Psychological Disorders: Major Depressive Disorder
American
Description
At least one of the following three abnormal moods which significantly
interfered with the person's life:
Abnormal depressed mood most of the day, nearly every day, for at
least 2 weeks.
Abnormal loss of all interest and pleasure most of the day, nearly
every day, for at least 2 weeks.
If 18 or younger, abnormal irritable mood most of the day, nearly
every day, for at least 2 weeks.
At least five of the following symptoms have been present during the
same 2 week depressed period.
Abnormal depressed mood (or irritable mood if a child or adolescent)
[as defined in criterion A].
Abnormal loss of all interest and pleasure [as defined in criterion
A2].
Appetite or weight disturbance, either:
Abnormal weight loss (when not dieting) or decrease in appetite.
Abnormal weight gain or increase in appetite.
Sleep disturbance, either abnormal insomnia or abnormal hypersomnia.
Activity disturbance, either abnormal agitation or abnormal slowing
(observable by others).
Abnormal fatigue or loss of energy.
Abnormal self-reproach or inappropriate guilt.
Abnormal poor concentration or indecisiveness.
Abnormal morbid thoughts of death (not just fear of dying) or suicide.
The symptoms are not due to a mood-incongruent psychosis.
There has never been a Manic Episode, a Mixed Episode, or a Hypomanic
Episode.
The symptoms are not due to physical illness, alcohol, medication,
or street drugs.
The symptoms are not due to normal bereavement.
Essential Features
By definition, Major Depressive Disorder cannot be due to:
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 Comorbidity
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.
Laboratory
Findings
There are no laboratory findings that are diagnostic for this disorder.
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
And Course
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.
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 Attention-Deficit Hyperactivity
Disorder.
European
Description
The disorder is characterized by repeated episodes of depression as
specified in depressive episode (mild, moderate, or severe), without
any history of independent episodes of mood elevation and overactivity
that fulfill the criteria of mania. However, the category should still
be used if there is evidence of brief episodes of mild mood elevation
and overactivity which fulfill the criteria of hypomania immediately
after a depressive episode (sometimes apparently precipitated by treatment
of a depression). The age of onset and the severity, duration, and
frequency of the episodes of depression are all highly variable. In
general, the first episode occurs later than in bipolar disorder,
with a mean age of onset in the fifth decade. Individual episodes
also last between 3 and 12 months (median duration about 6 months)
but recur less frequently. Recovery is usually complete between episodes,
but a minority of patients may develop a persistent depression, mainly
in old age (for which this category should still be used). Individual
episodes of any severity are often precipitated by stressful life
events; in many cultures, both individual episodes and persistent
depression are twice as common in women as in men.
The
risk that a patient with recurrent depressive disorder will have an
episode of mania never disappears completely, however many depressive
episodes he or she has experienced. If a manic episode does occur,
the diagnosis should change to bipolar affective disorder.
Recurrent
depressive episode may be subdivided, as below, by specifying first
the type of the current episode and then (if sufficient information
is available) the type that predominates in all the episodes.
Includes:
* recurrent episodes of depressive reaction, psychogenic depression,
reactive depression, seasonal affective disorder
* recurrent episodes of endogenous depression, major depression, manic
depressive psychosis (depressed type), psychogenic or reactive depressive
psychosis, psychotic depression, vital depression
Excludes:
* recurrent brief depressive episodes
F32
Depressive Episode
In typical depressive episodes of all three varieties described below
(mild, moderate, and severe), the individual usually suffers from
depressed mood, loss of interest and enjoyment, and reduced energy
leading to increased fatiguability and diminished activity. Marked
tiredness after only slight effort is common. Other common symptoms
are:
(a)
reduced concentration and attention;
(b) reduced self-esteem and self-confidence;
(c) ideas of guilt and unworthiness (even in a mild type of episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite.
The
lowered mood varies little from day to day, and is often unresponsive
to circumstances, yet may show a characteristic diurnal variation
as the day goes on. As with manic episodes, the clinical presentation
shows marked individual variations, and atypical presentations are
particularly common in adolescence. In some cases, anxiety, distress,
and motor agitation may be more prominent at times than the depression,
and the mood change may also be masked by added features such as irritability,
excessive consumption of alcohol, histrionic behaviour, and exacerbation
of pre-existing phobic or obsessional symptoms, or by hypochondriacal
preoccupations. For depressive episodes of all three grades of severity,
a duration of at least 2 weeks is usually required for diagnosis,
but shorter periods may be reasonable if symptoms are unusually severe
and of rapid onset.
Some
of the above symptoms may be marked and develop characteristic features
that are widely regarded as having special clinical significance.
The most typical examples of these "somatic" symptoms are:
loss of interest or pleasure in activities that are normally enjoyable;
lack of emotional reactivity to normally pleasurable surroundings
and events; waking in the morning 2 hours or more before the usual
time; depression worse in the morning; objective evidence of definite
psychomotor retardation or agitation (remarked on or reported by other
people); marked loss of appetite; weight loss (often defined as 5%
or more of body weight in the past month); marked loss of libido.
Usually, this somatic syndrome is not regarded as present unless about
four of these symptoms are definitely present.
The
categories of mild, moderate and severe depressive episodes described
in more detail below should be used only for a single (first) depressive
episode. Further depressive episodes should be classified under one
of the subdivisions of recurrent depressive disorder.
These
grades of severity are specified to cover a wide range of clinical
states that are encountered in different types of psychiatric practice.
Individuals with mild depressive episodes are common in primary care
and general medical settings, whereas psychiatric inpatient units
deal largely with patients suffering from the severe grades.
Acts
of self-harm associated with mood (affective) disorders, most commonly
self-poisoning by prescribed medication, should be recorded by means
of an additional code from Chapter XX of ICD-10 (X60-X84). These codes
do not involve differentiation between attempted suicide and "parasuicide",
since both are included in the general category of self-harm.
Differentiation
between mild, moderate, and severe depressive episodes rests upon
a complicated clinical judgement that involves the number, type, and
severity of symptoms present. The extent of ordinary social and work
activities is often a useful general guide to the likely degree of
severity of the episode, but individual, social, and cultural influences
that disrupt a smooth relationship between severity of symptoms and
social performance are sufficiently common and powerful to make it
unwise to include social performance amongst the essential criteria
of severity.
The
presence of dementia or mental retardation does not rule out the diagnosis
of a treatable depressive episode, but communication difficulties
are likely to make it necessary to rely more than usual for the diagnosis
upon objectively observed somatic symptoms, such as psychomotor retardation,
loss of appetite and weight, and sleep disturbance.
Includes:
* single episodes of depression (without psychotic symptoms), psychogenic
depression or reactive depression)
F32.0
Mild Depressive Episode
Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased fatiguability
are usually regarded as the most typical symptoms of depression, and
at least two of these, plus at least two of the other symptoms described
above should usually be present for a definite diagnosis. None of
the symptoms should be present to an intense degree. Minimum duration
of the whole episode is about 2 weeks.
An
individual with a mild depressive episode is usually distressed by
the symptoms and has some difficulty in continuing with ordinary work
and social activities, but will probably not cease to function completely.
A
fifth character may be used to specify the presence of the somatic
syndrome:
F32.00
Without somatic symptoms
The criteria for mild depressive episode are fulfilled, and there
are few or none of the somatic symptoms present.
F32.01
With somatic symptoms
The criteria for mild depressive episode are fulfilled, and four or
more of the somatic symptoms are also present. (If only two or three
somatic symptoms are present but they are unusually severe, use of
this category may be justified.)
F32.1
Moderate Depressive Episode
Diagnostic Guidelines
At least two of the three most typical symptoms noted for mild depressive
episode should be present, plus at least three (and preferably four)
of the other symptoms. Several symptoms are likely to be present to
a marked degree, but this is not essential if a particularly wide
variety of symptoms is present overall. Minimum duration of the whole
episode is about 2 weeks.
An
individual with a moderately severe depressive episode will usually
have considerable difficulty in continuing with social, work or domestic
activities.
A
fifth character may be used to specify the occurrence of somatic symptoms:
F32.10
Without somatic symptoms
The criteria for moderate depressive episode are fulfilled, and few
if any of the somatic symptoms are present.
F32.11
With somatic symptoms
The criteria for moderate depressive episode are fulfilled, and four
or more or the somatic symptoms are present. (If only two or three
somatic symptoms are present but they are unusually severe, use of
this category may be justified.)
F32.2
Severe Depressive Episode Without Psychotic Symptoms
In a severe depressive episode, the sufferer usually shows considerable
distress or agitation, unless retardation is a marked feature. Loss
of self-esteem or feelings of uselessness or guilt are likely to be
prominent, and suicide is a distinct danger in particularly severe
cases. It is presumed here that the somatic syndrome will almost always
be present in a severe depressive episode.
Diagnostic
Guidelines
All three of the typical symptoms noted for mild and moderate depressive
episodes should be present, plus at least four other symptoms, some
of which should be of severe intensity. However, if important symptoms
such as agitation or retardation are marked, the patient may be unwilling
or unable to describe many symptoms in detail. An overall grading
of severe episode may still be justified in such instances. The depressive
episode should usually last at least 2 weeks, but if the symptoms
are particularly severe and of very rapid onset, it may be justified
to make this diagnosis after less than 2 weeks.
During
a severe depressive episode it is very unlikely that the sufferer
will be able to continue with social, work, or domestic activities,
except to a very limited extent.
This
category should be used only for single episodes of severe depression
without psychotic symptoms; for further episodes, a subcategory of
recurrent depressive disorder should be used.
Includes:
* single episodes of agitated depression
* melancholia or vital depression without psychotic symptoms
F32.3
Severe Depressive Episode With Psychotic Symptoms
Diagnostic Guidelines
A severe depressive episode which meets the criteria given for severe
depressive episode without psychotic symptoms and in which delusions,
hallucinations, or depressive stupor are present. The delusions usually
involve ideas of sin, poverty, or imminent disasters, responsibility
for which may be assumed by the patient. Auditory or olfactory hallucinations
are usually of defamatory or accusatory voices or of rotting filth
or decomposing flesh. Severe psychomotor retardation may progress
to stupor. If required, delusions or hallucinations may be specified
as mood-congruent or mood-incongruent.
Differential
Diagnosis
Depressive stupor must be differentiated from catatonic schizophrenia,
from dissociative stupor, and from organic forms of stupor. This category
should be used only for single episodes of severe depression with
psychotic symptoms; for further episodes a subcategory of recurrent
depressive disorder should be used.
Includes:
* single episodes of major depression with psychotic symptoms, psychotic
depression, psychogenic depressive psychosis, reactive depressive
psychosis