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Depressive disorder

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Major depressive disorder, also known as major depression, unipolar depression, unipolar disorder, clinical depression, or simply depression, is a mental disorder characterized by a pervasive low mood and loss of interest or pleasure in usual activities. The diagnosis is made if a person has suffered one or more major depressive episodes, and is based on the patient's self-reported experiences and observed behavior. There is no laboratory test for major depression, although physicians often test for physical conditions that may cause similar symptoms before arriving at a diagnosis. The course of the disorder varies widely, from a one-off occurrence to a lifelong disorder with recurrent episodes. The most common time of onset is between the ages of 30 and 40, with a later peak between 50 and 60. Statistically, major depression occurs more often in women than men, although men are at higher risk for suicide.

Both psychological and biological causes have been proposed, and the determination of whether there are two separate conditions or a continuum of a single disorder has been researched since the 1920s. Current classification has favored biological theories since the creation of the term major depressive disorder in 1980. The neurotransmitters serotonin and norepinephrine have been implicated, and most antidepressants work to increase their active levels in the brain. However, the precise role of neurotransmitter levels in depressive illness is not fully understood. Psychological factors have also been implicated, and forms of psychotherapy are used to address them. Hospitalization may be necessary in cases associated with self-neglect or a significant risk of suicide, and electroconvulsive therapy is used in severe cases.

Ideas about what causes and constitutes depression have evolved over the centuries, and they remain a source of discussion. The term depression is commonly used to describe a temporary depressed or sad mood. By contrast, major depression is a serious and often disabling condition that can significantly affect a person's work, family and school life, sleeping and eating habits, and general health. However, authorities such as Australian psychiatrist Gordon Parker have argued that it is overdiagnosed, and that current diagnostic standards have the effect of medicalizing sadness.

In Western countries, approximately 3.4% of people with major depression eventually commit suicide. Up to 60% of all people who commit suicide have depression or another mood disorder, and their risk may be higher if they feel a marked sense of hopelessness or have both depression and borderline personality disorder. Depressed individuals have a shortened life expectancy, being more susceptible to conditions such as heart disease than the non-depressed.

Signs and symptoms

Major depression is a serious condition that affects a person's work, family and school life, sleeping and eating habits, and general health.[1] The impact on functioning and well-being has been equated to that of chronic medical conditions such as congestive heart failure.[2]

A person suffering a major depressive episode usually experiences a pervasive low mood, or loss of interest or pleasure in favored activities. Depressed people may be preoccupied with feelings of worthlessness, inappropriate guilt or regret, helplessness or hopelessness.[3] Other symptoms include poor concentration and memory, withdrawal from social situations and activities, reduced libido (sex drive), and thoughts of death or suicide. Insomnia is common: in the typical pattern, a person wakes very early and is unable to get back to sleep.[4] Hypersomnia, or oversleeping, is less common.[4] Appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur.[3] The person may report persistent physical symptoms such as fatigue, headaches, digestive problems, or chronic pain; this is a typical presentation in developing countries.[5] Family and friends may perceive that the person is either agitated or slowed down.[4] Older people with major depression are more likely than younger people to show cognitive symptoms such as forgetfulness and to show a more noticeable slowing of movements.[6][7] In severe cases, depressed people may experience psychotic symptoms such as delusions or, less commonly, hallucinations, usually of an unpleasant nature.[8][9]

Children may display an irritable rather than depressed mood,[3] and show different symptoms depending on age and situation.[10] Most exhibit a loss of interest in school and a decline in academic performance. Children with depression may be described as clingy, demanding, dependent, or insecure.[4] Those older than 12 years may begin abusing drugs or alcohol, or exhibit disruptive behavior.[11] Diagnosis may be delayed or missed when symptoms are interpreted as normal moodiness.[3]

Causes

In the biopsychosocial model, both biological and psychological (including social) factors play a role in causing depression. There is overlap, and the precise causes vary depending on individual circumstances. The heritability of depression—the degree to which it is genetically determined—has been estimated to be approximately 40% for women and 30% for men.[12] From the evolutionary standpoint, major depression might be expected to reduce an individual's reproductive fitness. Some evolutionary explanations for the apparent contradiction between biopsychosocial, psychological and psychosocial hypotheses and the high heritability and prevalence of major depression are explained by the proposal that certain components of depression are adaptations.[13][14]

Biological causes

Most antidepressants increase synaptic levels of the monoamine neurotransmitter serotonin. Some also enhance the levels of two other neurotransmitters, norepinephrine and dopamine. This observation gave rise to the monoamine theory of depression. In its contemporary formulation, the monoamine theory postulates that a deficiency of certain neurotransmitters is responsible for the corresponding features of depression: "Norepinephrine may be related to alertness and energy as well as anxiety, attention, and interest in life; [lack of] serotonin to anxiety, obsessions, and compulsions; and dopamine to attention, motivation, pleasure, and reward, as well as interest in life." The proponents of this theory recommend choosing the antidepressant with the mechanism of action impacting the most prominent symptoms. Anxious and irritable patients should be treated with SSRIs or norepinephrine reuptake inhibitors, and those experiencing a loss of energy and enjoyment of life with norepinephrine and dopamine enhancing drugs.[15]

Psychological causes

Various aspects of personality and its development are integral in the occurrence and persistence of depression.[16] Although episodes are strongly correlated with adverse events, how a person copes with stress also plays a role.[16] Low self-esteem, learned helplessness, and self-defeating or distorted thinking are related to depression. Depression may also be connected to feelings of religious alienation.[17] It is unclear whether these are causes or effects, but in either case depressed persons who are able to make corrections in their thinking patterns often show improved mood and self-esteem.[18]

Cognitive psychology and cognitive behavioral therapy are based on the theory that depression arises from cognitive biases and distortions stemming from deficits in memory and information processing. According to psychologist Martin Seligman, depression in humans is similar to learned helplessness in laboratory animals, who remain in unpleasant situations from which they are able to escape, but over which they initially learned they had no control.[19] Learned helplessness and depression may be related to what psychologist Julian Rotter called an external locus of control, a tendency to attribute personal outcomes to external events seen as uncontrollable.[20] A related idea, Aaron T. Beck's cognitive triad, proposes that depression entails cognitive errors about oneself, one's world, and one's future.[21][22]

On the other hand, depressed individuals often blame themselves for negative events, and believe that the effect of these events persists through time and pervades their entire lives.[21][23] This tendency is characteristic of a depressive attributional, or pessimistic explanatory style.[21] According to psychologist Albert Bandura, individuals become depressed if they have a negative self-concept and lack a sense of self-efficacy; in other words they have a habitual sense of an inability to influence events and to achieve personal goals.[24][25] Milder depression has been associated with what has been called depressive realism, or the "sadder-but-wiser" effect, a view of the world that is relatively undistorted by positive biases.[26][27]

A large body of research has documented the importance of interpersonal factors, including strained or critical personal relationships, in the onset of depressive symptoms and major depression in young and middle-aged adults. Vulnerability factors—such as early maternal loss, lack of a confiding relationship, responsibility for the care of several young children at home, and unemployment—can interact with life stressors to increase the risk of depression.[28][29] For older adults, the factors are often health problems, changes in relationships with a spouse or adult children due to the transition to a care-giving or care-needing role, the death of a significant other, or a change in the availability or quality of social relationships with older friends because of their own health-related life changes.[30]

From the psychoanalytic perspective, depression may be intertwined with self-criticism. Sigmund Freud wrote that the "super-ego becomes over-severe, abuses the poor ego, humiliates it and ill-treats it, threatens it with the direst punishments".[31] Freud argued that objective loss, as occurs through death or a romantic break-up, could result in subjective loss as well, when the depressed subject has identified with the object of its affection through an unconscious, narcissistic process called the libidinal cathexis of the ego. Such loss results in "a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of self-regarding feelings" that is more severe than mourning. "In mourning 'it is the world that has become poor and empty; in [depression] it is the ego itself.'"[32]

Existential psychologist Rollo May stated that "depression is the inability to construct a future".[33] From the existential perspective, in order to construct a future, individuals must be acutely aware of both their mortality and their freedom to act, and they must exercise their freedom within the explicit framework of an acute awareness of their mortality. This awareness produces "normal" anxiety,[34] whereas the lack of awareness leads to neurotic anxiety,[34] self-alienation,[35] inauthentic living,[36] guilt,[36] and depression. Humanistic psychologists agree with many facets of existentialism,[37] but argue that depression can result from an incongruity between society and the individual's innate drive to self-actualize. Abraham Maslow believed that depression is especially likely to arise when the world precludes a sense of "richness" or "totality" for the self-actualizer.[38][39]

Evolutionary psychology suggests that major depression can result from overactivation of psychological mechanisms that evolved to produce adaptive responses to material or social loss or defeat.[14][40][41] Some aspects of this approach have received empirical support and clinical application;[42][43] other components are still at a hypothetical stage.

Social causes

Long-term risks for developing major depression include family disruption and low socioeconomic status in early childhood.[44] The risk is independent of later adult social status and is related to various social inequalities.[45] Childhood emotional, physical, sexual abuse, or neglect are also associated with increased risk of developing depressive disorders later in life.[46] Such events are more likely to occur in dysfunctional families, for example, one with an alcoholic parent.[47] Early adverse events and stressful conditions that persist through childhood and adolescence may be linked to the later development of depression.[48] Social rejection also predicts later depression,[49] and adolescents who are victimized by peers are more vulnerable to developing depressive symptoms if it impacts on the development of their identity, although family cohesion and emotional involvement are protective factors.[50]

In adulthood, a correlation between stressful life events and the onset of major depressive episodes has been found consistently and is likely causal, although the specific mechanisms are unclear. Negative events such as assault, divorce or separation, legal issues, major problems with work, finances, housing, health, or friends and confidants, have been found to precede episodes if they represent a long-term threat, particularly if the threat is of a loss or humiliation that devalues an individual in a core role.[51] The first episode of major depressive is more likely to be immediately preceded by stressful life events than are recurrent ones.[52] Social isolation has also been found to predict onset of a first episode.[53] There is evidence that neighborhood social disorder, for example, due to crime or illicit drugs, is a risk factor, and that a high neighborhood socioeconomic status, with better amenities, is a protective factor. There is some evidence of risk from psychosocial stressors in the workplace, such as working at a job that is demanding but involves little opportunity for decision-making.[54] There is mixed evidence regarding the role of social capital (features of social organization including interpersonal trust, civic engagement and cooperation for mutual benefit).[55]

Diagnosis

Clinical assessment

A diagnostic assessment may be conducted by a general practitioner or by a psychiatrist or psychologist.[1] This includes a complete history of the person's current circumstances, biographical history and current symptoms, a discussion of alcohol and drug use, and a family medical history to see if other family members have suffered from a mood disorder. A mental state examination includes an assessment of the person's current mood and an exploration of thought content, in particular thoughts of hopelessness, self-harm or suicide.[1]

Before diagnosing a major depressive disorder, a doctor generally performs a medical examination and selected investigations to rule out other causes of symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism; basic electrolytes and serum calcium to rule out a metabolic disturbance; and a full blood count including ESR to rule out a systemic infection or chronic disease.[56] Testosterone levels may be used to diagnose hypogonadism, a cause of depression in men.[57] Subjective cognitive complaints appear in older depressed people, but they can also be indicative of the onset of a dementing disorder, such as Alzheimer's disease.[58] Depression is also a common initial symptom of dementia.[59] Conducted in older depressed people, screening tests such as the mini-mental state examination, or a more complete neuropsychological evaluation, can rule out cognitive impairment.[60] A CT scan can exclude brain pathology in those with psychotic, rapid-onset or otherwise unusual symptoms.[61] No biological tests confirm major depression.[62] Investigations are not generally repeated for a subsequent episode unless there is a specific medical indication, in which case serum sodium can rule out hyponatremia (low sodium) if the person presents with increased frequency of passing urine, a common side-effect of selective serotonin reuptake inhibitor (SSRI) antidepressants.[63]

Specialist mental health services are rare in rural areas, and thus diagnosis and management is largely left to primary care clinicians.[64] This issue is even more marked in developing countries.[65]

Rating scales

Diagnostic screening programs have been advocated to improve detection of depression, but there is evidence that the use of screening instruments does little to improve detection rates.[66] A study in the U.K. concluded that screening alone is costly and does not improve the treatment or outcome of depression.[67]

Several rating scales are used in research or as screening tools. The Beck Depression Inventory is a widely used tool in the diagnosis of depression, although its main purpose is not diagnosis, but determining the presence and severity of symptoms.[68][69] Originally designed by psychiatrist Aaron T. Beck in 1961, it is a 21-question self-report inventory that covers symptoms such as irritability, fatigue, weight loss, lack of interest in sex and thoughts including feelings of guilt, hopelessness or of being punished.[70] Other scales include the Geriatric Depression Scale in older populations, which is also valid in patients with mild to moderate dementia;[71][59] the Hamilton Depression Rating Scale (HRSD-21) designed by psychiatrist Max Hamilton in 1960;[72][73] and the Montgomery-Ã…sberg Depression Rating Scale (MADRS).[74][75] The Patient Health Questionnaires are two self-administered questionnaires for use in primary care. The PHQ-2 has two screening questions about the frequency of depressed mood and a loss of interest in activities; a positive to either question indicates further testing is required.[76] The PHQ-9 is a slightly more detailed nine-question survey for assessing symptoms of major depressive disorder in greater detail, and is often used to follow up a positive PHQ-2 test.[77]

DSM IV-TR and ICD-10 criteria

The most widely used criteria for diagnosing depressive conditions are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10). The latter system is typically used in European countries, while the former is used in the USA and many other non-European nations.[78]

Major depressive disorder is classified as a mood disorder in DSM IV-TR.[79] The diagnosis hinges on the presence of a single or recurrent major depressive episode.[3] Further qualifiers are used to classify both the episode itself and the course of the disorder. The category Depressive Disorder Not Otherwise Specified is diagnosed if the depressive episode's manifestation does not meet the criteria for a major depressive episode. The ICD-10 system does not use the term Major depressive disorder, but lists similar criteria for the diagnosis of a Depressive episode (mild, moderate or severe); the term recurrent may be added if there have been multiple episodes without mania.[80]

Major depressive episode

A major depressive episode is characterized by the presence of a severely depressed mood that persists for at least two weeks.[3] Episodes may be isolated or recurrent and are categorized as mild (few symptoms in excess of minimum criteria), moderate, or severe (marked impact on social or occupational functioning). An episode with psychotic features—commonly referred to as psychotic depression—is automatically rated as severe. If the patient has had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder is made instead.[81] Depression without mania is sometimes referred to as unipolar because the mood remains at one emotional state or "pole".[82]

The DSM excludes cases where the symptoms are a result of bereavement, although it is possible for normal bereavement to evolve into a depressive episode if the mood persists and the characteristic features of a major depressive episode develop.[83] The criteria have been criticized because they do not take into account any other aspects of the personal and social context in which depression can occur.[84][85] In addition, some studies have found little empirical support for the DSM-IV cut-off criteria, indicating they are a diagnostic convention imposed on a continuum of depressive symptoms of varying severity and duration:[86] excluded are a range of related diagnoses, including dysthymia which involves a chronic but milder mood disturbance,[87] Recurrent brief depression which involves briefer depressive episodes,[88][89] Minor depressive disorder which involves only some of the symptoms of major depression,[90] and Adjustment disorder with depressed mood which involves low mood resulting from a psychological response to an identifiable event or stressor.[91]

Subtypes

Diagnosticians recognize several subtypes, which are sometimes called "course specifiers":

  • Melancholic depression is characterized by a loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.[92]
  • Atypical depression is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (comfort eating), excessive sleep or sleepiness (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.[93]
  • Catatonic depression is a rare and severe form of major depression involving disturbances of motor behavior and other symptoms. Here the person is mute and almost stuporose, and either remains immobile or exhibits purposeless or even bizarre movements. Catatonic symptoms also occur in schizophrenia or in manic episodes, or may be caused by neuroleptic malignant syndrome.[94]
  • Postpartum depression refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which has incidence rate of 10–15% among new mothers, typically sets in within three months of labor, and lasts as long as three months.[95]
  • Seasonal affective disorder is a form of depression in which depressive episodes come on in the autumn or winter, and resolve in spring. The diagnosis is made if at least two episodes have occurred in colder months with none at other times, over a two-year period or longer.[96]

Differential diagnoses

In order to diagnose MDD, several other potential diagnoses must be ruled out, including the following:

  • Dysthymia is a chronic, milder mood disturbance in which a person reports a low mood almost daily over a span of at least two years. The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to secondary episodes of major depression (sometimes referred to as double depression).[87]
  • Adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode.[91]
  • Bipolar disorder, previously known as manic-depressive disorder, is a condition in which depressive phases alternate with periods of mania or hypomania. Although depression is currently categorized as a separate disorder, there is ongoing debate because individuals diagnosed with major depression often experience some hypomanic symptoms, indicating a mood disorder continuum.[97]
  • Loneliness and depression have enough features in common that loneliness may be viewed as a differential diagnosis.[98] In general, depression is likely to coexist with loneliness if the loneliness is chronic rather than transient. If the individual has global concerns that do not focus strictly on interpersonal relationships, feels a high degree of guilt, or is particularly vegetative, then the person is likely to be depressed; if these conditions are not met, he or she may be lonely instead.

Treatment

The three most common treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice for people under 18, while electroconvulsive therapy is only used as a last resort. Care is usually given on an outpatient basis, while treatment in an inpatient unit is considered if there is a significant risk to self or others.

Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy are often difficult. Development of mental health services is minimal in many countries; depression is viewed as a phenomenon of the developed world despite evidence to the contrary, and not as an inherently life-threatening condition.[99]

Psychotherapy

Psychotherapy can be delivered, to individuals or groups, by a variety of mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, counselors, and psychiatric nurses. With more complex and chronic forms of depression the most effective treatment is often considered to be a combination of medication and psychotherapy.[100] In people under 18, medication is usually offered only in conjunction with psychotherapy, not as a first line treatment.[101]

The most studied form of psychotherapy for depression is cognitive behavioral therapy (CBT), thought to work by teaching clients to learn a set of useful cognitive and behavioral skills. Earlier research suggested that cognitive-behavioral therapy was not as effective as antidepressant medication; however, more recent research suggests that it can perform as well as antidepressants in patients with moderate to severe depression.[102] Overall, systematic review reveals CBT to be an effective treatment in depressed adolescents,[103] although possibly not for severe episodes.[104] Combining fluoxetine with CBT appeared to bring no additional benefit[105][106] or, at the most, only marginal benefit.[107]

Two randomized, controlled trials of mindfulness-based cognitive therapy (MBCT), which includes elements of meditation, have been reviewed. MBCT was significantly more effective than usual care for the prevention of recurrent depression in patients who had had three or more depressive episodes. According to the review, the usual care did not include antidepressant treatment or any psychotherapy, and the improvement observed may have reflected the non-specific or placebo effects.[108]

Interpersonal psychotherapy focuses on the social and interpersonal triggers that may cause depression. There is evidence that it is an effective treatment. Here, the therapy takes a structured course with a set number of weekly sessions (often 12) as in the case of CBT, however the focus is on relationships with others. Therapy can be used to help a person develop or improve interpersonal skills in order to allow him or her to communicate more effectively and reduce stress.[109]

Psychoanalysis, a school of thought founded by Sigmund Freud that emphasizes the resolution of unconscious mental conflicts,[110] is used by its practitioners to treat clients presenting with major depression.[111] A more widely practiced, eclectic technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has an additional social and interpersonal focus.[112] In a meta-analysis of three controlled trials, Short Psychodynamic Supportive Psychotherapy (SPSP) was found to be as effective as medication for mild to moderate depression.[113]

Medication

Selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine, and citalopram are the primary medications considered, due to their relatively mild side effects and broad effect on the symptoms of depression and anxiety. Those who do not respond to the one SSRI can be switched to another; such a switch results in improvement in almost 50% of cases.[114] Another popular option is to switch to the atypical antidepressant bupropion (Wellbutrin) or to add bupropion to the existing therapy;[115] this strategy is possibly more effective.[116][117] It is not uncommon for SSRIs to cause or worsen insomnia; the sedating antidepressant mirtazapine (Zispin, Remeron) can be used in such cases.[118][119][120] Venlafaxine (Effexor), a serotonin-norepinephrine reuptake inhibitor, may be moderately more effective than SSRIs;[121] however, it is not recommended as a first-line treatment because of the higher rate of side effects,[122] and its use is specifically discouraged in children and adolescents.[123] Fluoxetine is the only antidepressant recommended for people under the age of 18.[123]

Tricyclic antidepressants have more side effects than SSRIs and are usually reserved for the treatment of inpatients, for whom the tricyclic antidepressant amitriptyline, in particular, appears to be more effective.[124][125] A different class of antidepressants, the monoamine oxidase inhibitors, have historically been plagued by questionable efficacy and life-threatening adverse effects. They are still used only rarely, although newer agents of this class, with a better side effect profile, have been developed.[126]

To find the most effective treatment, the dosages of antidepressants must often be adjusted, or different medications and combinations tried. Response rates to the first agent administered may be as low as 50%.[127] It may take anywhere from three to eight weeks after the start of medication before the therapeutic effects are fully revealed. Patients are advised not to stop taking an antidepressant suddenly and to continue its use for at least four months to prevent the chance of recurrence. People with chronic depression usually need to take medication for the rest of their lives.[1] The term refractory- or treatment-resistant depression is used to describe cases that do not respond to adequate courses of least two antidepressants.[128]

A doctor may add a medication with a different mode of action to bolster the effect of an antidepressant in cases of treatment resistance.[129] Lithium has been used to augment antidepressant therapy in those who have failed to respond to antidepressants alone.[130] Furthermore, lithium dramatically decreases the suicide risk in recurrent depression.[131] Addition of a thyroid hormone, triiodothyronine may work as well as lithium, even in patients with normal thyroid function.[132] Addition of atypical antipsychotics when the patient has not responded to an antidepressant is also known to increase the effectiveness of antidepressant drugs, albeit at the cost of more frequent side effects.[133]

Efficacy of medication and psychotherapy

Two recent meta-analyses of clinical trial results submitted to the FDA concluded that antidepressants are statistically superior to placebo but their overall effect is low to moderate; they often did not exceed the National Institute for Health and Clinical Excellence criteria for a clinically significant effect. In particular, the effect size was very small for moderate depression although did increase with severity and reach clinical significance for very severe depression.[134][135] These results were consistent with the earlier clinical studies in which only patients with severe depression benefited from either psychotherapy or treatment with an antidepressant, imipramine, more than from the placebo treatment.[136][137][138] Despite obtaining similar results, the authors argued about their interpretation. One author concluded that there "seems little evidence to support the prescription of antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed to provide benefit".[134] The other author agreed that the "antidepressant 'glass' is far from full" but disagreed "that it is completely empty". He pointed out that the first-line alternative to medication is psychotherapy, which does not have superior efficacy.[139]

Antidepressants in general are as effective as psychotherapy for major depression, and this conclusion holds true for both severe and mild forms of MDD.[140][141] In contrast, medication gives better results for dysthymia.[140][141] The subgroup of SSRIs may be slightly more efficacious than psychotherapy. On the other hand, significantly more patients drop off from the antidepressant treatment than from psychotherapy, likely because of the side effects of antidepressants.[140] Successful psychotherapy appears to prevent the recurrence of depression even after it has been terminated or replaced by occasional booster sessions. The same degree of prevention can be achieved by continuing antidepressant treatment.[141]

Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a procedure in which seizures are electrically induced in anesthetized patients. ECT is most often used as a last resort (from the perspective of hospital psychiatrists) for severe major depression which has not responded to trials of antidepressant or, less often, psychotherapy or supportive interventions.[142] It has a quicker effect than antidepressant therapy, and thus may be the treatment of choice in emergencies such as catatonic depression where the patient has ceased oral intake of fluid or nutrients, or where there is severe suicidality.[142] Some evidence suggests it is the most effective treatment for depression in the short-term[143] and one study without a comparison group or assessment of additional treatments given, suggested remission is related to improved self-rated quality of life in both the short-term (correlated with the degree of amnesia) and after six months.[144] However, ECT has been found to have much lower remission rates in real-world practice[145] and on its own does not have a sustained benefit as nearly everyone relapses.[146] The relapse rate in the first six months may be reduced by the use of psychiatric medications or further ECT (although some authorities, such as NICE, do not recommend the latter), but remains high.[147][148] Common initial adverse effects include short-term memory loss, disorientation, headache; long-term memory[149] and other cognitive deficits may persist. According to the American Psychiatric Association and the National Institute for Health and Clinical Excellence, available evidence suggests that the procedure, when administered according to their standards and without complications, does not cause brain damage in adults.[150][151]

Other methods of treatment

Two products, St John's wort and S-Adenosyl methionine, are available as prescription antidepressants in several European countries, but in the US are classified as herbal supplements and sold over-the-counter. There is inconsistent evidence on the effect of St John's wort extract on major depression. The pharmaceutical quality of the extract has an effect on the safety and efficacy for the treatment of any type of depression.[152][153] Clinical trials of S-Adenosyl methionine (SAM-e) have shown that it is equivalent to tricyclic antidepressants in effectiveness, although the safety and efficacy of over-the-counter versions is unknown.[154][155] Other supplements such as omega-3 fatty acids,[156] tryptophan, and 5-hydroxytryptophan (5-HTP),[157] have shown no effect beyond those of placebo.

Repetitive transcranial magnetic stimulation (rTMS) utilizes powerful magnetic fields which applied to the brain from outside the head. Multiple controlled studies support the use of this method in treatment-resistant depression; it has been approved for this indication in Europe, Canada and Australia, but not in the US.[158][159] It was inferior to ECT in a side-by-side randomized trial.[160]

Other therapeutic approaches have been used to treat depression. Bright light therapy has been found to be an effective treatment for the winter depression produced by seasonal affective disorder. There has been some conflicting evidence as to its effectiveness for non-seasonal depression.[161][162] Exercise has not been shown to reduce the symptoms of depression.[163]

Prognosis

Major depressive episodes often resolve over time whether they are treated or not. Outpatients on a waiting list show a 10–15% reduction in symptoms over a few months, and around 20% will no longer meet full criteria.[164] The median duration of an episode has been estimated at least 23 weeks, with the highest rate of recovery in the first three months.[165]

General population studies indicate around half those who have a major depressive episode (whether treated or not) recover and remain well, while 35% will have at least one more, and around 15% experience chronic recurrence.[166] Studies recruiting from selective inpatient sources suggest lower recovery and higher chronicity, while studies of mostly outpatients show that nearly all recover, with a median episode duration of 11 months. Around 90% of those with severe or psychotic depression, most of whom also meet criteria for other mental disorders, experience recurrence.[167][168]

Recurrence is more likely if symptoms have not fully resolved with treatment. Current guidelines recommend continuing antidepressants for four to six months after remission to prevent relapse. Evidence from many randomized controlled trials indicates continuing antidepressant medications after recovery can reduce the chance of relapse by 70% (41% on placebo vs. 18% on antidepressant). The preventive effect probably lasts for at least the first 36 months of use. Thus, depression recurs despite the prolonged antidepressant treatment in a significant minority of patients;[169] the reason for recurrence in these cases is poorly understood and could be a "true pharmacologic failure or a worsening of the disease, a relapse that overrides medication". Because of the difficulties of carrying out controlled clinical trials of longer duration, the approval of most antidepressants for the prevention of recurrence is based on trials that lasted up to a year.[170]

References

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Cited texts

  • American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc., 943. ISBN 0890420254. 
  • Barlow; Durand VM (2005). Abnormal psychology: An integrative approach (5th ed.). Belmont, CA, USA: Thomson Wadsworth. ISBN 0534633560. 
  • Kent, Deborah (2003). Snake Pits, Talking Cures & Magic Bullets: A History of Mental Illness. Twenty-First Century Books. ISBN 0761327045. 
  • Hergenhahn (2005). An Introduction to the History of Psychology, 5th edition, Belmont, CA, USA: Thomson Wadsworth. ISBN 0534554016. 
  • Parker, Gordon; Dusan Hadzi-Pavlovic, Kerrie Eyers (1996). Melancholia: A disorder of movement and mood: A phenomenological and neurobiological review. Cambridge: Cambridge University Press. ISBN 052147275X. 
  • Sadock, Benjamin J.; Sadock, Virginia A. (2002). Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 9th, Lippincott Williams & Wilkins. ISBN 0781731836. 

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