Major depressive disorder

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Depressive disorder or Depression

Epidemiology of Depressive disorder

Community studies generally show a high prevalence of depression in different countries. Estimations of the so called point prevalence (the number of people meeting criteria of the disorder at a certain moment in time) vary between 5 and 7.5%. The one-year prevalence of major depressive disorder in the United States varies from 3% in the Epidemiological Catchment Area Study[1] to 10% in the National Co-morbity Study.[2]

Diagnosis and classification of Depressive disorder

The core symptoms of depression are depressed mood and a lack of interest or pleasure from daily activities (anhedonia). Several additional features may be present, like lack of concentration, inappropriate guilt feelings, suicidal thoughts, psychomotor retardation or agitation and loss of libido. A diurnal variation, e.g. the symptoms are worse in the morning, may be present.

DSM-IV criteria

In Psychiatry a diagnosis is made with the use of a classification system. There are different classifications systems. The mostly used system is the Diagnostic and Statistical Manual of Mental Disorders (fourth version, DSM-IV)[3]. Another set of diagnostic criteria for Depressive disorder is the ICD 10, World Health Organization Diagnostic Criteria.

Criteria for a Major Depressive Episode according to DSM IV are:

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.

  1. 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).
  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 made by others)
  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.
  4. insomnia or hypersomnia nearly every day
  5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being 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 or a specific plan for committing suicide

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.e., 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.

Patient Health Questionnaire 2

The Patient Health Questionnaire (PHQ2) is a faster, two question questionnaire that may be as sensitive as the DSM-IV[4]: "During the past month, have you often been bothered by:"

  1. "little interest or pleasure in doing things?"
  2. "feeling down, depressed, or hopeless?"

If either question is positive, then the SALSA questionnaire should be used for more certainty[5]. A positive test is one of the above answers positive and two of the answers below positive:

  1. Sleep disturbance nearly every day for the last 2 weeks?
  2. Have you experienced little interest or pleasure in doing things nearly every day for the last 2 weeks (Anhedonia)?
  3. Have you experienced Low Self esteem nearly every day for the last 2 weeks?
  4. Have you experienced decreased Appetite nearly every day for the last 2 weeks?"


Patient Health Questionnaire 9

If the patient is diagnosed with depression, then use the Patient Health Questionnaire 9 (PHQ9) to measure severity (http://intermountainhealthcare.org/documents/61/2002_depression_phq9.pdf) and follow response to treatment. An adequate response is 50% change and a partial is 25% to 50% change.

Treatment

Medication

Augmentation

Approximately 30% of patients have remission of depression with medications.[6] For patients with inadequate response, either adding sustained-release bupropion (initially 200 mg per day then increase by 100 mg up to total of 400 mg per day) or buspirone (up to 60 mg per day) for augmentation as a second drug can cause remission in approximately 30% of patients[7], while switching medications can achieve remission in about 25% of patients[8].

References

  1. ↑ Regier DA et al.(1993). The defacto US mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psych 50:85-94.
  2. ↑ Kessler RC et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psych 51:8-19.
  3. ↑ American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental disorders (4th ed.) Washington DC: American Psychiatric Association.
  4. ↑ Spitzer RL, Kroenke K, Williams JB (1999). "Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire". JAMA 282 (18): 1737–44. PMID 10568646. [e]
  5. ↑ Brody DS, Hahn SR, Spitzer RL, et al (1998). "Identifying patients with depression in the primary care setting: a more efficient method". Arch. Intern. Med. 158 (22): 2469–75. PMID 9855385. [e]
  6. ↑ Trivedi MH, Rush AJ, Wisniewski SR, et al (2006). "Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice". The American journal of psychiatry 163 (1): 28–40. DOI:10.1176/appi.ajp.163.1.28. PMID 16390886. Research Blogging.
  7. ↑ Trivedi MH, Fava M, Wisniewski SR, et al (2006). "Medication augmentation after the failure of SSRIs for depression". N. Engl. J. Med. 354 (12): 1243–52. DOI:10.1056/NEJMoa052964. PMID 16554526. Research Blogging.
  8. ↑ Rush AJ, Trivedi MH, Wisniewski SR, et al (2006). "Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression". N. Engl. J. Med. 354 (12): 1231–42. DOI:10.1056/NEJMoa052963. PMID 16554525. Research Blogging.
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