Major depressive episode

A major depressive episode is a period characterized by the symptoms of major depressive disorder: primarily severely depressed mood and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and/or irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of or attempts at suicide. Insomnia or hypersomnia, aches, pains, or digestive problems that are resistant to treatment may also be present. The description has been formalised in psychiatric diagnostic criteria such as the DSM-IV and ICD-10^[1]

Significant emotional pain and economic costs are associated with depression. In the United States and Canada, the costs associated with major depression are comparable to those related to heart disease, diabetes, and back problems and are greater than the costs of hypertension.^[2] According to the Nordic Journal of Psychiatry, there is a direct correlation between major depressive episode and unemployment.^[3]

Treatments for a major depressive episode include psychotherapy and antidepressants, although in more serious cases, hospitalization or intensive outpatient treatment may be required.^[4]

Depressive disorders are illnesses in the brain. There are many theories as to how depression occurs. One interpretation is that neurotransmitters in the brain are out of balance, and this results in feelings of worthlessness and despair. Magnetic resonance imaging shows that brains of people who have depression look different than the brains of people not exhibiting signs of depression.^[5] Depression can also be inherited through genetics. A family history of depression increases the chance of being diagnosed.^[6]

Symptoms

The criteria below are based on the formal DSM-IV criteria for a major depressive episode. A diagnosis of major depressive episode requires that the patient has—over a two-week period—experienced five or more of the symptoms below, and these must be outside the patient's normal behaviour. Either depressed mood or decreased interest or pleasure must be one of the five (although both are frequently present).

Mood, anhedonia and loss of interest

A person experiencing a major depressive episode may report depressed mood or may appear depressed to others.^[7] Often, interest or pleasure in everyday activities is decreased; this is referred to as anhedonia. These feelings must be present on an everyday basis for two weeks or longer to meet DSM-IV criteria for a major depressive episode. ^[7] In addition, the person may experience one or more of the following emotions: sadness, emptiness, hopelessness, guilt, indifference, anxiety, tearfulness, pessimism, or irritability.^[1] Children and adolescents in particular may feel irritable.^[1] There may be a loss of interest in or desire for sex. Friends and family of the depressed person may notice that he/she has withdrawn from friends, or has neglected or quit doing activities that were once a source of enjoyment.^[8]

Depressed people may have feelings of guilt that go beyond a normal level or are delusional.^[7] Depressed people may think of themselves in very negative, unrealistic ways, such as manifesting a preoccupation with past failures, personalisation of trivial events, or believing that minor mistakes prove their inadequacy. They also may have an unrealistic sense of personal responsibility and see things beyond their control as being their fault. Additionally, self-loathing is common in clinical depression, and can lead to a downward spiral when combined with other symptoms.^[8]

Change in eating, appetite, or weight

A person experiencing a depressive episode may have a marked loss or gain of weight (such as 5% of their body weight in one month) or a change in appetite.^[7] Changes in appetite take on two manifestations: under- or over-eating. In the first instance, some people never feel hungry, can go long periods without wanting to eat, or may forget to eat; if they do eat, a small amount of food may be sufficient. In children, failure to make expected weight gains may be counted towards this criteria.^[1] Under-eating is often associated with a melancholic type of depression. In the second instance, some people tend toward an increase in appetite and may gain significant amounts of weight. They may crave certain types of food, such as sweets or carbohydrates. People with seasonal affective disorder (SAD) often crave foods high in carbohydrates. Over-eating is often associated with a type of depression called atypical depression.^[8]

Sleep

Nearly every day, the person may sleep excessively, known as hypersomnia, or not enough, known as insomnia.^[7] Insomnia is the most common type of sleep disturbance for people who are clinically depressed and is often associated with a melancholic type of depression. Symptoms of insomnia include trouble falling asleep, trouble staying asleep, and/or waking up too early in the morning. Hypersomnia is a less common type of sleep disturbance. It may include sleeping for prolonged periods at night or increased sleeping during the daytime. The sleep may not be restful, and the person may feel sluggish despite many hours of sleep. This impacts their everyday activities and ability to focus at home or work. According to the United States National Library of Medicine, people with seasonal affective disorder (SAD) may sleep longer during the winter months. Hypersomnia is often associated with an atypical depression.^[8] Hypersomnia is not as common as insomnia and up to 40% of people exhibits hypersomnia from time to time.^[9]

Motor activity

Nearly every day, others may see that the person's activity level is not normal.^[7] People suffering from depression may be overly active (psychomotor agitation) or be very lethargic (psychomotor retardation). If a person is agitated, he or she may find it difficult to sit still, may pace the room, wring his/her hands, or fidget with clothes or objects. Someone with psychomotor retardation tends to move sluggishly, may move across a room very slowly, avert his/her eyes, sit slumped in a chair and speak slowly, saying little. He/she may say that their arms and legs feel heavy. To meet diagnostic criteria, changes in motor activity must be so abnormal that it can be observed by others.^[8] Personal reports of feeling restless or feeling slow do not count towards the diagnostic criteria.^[1]

Fatigue and concentration

Nearly every day, the person will experience extreme fatigue, tiredness, or loss of energy.^[1][7] A person may feel tired without having engaged in any physical activity, and day-to-day tasks become increasingly difficult. Job tasks or housework become very tiring, and the patient finds that their work begins to suffer.^[8] The person may be indecisive or have trouble thinking or concentrating.^[7] Problems with memory and distraction are common. These issues cause significant difficulty in functioning for those involved in intellectually demanding activities, such as school and work, especially in difficult fields.^[8]

Thoughts of death and suicide

The person may have repeated thoughts about death (other than the fear of dying) or suicide (with or without a plan), or may have made a suicide attempt.^[7] The frequency and intensity of thoughts about suicide can range from believing that friends and family would be better off if one were dead, to frequent thoughts about committing suicide (generally related to wishing to stop the emotional pain), to detailed plans about how the suicide would be carried out. Those who are more severely suicidal may have made specific plans and decided upon a day and location for the suicide attempt.^[8]

Diagnosis

Healthcare providers may screen patients for depression using a screening tool, such as the Patient Healthcare Questionnaire-2 (PHQ-2).^[10]

To diagnose a major depressive episode, a trained healthcare provider must make sure that:

• The symptoms do not meet the criteria for a mixed episode.^[1]
• The symptoms must cause considerable distress or impair functioning at work, in social settings or in other important areas in order to qualify as an episode.^[1]
• The symptoms are not due to the direct physiological effects of a substance (e.g., abuse of a drug or medication) or a general medical condition (e.g., hypothyroidism).^[1]
• Other than in the case of severe symptoms (severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations or psychomotor retardation), the episode should not have begun within two months of the loss of a loved one.^[7] (See Bereavement)

Treatment

Depression is a treatable illness. Treatments for a major depressive episode may be obtained in one or more of the following settings: mental health specialists (i.e. psychologist, psychiatrists, social workers, counselors, etc), mental health centers or organizations, hospitals, outpatient clinics, social service agencies, private clinics, peer support groups, clergy, and employee assistance programs.^[11] The treatment plan could include psychotherapy alone, antidepressant medications alone, or a combination of medication and psychotherapy.

For major depressive episodes of severe intensity (multiple symptoms, minimal mood reactivity, severe functional impairment), combined psychotherapy and antidepressant medications are more effective than psychotherapy alone.^[1] Patients with severe symptoms may require outpatient treatment or hospitalization.^[4]

Psychotherapy, also known as talk therapy, counseling, or psychosocial therapy, is characterized by a patient talking about their condition and mental health issues with a trained therapist. Different types of psychotherapy can be effective for depression. These include cognitive behavioral therapy, interpersonal therapy, dialectical behavior therapy, acceptance and commitment therapy, and mindfulness techniques.^[4]

Medications used to treat depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine-dopamine reuptake inhibitors (NDRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and atypical antidepressants such as mirtazapine, which do not fit neatly into any of the other categories.^[4] Different antidepressants work better for different individuals. It is often necessary to try several before finding one that works best for a specific patient. Some people may find it necessary to combine medications, which could mean two antidepressants or an antipsychotic medication in addition to an antidepressant.^[12] If a person's close relative has responded well to a certain medication, that treatment will likely work well for him or her.^[4]

Sometimes, people stop taking antidepressant medications due to side effects, although side effects often become less severe over time.^[12] Suddenly stopping treatment or missing several doses may cause withdrawal-like symptoms.^[4] Some studies have shown that antidepressants may increase short-term suicidal thoughts or actions, especially in children, adolescents, and young adults. However, antidepressants are more likely to reduce a person's risk of suicide in the long run.^[4]

If left untreated, a typical major depressive episode may last for about six months. About 20% of these episodes can last two years or more. About half of depressive episodes end spontaneously. However, even after the major depressive episode is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability.^[2]

Demographics

Estimates of the numbers of people suffering from major depressive episodes and Major Depressive Disorder (MDD) vary significantly. In their lifetime, 10% to 25% of women, and 5% to 12% of men will suffer a major depressive episode. Fewer people, between 5% and 9% of women and between 2% and 3% of men, will have MDD, or full-blown depression. The greatest differences in numbers of men and women diagnosed are found in the United States and Europe.^[1] The peak period of development is between the ages of 25 and 44 years. Onset of major depressive episodes or MDD often occurs to people in their mid-20s, and less often to those over 65. Prepubescent girls and boys are affected equally. The symptoms of depression are the same in both children and adolescents though there is evidence that their expression within an individual may change as he or she ages.^[1]

In a National Institute of Mental Health study, researchers found that more than 40 percent of people with post-traumatic stress disorder suffered from depression 4 months after the traumatic event they experienced.^[13]

Cultural factors can influence the symptoms displayed by a person experiencing a major depressive episode. The values of a specific culture may also influence which symptoms are more concerning to the person or and their friends and family. It is essential that a trained professional knows not to dismiss specific symptoms as merely being the "norm" of a culture.^[1] However, socio-economic and environmental factors do not appear to have any bearing on the incidence of a major depressive episode or MDD.^[2]

Women who have recently given birth may be at increased risk for having a major depressive episode. This is referred to as postpartum depression and is a different health condition than the baby blues, a low mood that resolves within 10 days after delivery.^[14]

Comorbid disorders

Major depressive episodes may show comorbidity (association) with other physical and mental health problems. About 20-25% of individuals with a chronic general medical condition will develop major depression.^[2] Common comorbid disorders include: eating disorders, substance-related disorders, panic disorder, and obsessive-compulsive disorder. Up to 25% of people who experience a major depressive episode have a pre-existing dysthymic disorder.^[2]

Some persons who have a fatal illness or are at the end of their life may experience depression, although this is not universal.^[14]

See also

• Depressive personality disorder
• Depression (differential diagnoses)
• Major depressive disorder
• Mental breakdown

External links

• Depression and Bipolar Support Alliance (DBSA) website from the Depression and Bipolar Support Alliance
• Depression information from the National Institutes of Health
• The Truth About Depression

Notes