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Major Depressive Episode
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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
.

  1. 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:

    Bupropion (Wellbutrin).
    V enlafaxine (Effexor).
    Trazodone (Desyrel).
    Nefazodone (Serzone).
    Mirtazapine (Remeron).

 


DSM Code

296.3 Major Depressive Disorder Recurrent Unspecified

F32 Major Depression

Disorder Sheets

Depression Alliance
20 Great Dover Street
London
SE1 4LX
Tel: +448451232320
Email: Click Here
Website: Click Here
Facebook: Click here

    

MDF Bipolar Organisation
Midlands & North of England Office,
MDF The Bipolar Organisation,
2 Macon Court,
Herald Drive,
Crewe,
Cheshire.
CW1 6EA
Tel:+448454349970
Email: Click Here
Website: Cllick Here

Recommended Book

Treatment Works for Major Depressive Disorder: A Patient and Family Guide - Click Here to View


Major Depressive Episode

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