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Home » Major Depressive Disorder

  • Clinical Disorders

Major Depressive Disorder

  • - Written by admin
  • on August 3, 2021
major depressive disorder

Table of Contents

Overview 

Major Depressive Disorder (Major Depressive Disorder) is one of the most common mental disorders, and involves abnormalities in the mood, cognitive processes, physiological processes, sleep patterns, eating patterns, and psychomotor activities. The defining characteristics of the disorder include a depressed mood or loss of interest. 

The incidence of major depressive disorder is higher in women, and occurs mainly around adolescence, lasting through young adulthood, though it can also be diagnosed in childhood.

While the occurrence of Major Depressive Disorder continues on into later life, it is lower in people over 65, and can be difficult to diagnose in old age due to an overlap of symptoms with those of several medical illnesses such as dementia.

Causative factors have biological, neurological, environmental and sociodemographic bases.ย 

Major Depressive Disorder is a recurrent condition, and depressive episodes can typically last 6-9 months if untreated. In 20% of people with Major Depressive Disorder, symptoms do not remit for over two years, and Persistent Depressive Disorder is diagnosed.

Chronic major depression often relates to childhood trauma, family problems, and anxious personality during childhood.

A remission of depressive symptoms often occurs, with symptoms disappearing for a minimum of two months. However, symptoms return at some future point. Recurrence of symptoms is more common in those with comorbid symptoms. Relapse typically takes place when pharmacotherapy is terminated prematurely. 

The treatment for Major Depressive Disorder involves a combination of psychotherapy and medication. 

Signs and Symptoms of Major Depressive Disorder

Major Depressive Disorder requires a medical diagnosis. 

The signs and symptoms of major depressive disorder are: 

  • Feelings of sadness, emptiness, worthlessness and hopelessness 
  • Significantly decreased interest in all activities 
  • Loss or gain of weight that is not an effect of diet or exercise 
  • Fluctuating appetite nearly everyday
  • Experiencing sleep disturbances, such as excessively sleeping or not being able to sleep, nearly every day
  • Being restless or slowed down, enough to be observed by others 
  • Fatigue or loss of energy
  • Body pains, aches, or cramps that do not have a physical cause
  • Feelings of excessive or inappropriate guilt 
  • Decrease in the ability to think or concentrate
  • Feelings of indecisiveness 
  • Recurrent thoughts of death and suicide 

A diagnosis of Major Depressive Disorder requires five or more of the above symptoms to be present during a consecutive two-week period, with one of the symptoms being either depressed mood or loss of interest. 

Risk Factors 

Multiple studies have highlighted the importance of age, sex, marital status, education, heritability, immigration status and income as key sociodemographic factors associated with major depressive disorder. More women are affected by depression than men, and the prevalence of the disorder usually falls in early adolescence and adulthood.

A predisposition of neurotic tendencies, or negative affect, has also been linked to increasing vulnerability to Major Depressive Disorder. Traumatic childhood experiences and major life stressors can also be precursors to major depressive episodes. 

It is also possible for Major Depressive Disorder to develop in the background of other disorders, such as substance use disorder, anxiety disorders and borderline personality disorders. Chronic or disabling medical conditions can also prove to increase risks. 

Biological causal factors include genetic, neurochemical, neuroanatomical, neurophysiological, and hormonal influences. While there is speculation that sex differences in the prevalence of Major Depressive Disorder have biological bases, focusing mainly on hormonal and genetic factors, studies examining related hypotheses have been largely inconsistent and inconclusive. 

Diagnosis

Diagnoses of depression can be based on physical tests conducted to rule out underlying health problems as an influence, laboratory tests to ensure adequate hormonal balance, and psychological evaluations including self-report measures and interviews based around criteria outlined by the DSM-5.

The DSM-5 differs from its previous edition in that it removed the bereavement exclusion, which suggested that people who had recently experienced loss and met the diagnostic criteria for Major Depressive Disorder could be excluded from diagnosis. This is a controversial decision that gives rise to the concerns of pathologizing grief. 

The diagnostic criteria mentioned in the DSM-5 emphasize the presence of at least five of the following symptoms, one of which must be either depressed mood or loss of interest or pleasure: 

  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad, empty, hopeless) or observation made by others (e.g. appears tearful). (Note: in children and adolescents, can be irritable mood).
  2. Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day (as indicated by either subjective account or observation).
  3. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: in children, consider failure to make expected weight gain). 
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of being restless or slowed down). 
  6. Fatigue or loss of energy nearly every day. 
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt of a specific plan for committing suicide. 

It is important to consider that these symptoms are not better explained by other underlying mental disorders, are not a result of substance or medication, and cause significant distress in important areas of functioning.

These constitute the symptoms of a major depressive episode (MDE). For the diagnosis of Major Depressive Disorder, there must be presence of major depressive episodes and no experience of a manic, hypomanic or mixed episode.ย 

Individuals who meet the criteria for MDE also present additional symptomatic patterns, or specifiers, which can help evaluate the course development and preferred treatment. These are: 

  1. With melancholic features: involving three symptoms which can be early morning awakening, depression being worse in the morning, marked psychomotor agitation or retardation, loss of appetite or weight, excessive guilt, qualitatively different depressed mood
  2. With psychotic features (mood congruent/mood incongruent: Delusions or hallucinations that are related to mood, commonly feelings of guilt or worthlessness are present 
  3. With atypical features: wherein the individual brightens to positive events, and there is a presence of two symptoms which can be weight gain or increase in appetite, hypersomnia, heaviness of arms and legs (leaden paralysis), increased sensitivity to interpersonal rejection
  4. With catatonic features: various psychomotor symptoms, such as motoric immobility to increased psychomotor activity, including mutism and rigidity 
  5. With seasonal pattern: at least two or more episodes in the last two years, occurring in the same seasonal period (usually winter), and full remission in the same year (usually during summer). There is an absence of non-seasonal episodes in that duration. 

Other specifiers may include Major Depressive Disorder with anxious features, mixed features, or pre-partum or postpartum onset. 

Treatment for Major Depressive Disorder

Treatments of major depressive disorder follow the route of medication and psychotherapy. The course of treatment is determined by the symptoms present, and a mode of management that leads to improvement while also ensuring the patientโ€™s safety and functionality is chosen.

Severe depression can warrant hospital visits or admission, in the form of outpatient treatment programs or rehabilitation centres.

In cases of mild to moderate depression, initial courses of antidepressants are dependent on their side effects and safety of the medication, as effectiveness between different classes of antidepressants is generally uniform.

Depending on specifiers, medication may be modified in order to effectively treat presenting symptoms. Patients with psychotic depression are often difficult to treat and may need several forms of intervention including a combination of antipsychotic and antidepressant medication.

Electroconvulsive therapy (ECT) is administered for treatment-resistant depression, such as severe psychotic depression with severe suicidality, catatonia or refusal to eat. There is also evidence of transcranial magnetic stimulation being effective for treatment-resistant depression, including catatonia.

There has also been evidence of the efficacy of physical activity in alleviating symptoms of depression, such as yoga therapy, resistance training and aerobic exercise in mild cases.

Differential Diagnosis

1. Manic episodes with irritable mood or mixed episodes: Major depressive episodes with prominent irritable mood may be difficult to differentiate from manic episodes with irritable mood or from mixed episodes. This distinction requires a careful clinical evaluation of the presence of manic symptoms.

2. Mood disorder due to another medical condition: A major depressive episode is the appropriate diagnosis if the mood disturbance is not judged, based on individual history, physical examination, and laboratory findings, to be the direct pathophysiological consequence of a specific medical condition

3. Substance/medication-induced depressive or bipolar disorder: This disorder is distinguished from major depressive disorder by the fact that a substance intake is responsible for the mood disturbance.

4. Attention-deficit/hyperactivity disorder: HIgh distractibility and low frustration tolerance can occur in both attention-deficit/ hyperactivity disorder and a major depressive episode; if the criteria are met for both, attention-deficit/hyperactivity disorder may be diagnosed in addition to the mood disorder.

5. Adjustment disorder with depressed mood: A major depressive episode that occurs in response to a psychosocial stressor is distinguished from adjustment disorder with depressed mood by the fact that the full criteria for a major depressive episode are not met in adjustment disorder.

6. Sadness: Periods of sadness are natural for humans. These periods should not be diagnosed as a major depressive episode unless criteria are met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day, nearly every day for at least 2 weeks), and clinically significant distress or impairment.

Comorbidity

Disorders comorbid with which major depressive disorder are substance related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, and borderline personality disorder.

Specialist 

Primary healthcare providers will often conduct tests to dismiss underlying physical causes that coincide with depressive symptoms. Treatment options that involve psychopharmacological approaches are implemented by psychiatrists, who may also undertake the psychotherapeutic responsibilities. Alternatively, a therapist and psychiatrist may collaboratively provide psychotherapy and medication respectively. 

In Conclusion

You can’t just “snap out” of despair; it’s not a sign of weakness. Long-term treatment may be necessary for depression. But resist giving up. With medicine, counseling, or both, the majority of depressed persons get improved symptoms. There is no foolproof method to stop depression. 

However, these methods might be useful. Take action to manage your stress, build your resilience, and improve your self-esteem. To get through difficult times, reach out to family and friends, especially during times of crisis.

Consult Anandaโ€™s mental healthcare professionals and get help as soon as a problem arises to stop depression from getting worse.

Ready To Get Better? First Session at โ‚น99 Now.

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Table of Contents

Frequently Asked Questions

What is depression?

Depression is a clinical condition that is characterized by depressive episodes, often involving an inability to feel or anticipate pleasure and causing distress that hinders functionality. Depression can have physiological, emotional and cognitive symptoms, as well as affect eating and sleeping patterns.ย 

What is perinatal depression?

Perinatal depression occurs during pregnancy or in the duration following delivery (postpartum depression), due to a combination of social, hormonal, and genetic reasons. While having โ€˜postpartum bluesโ€™ is considered normal after delivery due to hormonal imbalances, if gone unchecked, it can lead to depression.

What is melancholia?

โ€˜Melancholiaโ€™ refers to one of the oldest terminologies in psychology, dating back to the 5th century BC. It refers to symptoms such as fear, loss of appetite, insomnia, restlessness, agitation and sadness, which are now used to characterize the melancholic specifier of major depression.

What is psychotic depression?

Psychotic depression is a form of major depressive disorder characterized by the presence of psychotic symptoms. There are often delusions and hallucinations that lead to the manifestations of feelings of worthlessness, failure, and guilt within an individual.ย 

What is atypical depression?

Atypical depression is a subtype marked by symptoms such as weight gain, increased appetite, excessive sleep, loss of energy, being sensitive to rejection, and moods that are intensely situationally affected.

What is catatonic depression?

The distinguishing symptoms of catatonic depression include an inability to move or speak for extended periods of time, in addition to other general symptoms of depression or catatonia.

What is seasonal depression?

Seasonal Affective Disorder, or seasonal depression, is a type of depression that manifests at the same time each year, usually in winter or autumn, and remits in summer or spring.

Does feeling extremely tired for one day constitute a depressive symptom?

Five symptoms, one being either depressive mood or loss of interest, must be present for two consecutive weeks in order to be considered a depressive episode. Hence, just a day of tiredness does not suffice.

What other conditions have similar signs and symptoms as depression?

Some characteristic symptoms of depression may also be seen in manic episodes with irritable mood or mixed episodes, mood disorders that are caused by medical conditions, substance/medication-induced depressive or bipolar disorder, attention-deficit/hyperactivity disorder, and adjustment disorder with depressed mood.

Which other disorders are frequently seen co-occurring with depression?

Major depressive disorder often co-occurs with substance related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, borderline personality disorder, and anxiety disorders.

Are suicidal tendencies always seen in individuals with Major Depressive Disorder?

While there is a possibility of suicidal thoughts and behavior at all times during Major Depressive Disorder, they are not a prerequisite for diagnosis. Suicidal tendencies can range from fleeting thoughts to attempts of suicide, often without any prior planning to carry out the attempt. Factors such as being isolated and marked feelings of hopelessness may increase the risk of suicidal tendencies.

How is grief different from depression?

The prominent factors of grief include feelings of loss or emptiness, while depression is a much more severe experience of distress that not only involves feelings outlined by grief, but also includes the inability to anticipate happiness.

Why is depression more prevalent in women than men?

While there has been no concrete breakthrough in the research pertaining to sex differences in the prevalence of depression, studies are mainly centred around biological, hormonal and psychosocial factors. The susceptibility to depression usually increases in women after adolescence. Additionally, women are more likely to face distressing environmental events and situations, which proves to be an added risk.ย 

Are depression and menstruation related?

Literature on โ€˜reproductive depressionโ€™ states that depression in women is commonly seen in times of hormonal changes such as during premenstrual days, postnatal months, and the transitional period leading up to menopause.

What are commonly overlooked signs of depression in men?

Signs such as physical pain symptoms, anger, substance abuse, and reckless behavior often tend to be neglected in men, due to social conditioning and stigma.

What are the environmental causes of depression?

Stressful life events or experiences of loss or bereavement are often considered primary precursors to depressive episodes. Adverse childhood experiences or trauma may also constitute potential risk factors.ย 

Can sustaining major injuries cause depression?

Suffering a major or life-altering injury, or the diagnosis of a major or life-altering disease can often increase the risk of depression. Chronic or disabling conditions can often make individuals think of themselves as a burden to others, thereby increasing negative affect.ย 

Who carries out the diagnosis for Major Depressive Disorder?

Diagnoses of major depressive disorder are mostly made by psychiatrists or clinical psychologists.

Can depression be self-diagnosed?

Depression requires a medical diagnosis made by a professional healthcare provider and cannot be self-diagnosed. Any self-report measures to diagnose the disorder should only be considered valid if implemented by a professional.

Is there a test for depression?

While there is no definitive test that confirms diagnosis, multiple screening inventories and tools are available to assist healthcare professionals in assessing individuals.

Are physical and laboratory tests involved in diagnosing depression?

The implementation of physical exams and laboratory tests is often carried out before diagnosing depression as methods of exclusion. Medical tests rule out any underlying physical causes that may be linked to depression, and lab tests can help determine hormonal levels. Other physical screenings may also be carried out in order to determine what sort of medication or treatment is suitable.

Are antidepressants addictive?

There is minimal evidence of antidepressants being addictive, and they are classified nowhere as addictive substances. While there have been reports of individuals experiencing withdrawal symptoms, it is often hard to differentiate them from relapse of illness.

What is treatment-resistant depression?

There are some cases of depression that do not respond to standard treatment. These cases are termed โ€˜treatment-resistantโ€™ cases of depression, and require eclectic approaches to treatment.

How effective is electroconvulsive therapy?

Electroconvulsive therapy (ECT) reportedly provides prompt relief in depression symptoms, with some trials reporting a remission rate of 75%. It has also proven to have a higher efficacy in treatment of psychotic depression than combination pharmacotherapy. However, due to its considerable side effects and risks, ECT is reserved for severe and chronic cases of treatment-resistant depression.

What are the alternatives to ECT?

Electromagnetic treatments, such as suitable amounts of transcranial magnetic stimulation, have had considerable efficacy along with strong safety profiles, though effect size is smaller than that of ECT. Vagus-nerve stimulation has also been approved for use with treatment-resistant depression, though with less speed of action and effect size than that of ECT.

Is exercise effective in treating depression?

In the absence of psychotherapy and in mild cases, exercise can be moderately effective in alleviating symptoms of depression. However, it is not more effective than psychotherapy and pharmacotherapy.

To whom can I reach out if I suspect I have depression?

Your primary healthcare provider will be able to provide necessary guidance and connect you with mental healthcare providers.

Can I buy antidepressants without a prescription from my doctor?

No, you cannot buy antidepressants over-the-counter. Antidepressants require a prescription from a professional.

What if I donโ€™t agree with my diagnosis?

If there are cases where you feel you have been misdiagnosed, or undiagnosed yet experiencing symptoms, you can always seek out second or even third opinions.

Who provides emergency assistance regarding depressive symptoms?

A number of hotlines and helplines are put in place which are either governmental or have been established by various private or non-government organizations. If you suspect you are facing symptoms of depression, especially suicidal thoughts or tendencies, reach out immediately.

References

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  14. Blumenthal, J. A., Babyak, M. A., Doraiswamy, P. M., Watkins, L., Hoffman, B. M., Barbour, K. A., Herman, S., Craighead, W. E., Brosse, A. L., Waugh, R., Hinderliter, A., & Sherwood, A. (2007). Exercise and pharmacotherapy in the treatment of major depressive disorder.ย Psychosomatic medicine,ย 69(7), 587โ€“596. https://doi.org/10.1097/PSY.0b013e318148c19a
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