Diagnostic Features Including Symptoms

Everyone experiences feelings of sadness at one time or another, but depression goes deeper. Depression affects a person’s daily life, whether or not they are able to function, and how well. Although sadness is usually triggered by a specific event, depression is not (Shelton, 2018). Depression can be triggered by anything, even activities that were once considered enjoyable. If sadness persists after a traumatic event and other symptoms develop it can turn into. To be diagnosed with Major Depressive Disorder, feelings of depression or a depressed mood, as well as certain criteria of symptoms are exhibited almost every day for at least two weeks. Major Depressive Disorder affects many different aspects such as neurovegetative functions: increased or decreased appetite and sleep disturbances, cognition: delusional guilt or feelings of worthlessness, and psychomotor activity: agitation or retardation (Fava and Kendler, 2000). Other symptoms may include changes in weight; decreased energy; difficulty thinking, concentrating, or making decisions; thoughts of death or suicide; or suicide plans or attempts.

Principal complaints experienced by the majority of patients is insomnia or fatigue; disturbances in sleep can be having trouble sleeping or in sleeping too much. The extensive effort may be required in completing simple tasks or activities, as decreased energy, tiredness, and fatigue may be experienced without putting forth exertion. Poor concentration and the inability to think, concentrate or focus, make even minor decisions, or function in day to day activities may become increasingly difficult. Some individuals eat less or “forget” to eat while others may eat more, causing either a substantial loss or gain in weight.

 Many describe feeling depressed, hopeless, discouraged, or feeling down; some individuals complain of a lack of emotions or feeling anxious. Others may initially deny unhappiness, but more information may be gleamed from discussion or inferred from facial expression and demeanor. Irritability and crankiness instead of sadness may be presented in young children and adolescents, with persistent anger, and an inclination to respond with irrational outbursts or exaggerated frustration over seemingly minor matters. Social detachment and a withdrawal of usual pleasurable activities is often noticed by family or friends. Symptoms that may be observed by others include nervousness, anxiousness or inability to sit still, wandering, handwringing; slowed vocalization, reasoning, and body movements; increased hesitation before answering; whispered speech, decrease in inflection while speaking, or amount spoke (Spielman, 2014).

Delusional guilt may include obsession over marginal previous failings, feeling blame for uncontrolled illness, shortcomings in responsibilities, or guilt of delusional proportions. Thoughts of death or suicide attempts may vary from wishing to not awaken in the morning, believing others would be better off without them, frequent suicidal thoughts, to a precise suicide plan including settling affairs and acquiring needed suicidal materials. A driving force for suicide can involve a longing to end what is perceived as an unending and excruciatingly troublesome emotional state, giving up in the face of insurmountable stumbling blocks, an inability to foresee any enjoyment in life, or wishing not to be a burden to others.

Prevalence

Onset of Major Depressive Disorder may first appear at any age; puberty increases the likelihood of onset with peak onset in the 20’s (Nemade, n.d.). Many patients experience their first episodes of Major Depressive Disorder during childhood or adolescence, typically continuing to suffer from episodes in adulthood as well. The prevalent ratio of males to females who experience Major Depressive Disorder is 1.5 to 2.5; women are almost twice as likely to develop the disorder.

A substantial increase to the chance of developing Major Depressive Disorder includes environmental adversities such as job loss, marital adversities, major health complications, and damage to close personal relationships. Causal relationships such as gender, stressful life events, adverse childhood experiences, and certain personality traits have also been suggested as potential risk factors. Childhood difficulties including physical and sexual abuse, poor parent-child relationships, low-income status, parental discord and divorce could increase the risk for Major Depressive Disorder later on in life (Fava & Kendler, 2000). Most people suffer their entire life with multiple occurrences averaging at least one occurrence in a five-year period, and 20-25% of Major Depressive Disorder patients experience chronic, unremitting symptoms. Since 2005 there has been a 20% increase in Major Depressive Disorder, and it was shown to be the greatest contributor to non-fatal health loss in 2015 (Fiorillo, Carpiniello, De Giorgi, La Pia, Maina, Sampogna, & Vita, 2018).

In the United States, various difficulties with work, home, and social activities were reported in about 50% of adults with depression, another 30% of adults reported moderate to extreme difficulties with work, home, and social activities (Brody, Pratt & Hughes, 2018). In 2016 approximately 16.2 million adults had a minimum of one major depressive episode, representing 6.7% of all U.S. adults. As seen in figure 1 the prevalence was higher in females compared to males and the age group with the highest episode were 18-25-year-olds. Overall, Asian adults had the lowest percentage suffering from Major Depressive Disorder, while adults reporting two or more races experienced the highest percentage (Tice, 2017).

*All other groups are non-Hispanic or Latino | **NH/OPI = Native Hawaiian / Other Pacific Islander | ***AI/AN = American Indian / Alaskan Native

Course

The course of Major Depressive Disorder varies greatly between short or long periods of time, mild or severe symptoms, or any variation in between. Problems with personality, anxiety, or substance use can cause or contribute to signs of depression, the longer and more severe the symptoms the greater chance of problems. Recovery is also dependent on the severity of symptoms and the length of which a person has suffered; someone who has been depressed for a short time can often recover quickly. Someone with severe symptoms of Major Depressive Disorder who has suffered for several months to years may require much longer to recover; the risk for recurring episodes is much greater (Nemade, n.d.). When psychotic features such as hallucinations or delirium accompany Major Depressive Disorder, it can transition into schizophrenia. Stressful life events, substance abuse, certain medications, abuse or neglect, and physical illnesses are also associated with increased risk of Major Depressive Disorder (Calvo, Collins, Neall, & Greenberg, 2018). In order to achieve full recovery, the true cause of the disorder must be diagnosed.

According to the DSM-V there are many levels of recovery associated with Major Depressive Disorder. “Full remission” means an absence of symptoms, “partial remission” refers to having fewer than five depressive symptoms currently or having no symptoms for less than two months, those suffering from “chronic” Major Depressive Disorder have met all of the criteria for two years or more (Nemade, n.d.). Despite the fact that partial remission is achieved by approximately 20-30% suffering from Major Depressive Disorder, another 5-10% experience chronic Major Depressive Disorder. While suicide is a risk for those afflicted with an episode of Major Depressive Disorder, women have an increased risk of attempts with a lower success rate. Although previous attempts raise the risk of suicide completion most suicides are ended by those attempting it for the first time.

Familial Pattern

Studies performed on families, twin, and adoption candidates suggest that genetic factors play significant parts in the development of Major Depressive Disorder. In twin studies the odds of inheriting a Major Depressive Disorder is 40% to 50%, in family studies the lifetime risk of Major Depression Disorder developing is two to three times as likely within close blood relatives (Lohoff, 2010). Very little is definite with regards to the genetic research concerning Major Depressive Disorder. Seeing that no single gene is mandatory or sufficient for Major Depressive Disorder to develop, and each vulnerable gene provides a small fraction of the overall genetic risk, it makes gene localization and mapping difficult. Studies show that differences in numerous genes, each with its own consequence, may combine to raise the risks of depression. Because depression carries many symptoms and signs that are similar to other diseases and the genetic variations for depression can be different between men and women it is even more challenging to determine the genetic risk factors (Calvo, Collins, Neall, & Greenberg, 2018). Not everyone who has a family history of Major Depressive Disorder develop it themselves, just as many who have no family history end up developing Major Depressive Disorder. Seeing that nongenetic or environmental factors also impact the increased risk of Major Depressive Disorder developing it is probable that nongenetic conditions combine with genetic factors in determining the overall risk.

Treatments

Currently there are numerous treatment options for Major Depressive Disorder including psychotherapy, pharmacotherapy, and brain stimulation therapy. The sooner treatment for depression is initiated, the more efficient it is likely to be at helping to improve and relieve symptoms and lessen the recurrence of episodes. The most common approach in treating Major Depressive Disorders are through medication used to reverse imbalances in brain chemistry, psychotherapy which focuses on altering negative patterns affecting emotions, or a combination of both. Studies have proven that a combination of psychotherapy and pharmacotherapy is more effective than either method on their own (Alberts, 2018). Treatment options vary and have various advantages and disadvantages for each form.

Psychotherapy is the treatment of a mental disorder through psychological rather than medical means and may include: psychoanalysis or psychodynamic therapies, behavior therapy, cognitive therapy, humanistic therapy, and holistic therapy, or integrative therapy (Fava & Kendler, 2000). The more commonly practiced psychoanalysis and psychodynamic therapies, work with the unconscious mind to offer insight and solutions to past experiences and deep-rooted emotions in order to resolve them. By discussing personal issues with a therapist, patients learn to evaluate and resolve their current issues by finding patterns in their emotions, thoughts, and beliefs, helping them to gain insight in their current situations (McLeod, 2017). Overall effectiveness may be limited and little data suggesting improvement has been shown, results can be subjective.

More modern versions of psychotherapy such as behavior therapy, cognitive therapy, humanistic therapy, and holistic therapy provide useful theoretical support, reduces stigma that may be associated with therapists, and has high patient approval (Fava & Kendler, 2000). Each of these therapies focus on emotions, and how the patient is thinking, behaving, and interacting currently, instead of on previous childhood experiences. The goal is to place emphasis on positive interactions, provide direction towards self-exploration and true identity, and encourage positive thinking (Fava & Kendler, 2000). Changes to behavior or biases in thinking can help make more positive changes in the way the patient is feeling, allowing them to effectively deal with current real-life issues. Finding a therapist with similar values and ethics consistent with potential patients is beneficial. Because these types of therapy are newer and less common, finding the right therapist may be more difficult.

Integrative therapy permits the therapist to modify the more than 400 varieties of psychotherapy to the specific needs of the individual patient. Most psychotherapists begin with one theoretical model and adapt it to relate to the patient’s current needs. Psychotherapists and researchers developed a general consensus that because each patient has different needs no single psychotherapeutic method can be helpful for all patients, symptoms, and circumstances (Zarbo, Tasca, Cattafi, & Compare, 2016). By allowing an individualized approach, integrative therapy uses behavioral, cognitive, and humanistic functioning with holistic spiritual beliefs and focuses on the best treatment for the single patient.

Pharmacotherapy, the medical treatment by way of drugs, has shown to be successful in treating Major Depressive Disorder through over twenty drugs that have been approved by the Food and Drug Administration. Prescription medications are available in several different classifications with various advantages and disadvantages to each. Due to patient approval and acceptable side effects the primary prescription prescribed by the majority of doctors for Major Depressive Disorder are Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRI’s) which block the uptake of serotonin in varying degrees. 

Long-term usage may present bothersome side effects such as sexual dysfunction, trouble sleeping, and weight gain. Atypical antidepressants have a proven effectiveness, but their pharmacological actions are very different from one another, affecting various neurotransmitters or mild serotonin reuptake depending on the specific medication. Although bothersome long-term side effects are less common, the possibility of sedation or having to take the medication twice a day limits some doctors prescribing them without first trying others. Tricyclic and Tetracyclic antidepressants are proven to be effective but with high rates of bothersome side effects such as weight gain, sedation, cardiac affects, and lethal overdosage, they are no longer used as a primary medication. Many other medications are under development and still being studied for their effectiveness in treating Major Depressive Disorder (Fava & Kendler, 2000).

For those patients who have not responded well to other treatments psychiatrists suggest the use of brain stimulation therapy. Electroconvulsive therapy (ECT) or shock therapy, is performed while under anesthesia and involves short electrical impulses that produce seizures which are believed to repair flawed wiring in the brain. Performed while a patient is awake and aware, Repetitive Transcranial Magnetic Stimulation (rTMS) uses a magnet to stimulate brain regions related to mood and emotions. Electroconvulsive therapy and Repetitive Transcranial Magnetic Stimulation have been extremely effective, however, considerable impacts on memory and cognitive functions have been experienced (Alberts, 2018).

Even though the availability of successful treatment options is widespread, a large portion of the population initially diagnosed and treated are unresponsive to treatment. Only about 50% of patients treated, respond to initial treatment. The remaining continue suffering with symptoms and struggling with functionality (Fava & Kendler, 2000). Lingering symptoms such as lack of energy, insomnia, problems with concentration, and cognitive deficits are the chief unmet needs during treatment. These remaining symptoms may signify the connection between symptomatic remission and functional recovery, seeing that cognitive symptoms limit functionality (Fiorillo, Carpiniello, Giorgi, La Pia, Maina, Sampogna … Vita, 2018). 

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