Major Depressive Episode

Bill Pelz, Herkimer Community College

280 Major Depressive Episode

DSM-IV-TR criteria

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure

NOTE: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). NOTE: In children and adolescents, can be irritable mood.
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 made by others)
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 gains.
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicid

B. The symptoms do not meet criteria for a Mixed Episode
C. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)
E. The symptoms are not better accounted for by Bereavement, i.d., after the loss of a loved one; the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness suicidal ideation, psychotic symptoms, or psychomotor retardation.

Associated features

The individual must have experienced at least one Major Depressive Episode in the absence of any history of manic episodes. Individuals with Major Depressive Episode show irritability, anxiety, phobias, worry over physical health, and complaints of pain.
Postpartum depression can precipitate a Major Depressive Episode.
Often experience tearfulness, irritability, brooding, obsessive rumination (thinking very deeply about something), anxiety, phobias, worry about health, and complaints of pain. Panic attacks are seen during some Major Depressive Episodes. Issues with close relationships, sexual functioning, and problems maintaining relationships/marriages. Occupational and academic problems may result from a Major Depressive Episode. Suicide risk is higher in individuals with Major Depressive Episodes, especially if they present psychotic features. Sleep abnormalities are seen in 40 to 60 percent of outpatients with a Major Depressive Episode, and 90 percent of inpatients.

Child vs. adult presentation

Core symptoms are the same for children and adolescents, although data suggests that the prominence of characteristic symptoms may change with age.
Children will experience separation anxiety more than adults.
The main symptoms of Major Depressive Episodes are the same in adults and children, but the presentation of symptoms may change with age.
Certain symptoms such as somatic complaints, irritability, and social withdrawal are particularly common in children, whereas psychomotor retardation, hypersomnia, and delusions are less common in prepuberty than in adolescence and adulthood. In prepubescent children, Major Depressive Episodes occur more frequently in conjunction with other mental disorders (especially Disruptive Behavior Disorders, Attention-Deficit Disorders, and Anxiety Disorders) than in isolation. In adolescents, Major Depressive Episodes are frequently associated with Disruptive Behavior Disorders, Attention-Deficit Disorders, Anxiety Disorders, Substance-Related Disorders, and Eating Disorders. In elderly adults, cognitive symptoms (e.g., disorientation, memory loss, and distractibility) may be particularly prominent.

Gender and cultural differences in presentation

Culture can influence the experience and communication of symptoms of depression. Underdiagnosis or misdiagnosis can be reduced by being alert to ethnic and cultural specificity in presenting complaints of a Major Depressive Episode. For example, in some cultures, depression may be experienced largely in somatic terms, rather than with sadness or guilt. Complaints of “nerves” and headaches (in Latino and Mediterranean cultures), weakness, tiredness, or “imbalance” (in Chinese and Asian cultures), problems of the “heart” (in Middle Eastern cultures), or of being “heart-broken” (among Hopi) may express the depressive experience. Such presentations combine features of the Depressive, Anxiety, and Somatoform Disorders. Cultures may also differ in judgments about the seriousness of experiencing or expressing dysphoria. Culturally distinctive experiences (e.g., fear of being hexed or bewitched, feelings of “heat in the head” or crawling sensations of worms or ants, or vivid feelings of being visited by those who have died) must be distinguished from actual hallucinations or delusions that may be part of a Major Depressive Episode, With Psychotic Features. It is also imperative that the clinician not routinely dismiss a symptom merely because it is viewed as the “norm” for a culture.
Women are at significantly greater risk than men to develop Major Depressive Episodes at some point during their lives, with the greatest differences found in studies conducted in the United States and Europe. This increased risk emerges during adolescence and may coincide with the onset of puberty. Thereafter, a significant proportion of women report a worsening of the symptoms of a Major Depressive Episode several days before the onset of menses. Women are especially vulnerable to depression after giving birth. This is a result of hormonal and physical changes. Although new mothers commonly experience temporary “blues,” depression that lasts longer than 2 – 3 weeks is not normal and requires treatment.
Some theorists believe that the reason minorities have differing rates of depressive disorder is that symptoms of depression are presented differently than Caucasians.
Men are more likely to successfully complete suicide during depression than women. Mainly because men will take more drastic measures (such as a gun, hanging, jumping, etc) whereas women will be more likely to cut their wrists the wrong way or take pills.

Epidemiology

Studies indicate that depressive episodes occur twice as frequently in women as in men.
A Cross-national synthesis of epidemiology evidence on major depressive disorders was done by the World Health Organization Composite International Diagnostic Interview and administered face-to-face in 10 different countries. They found that in a range of 40% to 55% in a 12 month to lifetime prevalence compared with a 30 day to 12 month prevalence of 45% to 65% where the consistent socio-demographic correlates in that being female and unmarried has a higher rate for major depression. Also, if the person has other disorders for a long period of time then the likelihood gets higher.

Etiology

Stressful life situations can contribute to the onset of symptoms of major depression, most of the time these events involve some type of loss. There are also several different biological and neural bases that can contribute to the development of major depression. There is evidence of abnormalities in brain regions such as the thalamus, cortex, and cerebellum among others. Problems such as the increased size of cerebral ventricles may cause the loss of neural tissues. Abnormal dopamine, norepinephrine, and serotonin neurotransmitters are also considered potential causes of major depression. It is also believed that some genes are components in the cause of major depressive episodes.

Empirically supported treatments

Both medication and psychotherapy can be used to treat depression. Antidepressantsare usually more effective in those with major depression, but psychotherapy can be effective in addition to these medications. CBT, or cognitive behavioral therapy, focuses on the relationship between events and emotions and helps patients with stress, social skills, and activities training.
Other forms of treatment include psychotherapy, and shock therapy. Medication wise, drugs like the SSRIs (selective serotonin reuptake inhibitors), Atypical antidepressants (non-SSRIs), TCAs (tricyclic antidepressants), and MAOIs (monoamine ocidase inhibitors)are often presribed. These drugs can often take up to two months to become effective so the soon the treatment is started, the better. Antidepressants increase the levels of the “feel good” chemicals in the brain (serotonin, dopamine, etc).
Antidepressant medications have just as many side effects as the next drug. Patients may encounter several effects including sexual side effects (decreased libido) , appetite changes, blurred vision, dry mouth, and others depending on the type and brand of drug.

Abraham Lincoln, one of the most well-known presidents, had major depression despite the fact that he was a renowned jokester.

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Additional Information

Depression affects individuals differently and has a spectrum of levels of depression. People who struggle with severe depression have trouble getting out of bed in the morning, socializing, and going to work (2009).

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