% on antidepressant therapy recover, whereas only
18% on placebo recover. For these severely depressed patients, significantly
more recover on antidepressant therapy than on interpersonal psychotherapy.
For these same patients, cognitive therapy has been shown to be no
more effective than placebo.
New research shows that a medication/psychotherapy combination - preferably
Cognitive
Behavior Therapy - seems to be most effective.
Poor Outcome:
Poor outcome or chronicity in Major
Depressive Disorder is associated with the following:
Inadequate treatment
Severe initial
symptoms
Early age of
onset
Greater number
of previous episodes
Only partial
recovery after one year
Having another
severe mental disorder (e.g. Alcohol Dependency, Cocaine Dependency)
Severe chronic
medical illness
Family dysfunction
Familial
Pattern And Genetics: There is strong evidence that major depression
is, in part, a genetic disorder:
Individuals
who have parents or siblings with Major
Depressive Disorder have a 1.5-3 times higher risk of developing
this disorder.
The concordance
for major depression in monozygotic twins is substantially higher
than it is in dizygotic twins. However, the concordance in monozygotic
twins is in the order of about 50%, suggesting that factors other
than genetic factors are also involved.
Children adopted
away at birth from biological parents who have a depressive illness
carry the same high risk as a child not adopted away, even if they
are raised in a family where no depressive illness exists.
Interestingly,
families having Major Depressive
Disorder have an increased risk of developing Alcoholism
and AttentionDeficit/Hyperactivity
Disorder.
Differential
Diagnosis
Some disorders display similar or sometimes even the same symptoms.
The clinician, therefore, in his diagnostic attempt has to differentiate
against the following disorders which he needs to rule out to establish
a precise diagnosis.
Exclude depressions
due to physical illness, medications, or street drug use:
If due to
physical illness, diagnose: Mood
Disorder Due to a General Medical Condition.
If due to
alcohol, diagnose: Alcohol-Induced
Mood Disorder.
If due to
other substance use, diagnose: Other
Substance-Induced Mood Disorder.
Organic
Causes Of Severe Depression:
Illnesses:
Organic Mood Syndromes caused by: Acquired Immune Deficiency Syndrome
(AIDS), Adrenal (Cushing's or Addison's Diseases), Cancer (especially
pancreatic and other GI), Cardiopulmonary disease, Dementias (including
Alzheimer's Disease); Epilepsy, Fahr's Syndrome, Huntington's Disease,
Hydrocephalus, Hyperaldosteronism, Infections (including HIV and neurosyphilis),
Migraines, Mononucleosis, Multiple Sclerosis, Narcolepsy, Neoplasms,
Parathyroid Disorders (hyper- and hypo-), Parkinson's
Disease, Pneumonia (viral and bacterial), Porphyria, Postpartum,
Premenstrual Syndrome, Progressive Supranuclear Palsy, Rheumatoid
Arthritis, Sjogren's Arteritis, Sleep Apnea, Stroke, Systemic Lupus
Erythematosus, Temporal Arteritis, Trauma, Thyroid Disorders (hypothyroid
and "apathetic" hyperthyroidism), Tuberculosis, Uremia (and
other renal diseases), Vitamin Deficiencies (B12, C, folate, niacin,
thiamine), Wilson's Disease.
Drugs: Acetazolamine,
Alphamethyldopa, Amantadine, Amphetamines, Ampicillin, Azathioprine
(AZT), 6-Azauridine, Baclofen, Beta Blockers, Bethanidine, Bleomycin,
Bromocriptine, C-Asparaginase, Carbamazepine, Choline, Cimetidine, Clonidine,
Clycloserin, Cocaine, Corticosteroids (including ACTH), Cyproheptadine,
Danazol, Digitalis, Diphenoxylate, Disulfiram, Ethionamide, Fenfluramine,
Griseofulvin, Guanethidine, Hydralazine, Ibuprofen, Indomethacin, Lidocaine,
Levodopa, Methoserpidine, Methysergide, Metronidazole, Nalidixic Acid,
Neuroleptics (butyrophenones, phenothiazines, oxyindoles), Nitrofurantoin,
Opiates, Oral Contraceptives, Phenacetin, Phenytoin, Prazosin, Prednisone,
Procainamide, Procyclidine, Quanabenzacetate, Rescinnamine, Reserpine,
Sedative/Hypnotics (barbiturates, benzodiazepines, chloral hydrate),
Streptomycin, Sulfamethoxazole, Sulfonamides, Tetrabenazine, Tetracycline,
Triamcinolone, Trimethoprim, Veratrum, Vincristine.
Exclude depressions
having a previous history of elevated, expansive, or euphoric mood:
If previous
history of a Manic
Episode, diagnose: Bipolar I
Disorder.
If previous
history of recurrent Major Depressive
Episodes and at least one Hypomanic
Episode, diagnose: Bipolar II
Disorder.
If previous
history of recurrent
Hypomanic Episodes and brief, mild depressive episodes (milder
than Major Depressive Episodes),
diagnose: Cyclothymic Disorder
.
Exclude depressions
that merely represent normal bereavement, instead diagnose: Uncomplicated
Bereavement.
Exclude depressions
associated with mood-incongruent psychosis:
If previous
history of at least 2 weeks of delusions or hallucinations occurring
in the absence of prominent mood symptoms, diagnose either: Schizoaffective
Disorder, Schizophrenia,
Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
Exclude mild depressions:
If only mild
depression present for most of past 2 years (or 1 year in children),
diagnose: Dysthymic Disorder.
If only brief
mild depression clearly triggered by stress, diagnose: Adjustment
Disorder with Depressed Mood, or Adjustment
Disorder with Mixed Anxiety and Depressed Mood.
If mild depression
is clinically significant, but does not meet the criteria for any
of the previously described disorders, diagnose: Depressive
Disorder Not Otherwise Specified.
In the elderly,
it is often difficult to distinguish between early dementia or Major
Depressive Disorder:
If there is
a premorbid history of declining cognitive function in the absence
of severe depression, diagnose: Dementia.
If there was
a relatively normal premorbid state and somewhat abrupt cognitive
decline associated with severe depression, diagnose: Major Depressive
Disorder.
Cause:
Changes in the
body's chemistry influence mood and thought processes, and biological
factors contribute to some cases of depression. In addition, chronic
and serious illness such as heart disease or cancer may be accompanied
by depression. With many individuals, however, depression signals
first and foremost that certain mental and emotional aspects of a
person's life are out of balance.
Significant transitions
and major life stressors such as the death of a loved one or the loss
of a job can help bring about depression. Other more subtle factors
that lead to a loss of identity or self-esteem may also contribute.
The causes of depression are not always immediately apparent, so the
disorder requires careful evaluation and diagnosis by a trained mental
health care professional.
Sometimes the
circumstances involved in depression are ones over which an individual
has little or no control. At other times, however, depression occurs
when people are unable to see that they actually have choices and
can bring about change in their lives.
Treatment
Depressive illnesses
are highly responsive to treatment. In fact, 80 percent of people
with depression report feeling better within a few weeks of starting
treatment.
There is still
some stigma, or reluctance, associated with seeking help for emotional
and mental problems, including depression. Unfortunately, feelings
of depression often are viewed as a sign of weakness rather than as
a signal that something is out of balance. The fact is that people
with depression can not simply 'snap out of it' and feel better spontaneously.
Both psychotherapy
and medication may be needed to treat depression. Although medication
may help to control it, individuals must learn to recognize their
own patterns of depression and develop more effective ways to cope
with them. Treatment success depends on factors such as the type of
depression, its severity, how long it has been going on, and how an
individual responds to treatment. Left untreated, depression can become
chronic and even worsen.
Counseling
and Psychotherapy [ See
Therapy Section ]:
There are several
approaches to psychotherapy -- including cognitive-behavioral, interpersonal,
psychodynamic and other kinds of 'talk therapy' -- that help depressed
individuals recover. Psychotherapy offers people the opportunity to
identify the factors that contribute to their depression and to deal
effectively with the psychological, behavioral, interpersonal and
situational causes.
Pharmacotherapy
[ See Psychopharmacology
Section ] :
Medication: Most
antidepressants believed to be equally effective in equivalent therapeutic
doses. Expect a 2- to 6- week latent period before the full effect
is seen at therapeutic doses. To prevent relapse, continue medication
for at least 4 to 9 months after patient becomes asymptomatic.
Tricyclic Antidepressants (TCAs):
Imipramine.
Nortriptyline .
Second-generation Antidepressants:
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