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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Surviving
Depression
Mood
Disorder's
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