Major Depression
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Contents |
Introduction
- A major mood disorder characterized by one (single) or more (recurrent) episodes of major depression, with or without full recovery between episodes.
Classification
- Categories of major depression:
- depression with psychotic features
- delusions or hallucinations
- generally concurrent & logically consistent with the depressed mood
- prominent psychomotor retardation or agitation
- loss of interest
- worsening in the morning
- early morning awakening
- depression with atypical features
- overeating
- oversleeping
- weight gain
- sensitivity to personal rejection
- mood that responds to external events
Etiology
- independent risk factors
- social isolation
- caregiver status
- bereavement [2]
- disability is a risk factor
- associated of chronic disease with major depression is related to degree of disablity rather than the chronic disease itself [2]
Epidemiology
- most often begins in mid 20's
- less common in community-dwelling elderly
- more prevalent in specific groups of elderly
- hospitalized patients (12%)
- patients with chronic illness
- nursing home residents (16%)
- prevalence is 9-21% in adolescents [4]
Genetics
- PDLIM5 is commonly increased in the brain of patients with bipolar disorder, schizophrenia, & major depression
- associated with defects in DCNP1 gene
- other implicated genes: CPLX2
Clinical-manifestations
- most elderly patients present with multiple somatic complaints, anxiety, poor sleep or concerns with cognitive impairment
- elderly patients may be unable/unwilling to express sadness [2]
Diagnostic-criteria
- Minimal criteria:
- a depressed mood or anhedonia resulting in impaired function
- symptoms should be present every day or nearly every day for at least 2 weeks
- at least 4 additional symptoms must be present:
- unintentional weight loss or decreased appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue
- feeling or inappropriate sense of worthlessness or guilt
- indecisiveness or inability to concentrate
- suicidal ideation or recurrent thoughts of death
- symptoms should NOT be due to bereavement
Complications
- increased morbidity & mortality [2]
- lower medical compliance
- lower participation in rehabilitation
- osteoporosis in young women, especially in connection with borderline personality disorder [3]
- disease interaction(s) of depression with anxiety
- disease interaction(s) of major depression with anxiety disorder(s)
- disease interaction(s) of ischemic heart disease with depression
Differential-diagnosis
- other depressed mood disorders
- dysthymia
- adjustment disorder with depressed mood
- seasonal affective disorder
- bereavement
- normal sadness
- comorbid personality disorder in 1/4 of inpatients with major depression [2]
Management
- see depression
- see STAR*D
- major depression with psychotic features (includes delusions)
- responds poorly to antidepressants alone
- addition of antipsychotic agent may improve response
- electroconvulsive therapy may be treatment of choice in the elderly [2]
- prognosis
- partial response at 4 weeks increases the liklihood of full remission [2]
- comorbidity of anxiety & major depression in the elderly predicts more severe & treatment-resistant disease than either alone [2]
- presence of a personality disorder is a negative indicator for return to full function [2]
- screening recommended for adolescents [4]
More General Terms
Additional Terms
- adjustment disorder
- atypical depression
- dysthymia
- seasonal affective disorder
- Sequenced Treatment Alternatives to Relieve Depression (STAR*D)
References
- Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
- Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
- Kahl KG et al, Bone mineral density, bone turnover and osteoprotegerin in depressed women with and without borderline personality disorder Psychosom Med 2006, 68:669 PMID: [1]
- US Preventive Services Task Force Screening and Treatment for Major Depressive Disorder in Children and Adolescents: US Preventive Services Task Force Recommendation Statement PEDIATRICS 2009 123:1223-1228 (doi:10.1542/peds.2008-2381) [2]
- Williams SB et al Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventive Services Task Force PEDIATRICS 2009, 123:e716-e735 (doi:10.1542/peds.2008-2415) [3] - Gelenberg AJ et al for the Work Group on Major Depressive Disorder American Psychiatric Association Practice Guideline for the treatment of patients with major depressive disorder, 3rd edition [4]
- National Guideline Clearinghouse
- Practice guideline for the treatment of patients with major depressive disorder, third edition American Psychiatric Association ngc-guideline: [5]
- VA/DoD clinical practice guideline for management of major depressive disorder (MDD). ngc-guideline: [6]
- Major depression in adults in primary care. Institute for Clinical Systems Improvement ngc-guideline: [7]
- Management of adults with major depression. Michigan Quality Improvement Consortium ngc-guideline: [8]
- Screening and treatment for major depressive disorder in children and adolescents: U.S. Preventive Services Task Force recommendation statement. ngc-guideline: [9]
- Best evidence statement (BESt). Screening of children and adolescents for major depressive disorder (MDD). Cincinnati Children's Hospital Medical Center. ngc-guideline: [10]
- Best evidence statement (BESt). Treatment of children and adolescents with major depressive disorder (MDD) during the acute phase. Cincinnati Children's Hospital Medical Center. ngc-guideline: [11]
- Clinical practice guideline on the management of major depression in adults. Galician Health Technology Assessment Agency ngc-guideline: [12]
- Clinical practice guideline on major depression in childhood and adolescence Galician Health Technology Assessment Agency ngc-guideline: [13]
