Major Depressive Disorder (296.xx)

Bill Pelz, Herkimer Community College

284 Major Depressive Disorder (296.xx)

DSM-IV-TR criteria

296.2x Major Depressive Disorder, Single Episode

A. Presence of a single Major Depressive Episode and a Unipolar disorder.
B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. NOTE: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.
It is important to maintain a healthy lifestyle to avoid major depressive disorder in the following: avoid drugs and alcohol, eat well balanced meals, get regular sleep and exercise, and seek supportive relationships. This might seem like simple tasks to obtain, but for many each one might be an obstacle.
If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:
- Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features
- Chronic
- With Catatonic Features
- With Melancholic Features
- With Atypical Features
- With Postpartum Onset
Beck’s Depression Scale Inventory or other screening tests for depression can be helpful in making the diagnosis. More information available at: Beck’s Depression Scale
If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:
- In Partial Remission, In Full Remission
- Chronic
- With Catatonic Features
- With Melancholic Features
- With Atypical Features
- With Postpartum Onset

296.3x Major Depressive Disorder, Recurrent

A. Presence of two or more Major Depressive Episodes
- NOTE: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.
B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. NOTE: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

If the full criteria are currently met for a Major Depressive Episode, specify its current clinical status and/or features:
- Mild, Moderate, Severe Without Psychotic Features/Severe With Psychotic Features
- Chronic
- With Catatonic Features
- With Melancholic Features
- With Atypical Features
- With Postpartum Onset
If the full criteria are not currently met for a Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:
- In Partial Remission, In Full Remission
- Chronic
- With Catatonic Features
- With Melancholic Features
- With Atypical Features
- With Postpartum Onset
Specify:
- Longitudinal Course Specifiers (With and Without Interepisode Recovery)
- With Seasonal Pattern

Associated features

Most people complain most about a sad mood that won’t go away. People that have MDD, experience a low mood over several days or weeks. Some of the symptoms are: depressed mood, loss of interest in pleasurable activities, change in appetite, insomnia, psychomotor retardation, and sense of worthlessness or guilt, problems with clear thinking or concentration, thoughts of death or suicide, etc. ”Depressed children often display an irritable rather than a depressed mood, and show varying symptoms depending on age and situation. Most show a loss of interest in school and a decline in academic performance. They may be described as clingy, demanding, dependent, or insecure. Diagnosis may be delayed or missed when symptoms are interpreted as normal moodiness.” The appetite tends to fluctuate. Individuals with this disorder may engage in “comfort eating,” and thus gain weight. The comfort foods they choose are are easy to eat and are often addictive.

Major Depressive Disorder often co-exists with other disorders. The National Comorbidity Survey reports that 51% of people with MDD also suffer from anxiety. Anxiety symptoms can delay recovery, have an increased risk of relapse and an increase in suicide attempts. Also, increased reports of alcohol and drug abuse exist. Attention Deficit Hyper-activity Disorder and Post Traumatic Stress Disorder are also often comorbid with MDD. Anhedonia is often expressed which means a significantly decreased interest or pleasure in all activities most of the day. The change in appetite is usually varies from significant weight gain, a considerable decrease in food consumption, or everyday variation basis.

Child vs. adult presentation

In childhood, boys and girls can be equally affected. But in adolescence and adulthood, it occurs twice as often in women than in males.
The symptoms are the same in children and adults but the characteristic of the symptoms change.
Children are usually associated with irritability and social withdrawal.
Elderly are usually associated with disorientation, memory loss, and distractibility.

Gender and cultural differences in presentation

It affects all races.
Latinos and Mediterranean cultures complain about nerves and headaches.
Chinese and Asian cultures complain about weakness, tiredness, or imbalance.
Middle Eastern cultures complain about problems of the heart or heartbreak.

Epidemiology

MDD is a very common condition. In the United States, 17.1% of people will experience at least one episode of MDD in their lifetime. Worldwide, it ranges from about 8-12%. Only 4.9% of the general population actually meets the DSM-IV criteria to be diagnosed with MDD. It is known to happen more to women than in men for reasons that are unknown. Before puberty, there is really no difference between the prevalence in males and females. It is documented that people commonly develop MDD in their late adolescence or early adulthood.

The lifetime prevalence for men and women vary in the general population. For women it is 10% to 25% and for men it is 5% to 12%. The prevalence rates are not prejudice in any way. It affects all races, sex, education, and income levels.

Etiology

Major Depressive Disorder seems to be highly inheritable. Researchers have studied twins, and found strong genetic influence in depression. Identical twins that were raised in the same environment have about a 50% chance of both developing depression whereas, fraternal twins that were raised in the same environment only have about a 20% chance of developing depression. Adoption studies have also been influences in determining whether depression is genetic. Researchers have found that children of depression are more susceptible to depression even when adopted. Environmental factors have also been known to influence depression. Early stressful life events can make children more prone to developing depression later on in life. Such as losing a parent, sibling or relative or parents getting divorced, etc. Other environmental factors include low socioeconomic status and/or frustrating or unpleasant relationships.

Empirically supported treatments

Successful treatment of patients with major depressive disorder is promoted by a complete assessment of the patient. Treatment generally consists of three phases: an acute phase, a continuation phase, and a maintenance phase. Psychiatrists treating patients suffering from this disorder often use a variety of medications, psychotherapeutic approaches, electroconvulsive therapy, and other treatments methods, such as light therapy. Regardless of the specific treatment selected, it is important that the patient is provided with psychiatric management throughout each phase of the treatment.

Medications include tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin re-uptake inhibitors (SSRIs), and some newer antidepressant drugs. Although antidepressant medications can be very effective, some may not be appropriate for everyone. For example, in 2007, the FDA proposed that all antidepressant medicines should warn of the risk of suicidal behavior in young adults ages 18 – 24 years. Lithium and thyroid supplements may be needed to enhance the effectiveness of antidepressants. People with psychotic symptoms, such as delusions or hallucinations, may need antipsychotic medications.

Antidepressant medications are often used as an initial primary treatment for mild major depressive disorder and psychotherapy alone is also used as an initial treatment for patients with mild to moderate major depressive disorder. A combination of psychotherapy and medication may also be used as an initial treatment for patients with psychosocial issues, interpersonal problems or a comorbid axis II disorder with moderate to severe major depressive disorder. Most people benefit with a combination of the two treatments. Lastly, electroconvulsive therapy can be used for patients with major depressive disorder with a high degree of severe symptoms or in patients in which psychotic symptoms or catatonia are present.

Most Recent Episode Depressed

Draft Criteria for Bipolar I Disorder- Retain structure, with changes limited to the definitions of mood episodes that define each.

Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Depressed

Currently (or most recently) in a Major Depressive Episode (see Criteria for Major Depressive Episode).
There has previously been at least one Manic Episode (see Criteria for Manic Episode).
The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify the Bipolar Subworkgroup will maintain whatever definition of MDE is finalized by the MDD Subworkgroup, with the exception that our review of the literature suggests the need to recognize the subgroup of those with MDE and mixed (i.e. manic/hypomanic) features.

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Additional Information

Finding of this study was that there does appear to be a discernable prodromal phase to depressive episodes as well as several symptoms that appear to be common to the depressive prodrome across individuals (Iacoviello, Alloy, Abramson, & Choi, 2010). A prodromal phase is a clear deterioration in function before the active phase of a mental disturbance. It is not caused by a disorder in mood or a psychoactive substance and includes some residual phase symptoms (Iacoviello, et al., 2010). There were seven symptoms that were included: sad mood, decreased interest in or pleasure from activities, difficulty concentrating, hopelessness, worrying/brooding, decreased self-esteem, and irritability. These symptoms tended to be present in the prodromal phase and also could serve as warning signs that lead to an acute episode of depression (Iacoviello, et al., 2010).

Cognitive behavioral therapy is an empirically supported type of treatment that focuses on maladaptive ways of thinking and why people think the way they do (Warman & Beck, 2003). Cognitive behavioral therapy is said to be a successful form of treatment for individuals with major depressive disorder.

In a study by Carlbring and colleagues (2009) conducted a study using an online form of cognitive behavioral therapy and results indicate that cognitive behavioral therapy is an effective type of treatment for individuals suffering from major depressive disorder when therapist interaction, through email and other forms of communication, was involved. Individuals participating in this study rated therapists on several different measures and results concluded that when asked about life satisfaction, all participants showed improvement which was shown by significant amounts of clustering of therapists data. This study is an example of how cognitive behavioral therapy can be effective is combined with communication to help individuals with major depressive disorder.
Research conducted by de Graaf, Hollon, and Huibers (2010) examined the short-term improvements of individuals with depression who used computerized cognitive behavioral therapy as a treatment for their depression. Individuals were divided into three groups; one group used the computerized cognitive behavioral approach only, the second used both CBT and regularly prescribed treatments, and the third group only used regular treatments. Results indicated that after 12 months, those individuals with high optimism improved using only the CBT approach, while those needing more support improved using both CBT and regular treatment. In most instances, individuals with mild to moderate depression gain the most benefits from cognitive behavioral therapies, but it is possible in some cases for individuals with severe depression to also benefit from computerized cognitive behavioral therapy. This research provides an example of the effective use of cognitive behavioral therapy as a means to improve symptoms of people suffering from depression.
Stuhlmiller and Tolchard (2009) make the argument, in their research, that computerized cognitive behavioral therapy is just a effective as other forms of cognitive behavioral therapies, but is less expensive, easy to teach, and more readily accessible to patients. Using technology and other tools that are easily accessible to individuals suffering from depression may result in cognitive behavioral therapy being more beneficial and used by more individuals.
According to Jungbluth and Shirk (2009), incorporating cognitive behavioral therapy in group counseling sessions that consist of adolescents with treatment-resistant depression, may result in several positive outcomes. Conclusions from research indicate that patient involvement and overall social functioning both show improvements as result of a cognitive behavioral approach. Research conducted by Matsunaga and colleagues (2010) also supports the results from the previous study that cognitive behavioral therapy can improve social functioning when added to a treatment plan for individuals with treatment-resistant depression.
Another study conducted by Kennard and colleagues (2009) also explored the effects of cognitive behavioral therapy in adolescents with depression. This particular research examined the effects of combining cognitive behavioral therapy with a medication regimen versus treatment using only medication. Early results reveal that when medication and cognitive behavioral approaches are combined, social skills and problem-solving are positively affected and improvements are made. Using cognitive behavioral approaches, in addition to medication, will hopefully lead to positive long-term benefits and reduce possible recurring depression in adult life.

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