Tag: MDE: Major Depressive Episode

What is Depressive Personality Disorder?

Published on by Andrew Marshall2 Comments

Introduction

Depressive personality disorder (also known as melancholic personality disorder) is a psychiatric diagnosis that denotes a personality disorder with depressive features.

Originally included in the American Psychiatric Association’s DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R. Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study. Although no longer listed as a personality disorder, the diagnosis is included under the section “personality disorder not otherwise specified”.

While depressive personality disorder shares some similarities with mood disorders such as dysthymia, it also shares many similarities with personality disorders including avoidant personality disorder. Some researchers argue that depressive personality disorder is sufficiently distinct from these other conditions so as to warrant a separate diagnosis.

Characteristics

The DSM-IV defines depressive personality disorder as “a pervasive pattern of depressive cognitions and behaviours beginning by early adulthood and occurring in a variety of contexts.” Depressive personality disorder occurs before, during, and after major depressive episodes (MDE), making it a distinct diagnosis not included in the definition of either MDE or dysthymic disorder. Specifically, five or more of the following must be present most days for at least two years in order for a diagnosis of depressive personality disorder to be made:

  • Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness and unhappiness.
  • Self-concept centres on beliefs of inadequacy, worthlessness and low self-esteem.
  • Is critical, blaming and derogatory towards the self.
  • Is brooding and given to worry.
  • Is negativistic, critical and judgmental toward others.
  • Is pessimistic.
  • Is prone to feeling guilty or remorseful.

People with depressive personality disorder have a generally gloomy outlook on life, themselves, the past and the future. They are plagued by issues developing and maintaining relationships. In addition, studies have found that people with depressive personality disorder are more likely to seek psychotherapy than people with Axis I depression spectra diagnoses.

Recent studies have concluded that people with depressive personality disorder are at a greater risk of developing dysthymic disorder than a comparable group of people without depressive personality disorder. These findings lead to the fact that depressive personality disorder is a potential precursor to dysthymia or other depression spectrum diagnoses. If included in the DSM-V, depressive personality disorder would be included as a warning sign for potential development of more severe depressive episodes.

Millon’s Subtypes

Theodore Millon identified five subtypes of depression. Any individual depressive may exhibit none, or one or more of the following:

SubtypeDescriptionPersonality Traits
Ill-Humoured DepressiveIncluding negativistic features1. Patients in this subtype are often hypochondriacal, cantankerous and irritable, and guilt-ridden and self-condemning.
2. In general, ill-humoured depressives are down on themselves and think the worst of everything.
Voguish DepressiveIncluding histrionic and narcissistic features1. Voguish depressives see unhappiness as a popular and stylish mode of social disenchantment, personal depression as self-glorifying, and suffering as ennobling.
2. The attention from friends, family, and doctors is seen as a positive aspect of the voguish depressive’s condition.
Self-Derogating DepressiveIncluding dependent features1. Patients who fall under this subtype are self-deriding, discrediting, odious, dishonourable, and disparage themselves for weaknesses and shortcomings.
2. These patients blame themselves for not being good enough.
Morbid DepressiveIncluding schizoid and masochistic features1. Morbid depressives experience profound dejection and gloom, are highly lugubrious, and often feel drained and oppressed.
Restive DepressiveIncluding borderline and avoidant features1. Patients who fall under this subtype are consistently unsettled, agitated, wrought in despair, and perturbed.
2. This is the subtype most likely to commit suicide in order to avoid all the despair in life.

Not all patients with a depressive disorder fall into a subtype. These subtypes are multidimensional in that patients usually experience multiple subtypes, instead of being limited to fitting into one subtype category. Currently, this set of subtypes is associated with melancholic personality disorders. All depression spectrum personality disorders are melancholic and can be looked at in terms of these subtypes.

DSM-5

Similarities to Dysthymic Disorder

Much of the controversy surrounding the potential inclusion of depressive personality disorder in the DSM-5 stems from its apparent similarities to dysthymic disorder, a diagnosis already included in the DSM-IV. Dysthymic disorder is characterised by a variety of depressive symptoms, such as hypersomnia or fatigue, low self-esteem, poor appetite, or difficulty making decisions, for over two years, with symptoms never numerous or severe enough to qualify as major depressive disorder. Patients with dysthymic disorder may experience social withdrawal, pessimism, and feelings of inadequacy at higher rates than other depression spectrum patients. Early-onset dysthymia is the diagnosis most closely related to depressive personality disorder.

The key difference between dysthymic disorder and depressive personality disorder is the focus of the symptoms used to diagnose. Dysthymic disorder is diagnosed by looking at the somatic senses, the more tangible senses. Depressive personality disorder is diagnosed by looking at the cognitive and intrapsychic symptoms. The symptoms of dysthymic disorder and depressive personality disorder may look similar at first glance, but the way these symptoms are considered distinguish the two diagnoses.

Comorbidity with other Disorders

Many researchers believe that depressive personality disorder is so highly comorbid with other depressive disorders, manic-depressive episodes and dysthymic disorder, that it is redundant to include it as a distinct diagnosis. Recent studies however, have found that dysthymic disorder and depressive personality disorder are not as comorbid as previously thought. It was found that almost two thirds of the test subjects with depressive personality disorder did not have dysthymic disorder, and 83% did not have early-onset dysthymia.

The comorbidity with Axis I depressive disorders is not as high as had been assumed. An experiment conducted by American psychologists showed that depressive personality disorder shows a high comorbidity rate with major depression experienced at some point in a lifetime and with any mood disorders experienced at any point in a lifetime. A high comorbidity rate with these disorders is expected of many diagnoses. As for the extremely high comorbidity rate with mood disorders, it has been found that essentially all mood disorders are comorbid with at least one other, especially when looking at a lifetime sample size.

What is Cyclothymia?

Published on by Andrew Marshall8 Comments

Introduction

Cyclothymia, also known as cyclothymic disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood.

These symptoms, however, are not sufficient to be a major depressive episode or a hypomanic episode. Symptoms must last for more than one year in children and two years in adults.

The cause of cyclothymia is unknown. Risk factors include a family history of bipolar disorder. Cyclothymia differs from bipolar in that major depression, mania, or hypomania have never occurred.

Treatment is generally with counselling and mood stabilisers such as lithium. It is estimated that 0.4-1% of people have cyclothymia at some point in their life. Onset is typically in late childhood to early adulthood. Males and females are affected equally often.

Brief History

In 1883, Karl Ludwig Kahlbaum identified a disorder characterised by recurring mood cycles. The disorder contained both melancholic and manic episodes that occurred in a milder form than in bipolar disorder. This condition was coined “cyclothymia” by Kahlbaum and his student Ewald Hecker. Kahlbaum developed his theory of cyclothymia through his work with people presenting with these symptoms at the Kahlbaum Sanitarium in Goerlitz, Silesia (Germany). He was recognised as a leading hypnotherapist and psychotherapist of his day. He was a progressive in the field of mental health, believing that mental illness should not carry a stigma and that people dealing with mental health issues should be treated humanely. Kalhbaum was the first to recognise that people with cyclothymia often do not seek help for the disorder due to its mild symptoms.

Cyclothymia has been conceptualised in a variety of ways, including as a subtype of bipolar disorder, a temperament, a personality trait, and a personality disorder. There is also an argument that cyclothymia should be considered a neurodevelopmental disorder. The two defining features of the disorder, according to DSM-5, are the presence of depressive and hypomanic symptoms, not meeting the threshold for a depressive or hypomanic episode. Cyclothymia is also classified as a subtype of bipolar disorder in DSM-5, but some researchers disagree with this classification and argue that it should be primarily defined as an exaggeration of mood and emotional instability. In the past, cyclothymia has been conceptualised to include other characteristics in addition to the flux between depression and hypomania, such as mood reactivity, impulsivity, and anxiety.

Symptoms

People with cyclothymia experience both depressive phases and hypomanic phases (which are less severe than a full hypomanic episode). The depressive and manic symptoms in cyclothymia last for variable amounts of time due to the unstable and reactive nature of the disorder. The depressive phases are similar to major depressive disorder and are characterised by dulled thoughts and sensations and the lack of motivation for intellectual or social activities. Most people with cyclothymia are generally fatigued and tend to sleep frequently and for long periods of time. However, other people experience insomnia.

Other symptoms of cyclothymic depression include indifference toward people or activities that used to be extremely important. Cyclothymic depression also leads to difficulty making decisions. In addition, people with this condition tend to be critical and complain easily. Suicidal thoughts are common, even in mild forms of cyclothymia. In the depressive state, people with cyclothymia also experience physical complaints including frequent headaches, tightness in the head and chest, an empty sensation in the head, weakness, weight loss, and hair loss.

The distinguishing factor between typical depression and cyclothymic depression is that in cyclothymic depression, there are instances of hypomania. People with cyclothymia can switch from the depressive state to the hypomanic state without warning to them or others. The duration and frequency of phases is unpredictable.

In the hypomanic state, people’s thoughts become faster and they become more sociable and talkative. They may engage in spending sprees, spontaneous actions, have heightened self-esteem, and greater vanity. In contrast to a regular manic state that would be associated with bipolar I, symptoms in the hypomanic phase generally occur in a less severe form.

Comorbidities

Cyclothymia commonly occurs in conjunction with other disorders. Between 20-50 percent of people with depression, anxiety, and related disorders also have cyclothymia. When people with cyclothymia seek mental health resources it tends to be for symptoms of their comorbid condition rather than for their symptoms of cyclothymia. In children and adolescents, the most common comorbidities with cyclothymia are anxiety disorders, impulse control issues, eating disorders, and ADHD. In adults, cyclothymia also tends to be comorbid with impulse control issues. Sensation-seeking behaviours occur in hypomanic states. These often include gambling and compulsive sexuality in men, or compulsive buying and binge eating in women.

In addition to sensation-related disorders, cyclothymia has also been associated with atypical depression. In one study, a connection was found between interpersonal sensitivity, mood reactivity (i.e. responding to actual or potential positive events with brighter mood), and cyclothymic mood swings, all of which are symptoms of atypical depression. Cyclothymia also tends to occur in conjunction with separation anxiety, where a person has anxiety as a result of separation from a caregiver, friend, or loved one. Other issues that tend to co-occur with cyclothymia include social anxiety, fear of rejection and a tendency toward hostility to those connected with past pain and rejection. People with cyclothymia tend to seek intense interpersonal relationships when in a hypomanic state and isolation when in a depressed state. This generally leads to short, tumultuous relationships.

Causes

The cause is unknown. Risk factors include a family history of bipolar disorder.

First-degree relatives of people with cyclothymia have major depressive disorder, bipolar I disorder, and bipolar II disorder more often than the general population. Substance-related disorders also may be at a higher risk within the family. First-degree relatives of a bipolar I individuals may have a higher risk of cyclothymic disorder than the general population.

Diagnosis

Cyclothymia is classified in DSM-5 as a subtype of bipolar disorder. The criteria are:

  • Periods of elevated mood and depressive symptoms for at least half the time during the last two years for adults and one year for children and teenagers.
  • Periods of stable moods last only two months at most.
  • Symptoms create significant problems in one or more areas of life.
  • Symptoms do not meet the criteria for bipolar disorder, major depression, or another mental disorder.
  • Symptoms are not caused by substance use or a medical condition.

The DSM-5 criteria for cyclothymia are restrictive according to some researchers. This affects the diagnosis of cyclothymia because fewer people get diagnosed than potentially could. This means that a person who has some symptoms of the disorder might not be able to get treatment because they do not meet all of the necessary criteria described in DSM-5. Furthermore, it also leads to more attention being placed on depression and other bipolar-spectrum disorders because if a person does not meet all the criteria for cyclothymia they are often given a depression or bipolar spectrum diagnosis. Improper diagnosis may lead some people with cyclothymia to be treated for a comorbid disorder rather than having their cyclothymic tendencies addressed.

Cyclothymia is often not recognised by the affected individual or medical professionals due to its ostensibly mild symptoms. In addition, it is difficult to identify and classify. Due to disagreement and misconceptions among health and mental health professionals, cyclothymia is often diagnosed as “bipolar not otherwise specified”. Cyclothymia is also often confused with borderline personality disorder due to their similar symptoms, especially in older adolescents and young adults.

Most people with the disorder present in a depressive state, not realising that their hypomanic states are abnormal. Mild manic episodes tend to be interpreted as part of the person’s personality or simply a heightened mood. In addition, the disorder often manifests during childhood or adolescence, making it even more difficult for the person to distinguish between symptoms of the disorder and their personality. For example, people may think that they just suffer from mood swings and not realise that these are a result of a psychiatric condition.

Management

Cognitive behavioural therapy (CBT) is considered potentially effective for people diagnosed with cyclothymia.

Medication can be used in addition to behavioural approaches. However, mood stabilisers should be used before antidepressants, and if antidepressants are used they should be used with caution. Antidepressants are a concern due to the possibility of inducing hypomanic switches or rapid cycling.

Epidemiology

Cyclothymia, known today as cyclothymic disorder, tends to be underdiagnosed due to its low intensity. The exact rates for cyclothymia have not been widely studied. Some studies estimate that between 5 and 8% are affected at some point in their life whereas other studies suggest a rate ranging from 0.4 to 2.5%.

Males appear to be affected equally often, though women are more likely to receive treatment. Cyclothymia is diagnosed in around fifty percent of people with depression who are evaluated in psychiatric outpatient settings.

Etymology

Cyclothymia is derived from the Greek word κυκλοθυμία (from κῦκλος kyklos, “circle” and θυμός thymos, “mood, emotion”). Therefore, it means “to cycle or circle between moods or emotions”.

Research

Whether subtypes of bipolar disorder, such as cyclothymia, truly represent separate disorders or are part of a unique bipolar spectrum is debated in research. Cyclothymia is typically not described in research studies or diagnosed in clinical settings, making it less recognisable and less understood by professionals. This absence of cyclothymia in research and clinical settings suggests that cyclothymia is either being diagnosed as another mood disorder or as a non-affective psychiatric disorder or not coming to scientific or clinical attention due to a lack of diagnostic clarity or because the nature of cyclothymia is still highly contested. Additionally, the current diagnostic criterion for cyclothymia emphasizes that symptoms are persistent, which suggests that they are enduring traits rather than a psychological state, thus, it has been argued that it should be diagnosed as a personality disorder. Since the symptoms tend to overlap with personality disorders, the validity and distinction between these two diagnostic categories has been debated.

Lastly, the tendency of cyclothymia to be comorbid with other mental disorders makes diagnosis difficult. These issues prevent consensus on the definition of cyclothymia and its relationship with other mental disorders among researchers and clinicians. This lack of consensus on an operational definition and symptom presentation is especially pronounced with children and adolescents because the diagnostic criteria have not been adequately adapted to take into account their developmental level.

Society and Culture

Actor Stephen Fry has spoken about his experience with cyclothymia, which was depicted in the documentary Stephen Fry: The Secret Life of the Manic Depressive.

Singer Charlene Soraia had cyclothymia and wrote a song about her experiences with the disorder.

What is Depressive Disorder Not Otherwise Specified?

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Introduction

Depressive Disorder Not Otherwise Specified (DD-NOS) is designated by the code 311 in the DSM-IV for depressive disorders that are impairing but do not fit any of the officially specified diagnoses. According to the DSM-IV, DD-NOS encompasses “any depressive disorder that does not meet the criteria for a specific disorder.” In the DSM-5, it is called unspecified depressive disorder.

Refer to Dissociative Disorder Not Otherwise Specified (DDNOS).

Background

Examples of disorders in this category include those sometimes described as minor depressive disorder and recurrent brief depression.

“Depression” refers to a spectrum of disturbances in mood that vary from mild to severe and from short periods to constant illness. DD-NOS is diagnosed if a patients symptoms fail to meet the criteria more common depressive disorders such as major depressive disorder or dysthymia. Although DD-NOS shares similar symptoms to dysthymia, dysthymia is classified by a period of at least 2 years of constantly recurring depressed mood, where as DD-NOS is classified by much shorter periods of depressed moods.

For most people who suffer the condition, their life will be significantly affected. DD-NOS can make many aspects of a person’s daily life difficult to manage, inhibiting their ability to enjoy the things that used to make them happy. Sufferers of the disorder tend to isolate themselves from their friends and families, lose interest in some activities, and experience behavioural changes and sleeping disorders. Some sufferers also experience suicidal tendencies or suicide attempts. In addition to having these symptoms, a diagnosis of DD-NOS will only be made if the symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning. For the diagnosis to be accurate, a psychiatrist is required to spend extensive time with the patient.

Symptoms of the disorder may arise due to several reasons. These include:

  • Distress due to medical conditions.
  • Environmental effects and situations.

However, the effects of drugs or medication or bereavement are not classified under the diagnosis.

A person will not be diagnosed with the condition if they have or have had any of the following: a major depressive episode, manic episode, mixed episode or hypomanic episode.

A diagnosis of the disorder will look like: “Depressive Disorder NOS 311”.

Concerns

Accurately assessing for a specific Depressive Disorder diagnosis requires an expenditure of time that is deemed unreasonable for most primary care physicians. For this reason, physicians often use this code as a proxy for a more thorough diagnosis. There is concern that this may lead to a “wastebasket” mindset for certain disorders. In addition reimbursement through Medicare may be lower for certain non specific diagnosis.

Treatment

It is possible for this disorder to progress over time. A patient suffering from the disorder can improve the condition with treatments. There are several types of therapies that may improve the condition, but depending on a patient’s experience of the disorder or the cause of the disorder, treatments will vary.

  • Psychotherapy including behaviour therapy, Gestalt therapy, Adlerian therapy, psychoanalytic therapy and existential therapy.
  • Pharmacotherapy through medications including antidepressants.

What is Recurrent Brief Depression?

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Introduction

Recurrent brief depression (RBD) defines a mental disorder characterised by intermittent depressive episodes, not related to menstrual cycles in women, occurring between approximately 6-12 times per year, over at least one year or more fulfilling the diagnostic criteria for major depressive episodes (DSM-IV and ICD-10) except for duration which in RBD is less than 14 days, typically 5-7 days.

Despite the short duration of the depressive episodes, such episodes are severe, and suicidal ideation and impaired function is rather common. The majority of patients with RBD also report symptoms of anxiety and increased irritability. Hypersomnia is also rather frequent. About 1/2 of patients fulfilling diagnostic criteria for RBD may have additional short episodes of brief hypomania which is a severity marker of RBD. RBD may be the only mental disorder present, but RBD may also occur as part of a history of recurrent major depressive episodes or bipolar disorders. RBD is also seen among some patients with personality disorders.

Prevalence

The lifetime prevalence of RBD has been estimated at 2.6-10.0%, and the one-year prevalence at 5.0-8.2%. The WHO project on “Psychological problems in general health care”, which was based on primary care samples, reported a one-year prevalence of 3.7-9.9%. However none of these studies differentiate between RBD with and without a history of other mood disorders (e.g. major depression). DSM-IV field trial estimated the lifetime of RBD only to be about 2%.

Brief History

Disorders characterised by periods with depressive episodes lasting hours to days have been described since 1852 and have been labelled “periodic melancholia”, “intermittent depressive disorder” or “very brief depression”. The third version of the Diagnostic and Statistical Manual of Mental Disorders (1980), which relied heavily on findings from studies conducted in psychiatric in- and out-patient settings, required at least 14 days duration for a diagnosis of depression. No diagnostic category was allocated a depressive episode of shorter duration. Thus, intermittent depressive disorder, included in the Research Diagnostic Criteria (1975) was considered to identify minor versions of major depression (“minor depression”) and not included in the DSM-III.

However, based on data from epidemiological studies, the Swiss psychiatrist and researcher, Jules Angst, coined the concept “recurrent brief depression” (RBD) and provided diagnostic criteria for this type of mood disorder in 1985. Several other European studies independently confirmed the occurrence of RBD in the general population and clinical samples. RBD was thus included in the 10th classification of mental and behavioural disorders (ICD-10 F38.1) published by the World Health Organisation in 1992 (WHO, 1992; WHO, 1993). Less frequent episodes of brief depressions were labelled infrequent brief depression and not included in ICD-10. The American classification system of mental disorders, DSM-IV (1994), provided provisional diagnostic criteria for RBD, but decided to await further studies before including RBD in the classification system. The fate of RBD in DSM-5, expected to occur in 2013, is not known.

Causes

The cause (aetiology) of RBD is unknown, but recent findings may suggest a link between RBD and bipolar disorders, pointing to the importance of genetic factors. A small subgroup of patients with RBD has temporal lobe epilepsy.

Diagnosis

From the International Statistical Classification of Mental and Behavioral Disorders:

F33 Recurrent depressive disorder

  • G1. There has been at least one previous episode, mild (F32.0), moderate (F32.1), or severe (F32.2 or F32.3), lasting a maximum of two weeks and separated from the current episode by at least two months free from any significant mood symptoms.
  • G2. At no time in the past has there been an episode meeting the criteria or hypomanic or manic episode (F30.-).
  • G3. Most commonly used exclusion criteria: the episode is not attributable to psychoactive substance use (F1) or any organic mental disorder, in the sense of F0. It is recommended to specify the predominant type of previous episodes (mild, moderate, severe, uncertain).

F33.0 Recurrent depressive disorder, current episode mild

  • A. The general criteria for recurrent depressive disorder (F33) are met.
  • B. The current episode meets the criteria for depressive episode, mild severity (F32.0).
  • A fifth character may be used to specify the presence of the somatic syndrome, as defined in F32, in the current episode:
    • F33.00 without somatic syndrome.
    • F33.01 with somatic syndrome.

F33.1 Recurrent depressive disorder, current episode moderate

  • A. The general criteria for recurrent depressive disorders (F33) are met.
  • B. The current episode meets the criteria for depressive episode, moderate severity (F32.1).
  • A fifth character may be used to specify the presence of the somatic syndrome, as defined in F32, in the current episode:
    • F33.10 without somatic syndrome
    • F33.11 with somatic syndrome.

F33.2 Recurrent depressive disorder, current episode severe without psychotic symptoms

  • A. The general criteria for recurrent depressive disorders (F33) are met.
  • B. The current episode meets the criteria for severe depressive episode without psychotic symptoms (F32.2).

F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms

  • A. The general criteria for recurrent depressive disorders (F33) are met.
  • B. The current episode meets the criteria for severe depressive episode with psychotic symptoms (F32.3). A fifth character may be used to specify whether the psychotic symptoms are congruent or incongruent with the mood:
    • F33.30 with mood congruent psychotic symptoms.
    • F33.31 with mood incongruent psychotic symptoms.

F33.4 Recurrent depressive disorder, currently in remission

  • A. The general criteria for recurrent depressive disorder (F33) have been met in the past.
  • B. The current state does not meet the criteria for a depressive episode (F32.-) of any severity, or for any other disorder in F3 (the patient may receive treatment to reduce the risk of further episodes).

F33.8 Other recurrent depressive disorders.

F33.9 Recurrent depressive disorder, unspecified.

Treatment

Both psychotherapy as well as different drugs (e.g. serotonin reuptake inhibitors – SSRIs or mood stabilisers, e.g. lithium, antiepileptics) have been suggested as treatments. However, no randomised controlled treatment trial of RBD has been conducted.

What is a Major Depressive Episode?

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Introduction

A major depressive episode (MDE) is a period characterised by the symptoms of major depressive disorder.

Sufferers primarily have a depressed mood for two weeks or more, and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of suicide. Insomnia or hypersomnia, aches, pains, or digestive problems that are resistant to treatment may also be present. The description has been formalized in psychiatric diagnostic criteria such as the DSM-5 and ICD-10.

Biological, psychological, and social factors are believed to be involved in the cause of depression, although it is still not well understood. Factors like socioeconomic status, life experience, and personality tendencies play a role in the development of depression and may represent increases in risk for developing a MDE. There are many theories as to how depression occurs. One interpretation is that neurotransmitters in the brain are out of balance, and this results in feelings of worthlessness and despair. Magnetic resonance imaging shows that brains of people who have depression look different than the brains of people not exhibiting signs of depression. A family history of depression increases the chance of being diagnosed.

Emotional pain and economic costs are associated with depression. In the United States and Canada, the costs associated with major depression are comparable to those related to heart disease, diabetes, and back problems and are greater than the costs of hypertension. According to the Nordic Journal of Psychiatry, there is a direct correlation between major depressive episode and unemployment.

Treatments for a major depressive episode include psychotherapy and antidepressants, although in more serious cases, hospitalization or intensive outpatient treatment may be required.

Signs and Symptoms

The criteria below are based on the formal DSM-V criteria for a major depressive episode. A diagnosis of major depressive episode requires that the patient has experienced five or more of the symptoms below, and one of the symptoms must be either depressed mood or loss of interest or pleasure (although both are frequently present). These symptoms must be present for at least 2 weeks and represent a change from the patient’s normal behaviour.

Depressed Mood and Loss of Interest (Anhedonia)

Either depressed mood or a loss of interest or pleasure must be present for the diagnosis of a MDE. Depressed mood is the most common symptom seen in major depressive episodes. Interest or pleasure in everyday activities can be decreased; this is referred to as anhedonia. These feelings must be present on an everyday basis for two weeks or longer to meet DSM-V criteria for a MDE. In addition, the person may experience one or more of the following emotions: sadness, emptiness, hopelessness, indifference, anxiety, tearfulness, pessimism, emotional numbness, or irritability. In children and adolescents, a depressed mood often appears more irritable in nature. There may be a loss of interest in or desire for sex, or other activities once found to be pleasant. Friends and family of the depressed person may notice that they have withdrawn from friends, or neglected or quit doing activities that were once a source of enjoyment.

Sleep

Nearly every day, the person may sleep excessively, known as hypersomnia, or not enough, known as insomnia. Insomnia is the most common type of sleep disturbance for people who are clinically depressed. Symptoms of insomnia include trouble falling asleep, trouble staying asleep, or waking up too early in the morning. Hypersomnia is a less common type of sleep disturbance. It may include sleeping for prolonged periods at night or increased sleeping during the daytime. The sleep may not be restful, and the person may feel sluggish despite many hours of sleep, which may amplify their depressive symptoms and interfere with other aspects of their lives. Hypersomnia is often associated with an atypical depression, as well as seasonal affective disorder.

Feelings of Guilt or Worthlessness

Depressed people may have feelings of guilt that go beyond a normal level or are delusional. These feelings of guilt and/or worthlessness are excessive and inappropriate. MDE’s are notable for a significant, often unrealistic, drop in self-esteem. The guilt and worthlessness experienced in a MDE can range from subtle feelings of guilt to frank delusions or to shame and humiliation. Additionally, self-loathing is common in clinical depression, and can lead to a downward spiral when combined with other symptoms.

Loss of Energy

Persons going through a MDE often have a general lack of energy, as well as fatigue and tiredness, nearly every day for at least 2 weeks. A person may feel tired without having engaged in any physical activity, and day-to-day tasks become increasingly difficult. Job tasks or housework become very tiring, and the patient finds that their work begins to suffer.

Decreased Concentration

Nearly every day, the person may be indecisive or have trouble thinking or concentrating. These issues cause significant difficulty in functioning for those involved in intellectually demanding activities, such as school and work, especially in difficult fields. Depressed people often describe a slowing of thought, inability to concentrate and make decisions, and being easily distracted. In the elderly, the decreased concentration caused by a MDE may present as deficits in memory. This is referred to as pseudodementia and often goes away with treatment. Decreased concentration may be reported by the patient or observed by others.

Change in Eating, Appetite, or Weight

In a major depressive episode, appetite is most often decreased, although a small percentage of people experience an increase in appetite. A person experiencing a depressive episode may have a marked loss or gain of weight (5% of their body weight in one month). A decrease in appetite may result in weight loss that is unintentional or when a person is not dieting. Some people experience an increase in appetite and may gain significant amounts of weight. They may crave certain types of food, such as sweets or carbohydrates. In children, failure to make expected weight gains may be counted towards this criteria. Overeating is often associated with atypical depression.

Motor Activity

Nearly every day, others may see that the person’s activity level is not normal. People suffering from depression may be overly active (psychomotor agitation) or be very lethargic (psychomotor retardation). Psychomotor agitation is marked by an increase in body activity which may result in restlessness, an inability to sit still, pacing, hand wringing, or fidgeting with clothes or objects. Psychomotor retardation results in a decrease in body activity or thinking. In this case, a depressed person may demonstrate a slowing of thinking, speaking, or body movement. They may speak more softly or say less than usual. To meet diagnostic criteria, changes in motor activity must be so abnormal that it can be observed by others. Personal reports of feeling restless or feeling slow do not count towards the diagnostic criteria.

Thoughts of Death and Suicide

A person going through a MDE may have repeated thoughts about death (other than the fear of dying) or suicide (with or without a plan), or may have made a suicide attempt. The frequency and intensity of thoughts about suicide can range from believing that friends and family would be better off if one were dead, to frequent thoughts about committing suicide (generally related to wishing to stop the emotional pain), to detailed plans about how the suicide would be carried out. Those who are more severely suicidal may have made specific plans and decided upon a day and location for the suicide attempt.

Comorbid Disorders

MDE’s may show comorbidity (association) with other physical and mental health problems. About 20-25% of individuals with a chronic general medical condition will develop major depression. Common comorbid disorders include: eating disorders, substance-related disorders, panic disorder, and obsessive-compulsive disorder. Up to 25% of people who experience a major depressive episode have a pre-existing dysthymic disorder.

Some persons who have a fatal illness or are at the end of their life may experience depression, although this is not universal.

Causes

The cause of a MDE is not well understood. However, the mechanism is believed to be a combination of biological, psychological, and social factors. A MDE can often follow an acute stress in someone’s life. Evidence suggests that psychosocial stressors play a larger role in the first 1-2 depressive episodes, while having less influence in later episodes. People who experience a major depressive episode often have other mental health issues.

Other risk factors for a depressive episode include:

  • Family history of a mood disorder;
  • Recent negative life events;
  • Personality (insecure, worried, stress-sensitive, obsessive, unassertive, dependent);
  • Early childhood trauma;
  • Postpartum; and
  • Lack of interpersonal relationships.

One gene by itself has not been linked to depression. Studies show that depression can be passed down in families, but this is believed to be due to a combined effect of genetic and environmental factors. Other medical conditions, like hypothyroidism for example, may cause someone to experience similar symptoms as a MDE, however this would be considered a mood disorder due to a general medical condition, according to the DSM-V.

Diagnosis

Criteria

The two main symptoms in a major depressive episode are a depressed mood or a loss of interest or pleasure. From the list below, one bold symptom and four other symptoms must be present for a diagnosis of MDE. These symptoms must be present for at least 2 weeks and must be causing significant distress or impairment in functioning.

  • Depressed mood.
  • Loss of interest or pleasure.
  • Change in appetite.
  • Change in sleep.
  • Change in body activity (psychomotor changes).
  • Loss of energy.
  • Feelings of worthlessness and excessive or inappropriate guilt.
  • Indecisiveness or a decrease in concentration.
  • Suicidal ideation.

To diagnose a major depressive episode, a trained healthcare provider must make sure that:

  • The symptoms do not meet the criteria for a mixed episode.
  • The symptoms must cause considerable distress or impair functioning at work, in social settings or in other important areas in order to qualify as an episode.
  • The symptoms are not due to the direct physiological effects of a substance (e.g. abuse of a drug or medication) or a general medical condition (e.g. hypothyroidism).

Workup

No labs are diagnostic of a depressive episode. But some labs can help rule out general medical conditions that may mimic the symptoms of a depressive episode. Healthcare providers may order some routine blood work, including routine blood chemistry, CBC with differential, thyroid function studies, and Vitamin B12 levels, before making a diagnosis.

Differential Diagnosis

There are other mental health disorders or medical conditions to consider before diagnosing a MDE:

  • Bipolar disorder.
  • Cyclothymic disorder.
  • Disruptive mood dysregulation disorder.
  • Persistent depressive disorder.
  • Anxiety disorder (Generalised anxiety, PTSD, obsessive compulsive disorder).
  • Substance abuse or Substance Use Disorder.
  • Personality disorder with depressive symptoms.
  • Adjustment disorder.
  • Depression due to a general medical condition.
  • Premenstrual dysphoric disorder.

Screening

Healthcare providers may screen patients in the general population for depression using a screening tool, such as the Patient Healthcare Questionnaire-2 (PHQ-2). If the PHQ-2 screening is positive for depression, a provider may then administer the PHQ-9. The Geriatric Depression Scale is a screening tool that can be used in the elderly population.

Treatment

Depression is a treatable illness. Treatments for a MDE may be provided by mental health specialists (i.e. psychologist, psychiatrists, social workers, counsellors, etc.), mental health centres or organisations, hospitals, outpatient clinics, social service agencies, private clinics, peer support groups, clergy, and employee assistance programmes. The treatment plan could include psychotherapy alone, antidepressant medications alone, or a combination of medication and psychotherapy.

For major depressive episodes of severe intensity (multiple symptoms, minimal mood reactivity, severe functional impairment), combined psychotherapy and antidepressant medications are more effective than psychotherapy alone. Meta-analyses suggest that the combination of psychotherapy and antidepressant medications is more effective in treating mild and moderate forms of depression as well, compared to either type of treatment alone. Patients with severe symptoms may require outpatient treatment or hospitalisation.

The treatment of a major depressive episode can be split into 3 phases:

  • Acute phase: the goal of this phase is to resolve the current major depressive episode.
  • Continuation: this phase continues the same treatment from the acute phase for 4-8 months after the depressive episode has resolved and the goal is to prevent relapse.
  • Maintenance: this phase is not necessary for every patient but is often used for patients who have experienced 2-3 or more MDE’s.
    • Treatment may be maintained indefinitely to prevent the occurrence and severity of future episodes.

Therapy

Psychotherapy, also known as talk therapy, counselling, or psychosocial therapy, is characterised by a patient talking about their condition and mental health issues with a trained therapist. Different types of psychotherapy are used as a treatment for depression. These include cognitive behavioural therapy, interpersonal therapy, dialectical behaviour therapy, acceptance and commitment therapy, and mindfulness techniques. Evidence shows that cognitive behavioural therapy can be as effective as medication in the treatment of a MDE.

Psychotherapy may be the first treatment used for mild to moderate depression, especially when psychosocial stressors are playing a large role. Psychotherapy alone may not be as effective for more severe forms of depression.

Some of the main forms of psychotherapies used for treatment of a major depressive episode along with what makes them unique are included below:

  • Cognitive psychotherapy: focus on patterns of thinking.
  • Interpersonal psychotherapy: focus on relationships, losses, and conflict resolution.
  • Problem-solving psychotherapy: focus on situations and strategies for problem-solving.
  • Psychodynamic psychotherapy: focus on defence mechanisms and coping strategies.

Medication

Medications used to treat depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine-dopamine reuptake inhibitors (NDRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and atypical antidepressants such as mirtazapine, which do not fit neatly into any of the other categories. Different antidepressants work better for different individuals. It is often necessary to try several before finding one that works best for a specific patient. Some people may find it necessary to combine medications, which could mean two antidepressants or an antipsychotic medication in addition to an antidepressant. If a person’s close relative has responded well to a certain medication, that treatment will likely work well for him or her. Antidepressant medications are effective in the acute, continuation, and maintenance phases of treatment, as described above.

The treatment benefits of antidepressant medications are often not seen until 1-2 weeks into treatment, with maximum benefits being reached around 4-6 weeks. Most healthcare providers will monitor patients more closely during the acute phase of treatment and continue to monitor at longer intervals in the continuation and maintenance phases.

Sometimes, people stop taking antidepressant medications due to side effects, although side effects often become less severe over time. Suddenly stopping treatment or missing several doses may cause withdrawal-like symptoms. Some studies have shown that antidepressants may increase short-term suicidal thoughts or actions, especially in children, adolescents, and young adults. However, antidepressants are more likely to reduce a person’s risk of suicide in the long run.

Below are listed the main classes of antidepressant medications, some of the most common drugs in each category, and their major side effects:

  • Selective serotonin reuptake inhibitors (citalopram, escitalopram, paroxetine, fluoxetine, sertraline): major side effects include nausea, diarrhoea, and sexual dysfunction.
  • Serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, desvenlafaxine): major side effects include nausea, diarrhoea, increased heart rate, increased blood pressure, and tremor.
  • Tricyclic antidepressants (amitryptiline, desipramine, doxepin, imipramine, nortriptyline): major side effects include sedation, low blood pressure when moving from sitting to standing (orthostatic hypotension), tremor, and heart issues like conduction delays or arrhythmias.
  • Monoamine oxidase inhibitors (isocarboxazid, phenelzine, selegiline): major side effects include high blood pressure (emergency) if eaten with foods rich in tyramine (e.g. cheeses, some meats, and home-brewed beer), sedation, tremor, and orthostatic hypotension.

Alternative Treatments

There are several treatment options that exist for people who have experienced several episodes of major depression or have not responded to several treatments.

Electroconvulsive therapy is a treatment in which a generalised seizure is induced by means of electrical current. The mechanism of action of the treatment is not clearly understood but has been show to be most effective in the most severely depressed patients. For this reason, electroconvulsive therapy is preferred for the most severe forms of depression or depression that has not responded to other treatments, known as refractory depression.

Vagus nerve stimulation is another alternative treatment that has been proven to be effective in the treatment of depression, especially people that have been resistant to four or more treatments. Some of the unique benefits of vagus nerve stimulation include improved neurocognitive function and a sustained clinical response.

Transcranial magnetic stimulation is also an alternative treatment for a major depressive episode. It is a non-invasive treatment that is easily tolerated and shows an antidepressant effect, especially in more typical depression and younger adults.

Prognosis

If left untreated, a typical MDE may last for several months. About 20% of these episodes can last two years or more. About half of depressive episodes end spontaneously. However, even after the MDE is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability. 50% of people will have another major depressive episode after the first. However, the risk of relapse is decreased by taking antidepressant medications for more than 6 months.

Symptoms completely improve in six to eight weeks in 60%-70% of patients. The combination of therapy and antidepressant medications has been shown to improve resolution of symptoms and outcomes of treatment.

Suicide is the 8th leading cause of death in the United States. The risk of suicide is increased during a MDE. However, the risk is even more elevated during the first two phases of treatment. There are several factors associated with an increased risk of suicide, listed below:

  • Greater than 45 years of age;
  • Male;
  • History of suicide attempt or self-injurious behaviours;
  • Family history of suicide or mental illness;
  • Recent severe loss;
  • Poor health;
  • Detailed plan;
  • Inability to accept help;
  • Lack of social support
  • Psychotic features (auditory or visual hallucinations, disorganisation of speech, behaviour, or thought);
  • Alcohol or drug use or comorbid psychiatric disorder; and/or
  • Severe depression.

Epidemiology

Estimates of the numbers of people suffering from MDE’s and major depressive disorder (MDD) vary significantly. Overall, 13-20% of people will experience significant depressive symptoms at some point in their life. The overall prevalence of MDD is slightly lower ranging from 3.7-6.7% of people. In their lifetime, 20% to 25% of women, and 7% to 12% of men will suffer a MDE. The peak period of development is between the ages of 25 and 44 years. Onset of major depressive episodes or MDD often occurs to people in their mid-20s, and less often to those over 65. The prevalence of depressive symptoms in the elderly is around 1-2%. Elderly persons in nursing homes may have increased rates, up to 15-25%. African-Americans have higher rates of depressive symptoms compared to other races. Prepubescent girls are affected at a slightly higher rate than prepubescent boys.

In a National Institute of Mental Health study, researchers found that more than 40% of people with post-traumatic stress disorder suffered from depression four months after the traumatic event they experienced.

Women who have recently given birth may be at increased risk for having a major depressive episode. This is referred to as postpartum depression and is a different health condition than the baby blues, a low mood that resolves within 10 days after delivery.