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What is Major Depression?

Major depression is one of the commonest psychiatric illnesses globally. There is no test for depression and the diagnosis is based on a good history and examination. The signs and symptoms of clinical depression are often missed or explained away. One example is postpartum depression that occurs in one out of 10 pregnant mothers and is often undiagnosed bipolar depression.

There is no cure for depression but very effective treatments are available with a good evidence base. The treatments for depression include medications like SSRIs or SNRIs or other new generation antidepressants as well as augmentation therapies. For treatment resistant cases ECT, rTMS, VNS and DBS are often helpful. Finally there are several proven therapies that help patients with depression. These include cognitive behavior therapy, and interpersonal therapy.

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What is Major Depression?

Individuals with Major Depression often report:

- Depressed mood*
- Psychomotor activity changes
- Sleep disturbances
- Lost interest in pleasurable activities*
- Guilt feelings or hopelessness
- Decreased energy
- Trouble concentrating
- Appetite changes
- Suicidal thoughts or attempts

* At least one required for diagnosis + 4/9 for at least 2 weeks

Atypical Depression is characterized by:

Reactive mood, heaviness of the extremities, sensitivity to interpersonal rejection, and phobic anxiety. It is overrepresented in bipolar disorder and is often missed.

1 in 6 Americans will develop Major Depressions in their lifetime. Major Depression affects 121 million people worldwide.
Women are twice as likely to develop depression as men.

One out of 10 new mothers will develop post-partum depression.

The average age of onset of Major Depression is 32 years.

2 out of 3 individuals with depression do not receive adequate treatment.

When Was Major Depression First Described?

Depression has been described since ancient times.

Major Depression was once blamed upon “black bile” with blood-letting as one of the treatments.

The term Major depressive disorder was introduced by a group of US clinicians in the mid-1970s as part of proposals for diagnostic criteria based on patterns of symptoms called the “research Diagnostic Criteris,” building on earlier Feighner Criteria.

How Is A Person Diagnosed with Major Depression?

A health professional will perform a thorough mental status examination, medical evaluation and ask an individual about their personal and family psychiatric history. Individuals may also have to complete a depression-screening test as part of the diagnostic process.

Laboratory tests that may be indicated in the work-up of a depressed patient include: Thyroid function tests, B-12 and folate levels, sleep studies (if sleep apnea is suspected), EEG (if seizure disorder is suspected), drug screen and EKG.

Based on the results of the evaluation, a person may be diagnosed with one of the following subtypes of depression:

- Major Depression: presence of 5 or more symptoms of depression during the same two week period: with or without psychosis , hypomanic symptoms, or anxious features.

- Bipolar Depression: presence of hypomanic or manic episodes interspersed with episodes of Major Depression.

- Persistent Depressive Disorder: presence of 2 or more symptoms of depression for more days than not for at least 2 years or chronic Major Depression lasting for more than two years.

35,000 people commit suicide every year due to their depression.

Depressed individuals are 5x more likely to commit suicide.

Depression is the leading cause of medical disability for people aged 14 to 44.

What Are the Main Changes in DSM 5 for the Diagnosis of Major Depression?

- Bereavement exclusion is removed and clinical judgment is to be applied for depression after significant loss.

- Specifiers  for “anxious features” and  “mixed features” added.

- “Psychotic features” specifier  no longer tied to severity.

- Persistent depressive disorder replaces dysthymic disorder

On average, people who suffer from depression can lose $10,400 per year in income by age 50.

Patients with depression are more likely to have heart attacks or strokes compared to non-depressed individuals.

If you develop depression after a heart attack, you are 4x more likely to die with the greatest risk being in the first 6 months.

One out of 10 adolescents will have a depressive disorder by the age of 18.

Compared to adults, children with depression may be more likely to present with temper tantrums, somatic complaints, social withdrawal, or mood lability.

How Do Doctors Treat Major Depression?

Hospitalization

Patients who have psychotic symptoms, are suicidal or homicidal or have severe illness may need to be hospitalized for stabilization.
 
Prescription Treatment

Some of the most common types of medications used to treat Major Depression are SSRIs, SNRIs, other new generation antidepressants like vilazodone, whereas  folate, some atypical antipsychotics,  lithium, thyroid hormone,, and some psychostimulants are often used as adjuncts in partial responders. ECT, rTMS and VNS are used in treatment resistant cases.

Continued Treatment

Patients with 3+ episodes of depression, or patients with their first episode after the age of 50, may need lifelong maintenance treatment.

The initial antidepressant leads to remission in only 1 out of 3 patients with depression.

Did You Know?: Some prescription medications including beta-interferon, corticosteroids, benzodiazepines, mefloquine, and tamoxifen can cause depression as a side effect.

Proper Medication Use

When treating depression with antidepressants a 10 – 12 week trial is necessary to achieve remission.  The dose and the combination of medicine that gets you better, keeps you better and should be continued for maintenance therapy for at least 1 year.

Therapy

Most patients with depression will benefit from a combination of medications and psychotherapy. Cognitive behavior therapy and interpersonal psychotherapy are as efficacious as antidepressants in mild to moderate depression.

Substance Abuse Treatment

There is a high rate of comorbid substance abuse in Major Depression. Often it is necessary to treat the depression first even though ideally you would like the patient to stop abusing substances before treating depression. If the substance abuse is not treated, remission of depression is unlikely and recurrences of both more common.

Can Someone With Major Depression Still Lead a Successful Life?

There are several successful people who have had Major Depression:

- Oprah Winfrey
- J.K. Rowling
- Billy Joel
- Charles Darwin
- Calvin Coolidge
- Brad Pitt
- Buzz Aldrin
- Eric Clapton
- Terry Bradshaw

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