Depressive illnesses affect the lives of million of Americans and cost billion of dollars.

Persistent sad, anxious or “empty” feelings

Decreased energy, fatigue, being “slowed down”

Loss of interest or pleasure in usual activities, including sex

Sleep disturbances (insomnia, early-morning waking, or oversleeping)

Appetite and weight changes (either loss or gain)

Feelings of hopelessness, pessimism

Feelings of guilt, worthlessness, helplessness

Thoughts of death or suicide, attempts

Difficulty in concentrating, remembering, making decisions

Chronic aches or persistent bodily symptoms that are not caused by physical disease.  

Decreased need for sleep

Increased risk-taking

Increased energy

Unrealistic beliefs in their own abilities

Increased talking and physical, social and sexual activity

Feelings of mood elevation or irritability

Aggressive response to frustration.

physical examination which includes a neurological examination and lab tests.

a medical and psychiatric history

a mental status examination  

high incidence of depressive illness could be inherited

mood disorders could be a function of a biochemical disturbance and could be treated with drugs

sleep patterns of both unipolar and bipolar depressed patients are different from those in persons who do not have a mood disorder.

Personal losses, financial problems, physical illness midlife crises, sex role expectations, and psychosocial phenomena, such as personality, upbringing, and negative thinking style have been cited as contributors to depressive illness.

Social conditioning also has been cited as contributing to a higher incidence of depression among women.  

Three categories of drugs are most often prescribe: tricyclics, monoamine oxidase inhibitors (MAOIs) and lithium.

There are “talking” therapies during which problems are discussed and resolved through the emotional support, insights and understanding gained from the verbal give-and-take.   Other therapies concentrate on behaviors: patients are taught to be more effective in obtaining rewards and satisfaction through their own actions.

Although ECT has received unfavorable publicity, it continues to be the most effective treatment for major endogenous or delusional depression.  

Childhood depression may be recognized or misdiagnosed when depressive symptoms are mixed with other type of behavior, such as hyperactivity, delinquency, school problems, or psychosomatic complaints.

Manic-depressive disorder in adolescents is often manifested by episodes of impulsivity, irritability, and loss of control alternating with periods of withdrawal.

The wide range of estimates of occurrence of depression among older populations–from 10 percent to 65 percent–attests to the difficulties of diagnosing depression in an elderly person.  Symptoms of depression are often misdiagnosed as senility (organic brain syndrome) or mistaken for the everyday problems of the aged.

Women are disproportionately affected by depression, experiencing it at roughly twice the rate of men.

 Research continues to explore how the illness affects women and to identify new areas that hold promise of deepening our understanding.

Varied factors unique to women’s lives are suspected to contribute to depression–developmental, reproductive, hormonal, genetic, and other biological factors; abuse and oppression; interpersonal factors; and certain psychological and personality characteristics.

Who gets depressed?

What is depression?

How will I know if I am depressed?

What should I do if I have these symptoms?

How will I treatment help me?

What type of treatment will I get?  

General health care provider

physician

physician assistant

nurse practitioner

Mental health specialists

psychiatrist

psychologist

social worker

psychiatric nurse specialist  

antidepressant medicine

psychotherapy

antidepressant medicine combined with psychotherapy.

How well each of these treatments works depends on the type of depression, how severe the depression is, how long you have been depressed, how you as an individual may react to treatment, and other factors.  

Major depressive disorder consists of one or more moods disorders episodes of major depression with

or without full recovery between episodes.

Dysthymic disorder features a low-grade, more persistent depressed mood and associated symptoms

for at least 2 years, during which a major depressive episode has not occurred. Over extended followup, many patients with this disorder develop episodes of major depression.

Depression not otherwise specified (DNOS) is a residual category for patients with symptoms and signs of depression that do not meet the formal diagnostic criteria for either major depressive or dysthymic disorder.

Bipolar I disorder features at least one manic episode along with (nearly always) major depressive episodes.

Bipolar disorder not otherwise specified is a residual category that includes bipolar II disorder, a condition characterized by recurrent episodes of major depression along with hypomanic (but not full-blown manic) episodes, as well as other forms that do not meet formal criteria for bipolar I or cyclothymic disorder.

Cyclothymic disorder is characterized by numerous periods of mild depressive symptoms insufficient in duration or severity to meet the criteria for major depressive episodes interspersed with hypomanic episodes; it lasts at least 2 years by definition. Patients with this condition are rarely free of mood symptoms.  

Conduct a clinical interview to determine whether the nine specific signs/symptoms of major depressive disorder according to DSM-III-R are present.

Interview the patient to investigate the possibility of concurrent substance or alcohol abuse and current use

of medications that may cause depressive symptomatology.

Conduct a medical review of systems to detect the existence of medical disorders that may biologically cause or be commonly associated with depressive symptoms.

Interview the patient further to detect the presence of  another concurrent nonmood psychiatric condition that  may be associated with and be responsible for the depressive symptoms.

Exclude alternative causes (1 through 4, above) for depressive symptoms or syndromes to diagnose a primary mood disorder.

Major depressive disorder may begin at any age, although it usually begins in the mid-20s and 30s.  Symptoms develop over days to weeks.  Some people have only a single episode, with a full return to premorbid functioning.  However, more than 50 percent of those who initially suffer a single major depressive episode eventually develop another.  

The point prevalence for major depressive disorder in the Western Industrialized nations is 2.3 to 3.2 percent for men and 4.5 to 9.3 percent for women.  The lifetime risk for major depressive disorder is 7 to 12 percent for men and 20 to 25 percent for women.  

Patients with major depressive disorder have substantial amounts of physical and psychological disability, as well as occupational difficulties.  

Melancholic

Atypical

Postpartum psychosis/depression

Seasonal

Postpartum psychosis/depression.  

Psychotic features refer to the presence of delusions or hallucinations.  They occur in 15 percent of patient with major depressive disorders.  

Psychomotor retardation or agitation

Loss of interest or pleasure

Lack of reactivity to usually pleasant stimuli

Worse depression in the morning

Early morning awakening  

overeating

oversleeping

weight gain

a mood that still responds to events (reactive mood).

extreme sensitivity to interpersonal rejection

a feeling of heaviness in the arms and legs.

marked anxiety

difficulty in falling asleep

phobic symptoms

symptoms of sympathetic arousal  

episodes are recurrent (at least two episodes by some criteria, three by other criteria).

there has been a regular temporal relationship between the onset of the major depressive episodes and a particular period of the year (such as regular onset of depression in fall and offset in spring).

seasonal episodes substantially outnumber nonseasonal episodes.

The essential feature of dysthymic disorder is a chronic of mood disturbance (sadness in adults; sadness and, possibly, irritability in children and adolescents) present most of the time for at least 2 consecutive years (1 year for children and adolescents).

Cyclothymic disorder features numerous, alternating hypomanic and mild depressive periods, lasting daysto weeks and nearly continuous.  There are few truly symptoms-free periods.  The symptoms fluctuate, but never reach the severity/duration, criteria of major depressive or manic episodes.  The course is chronic, often lasting years.  

Depressive symptoms or syndromes often accompany anxiety, panic, or phobic disorders.  Furthermore, anxiety disorder may be the forerunner of and part of the longitudinal course of a mood disorder.  The presence of both anxiety/panic and a major depressive disorder results in a more severe disorder with greater impairment than does either disorder alone.  When the patient complains  of anxiety symptoms, major depressive symptoms should  be elicited.

The practitioner is advised to ask about anorexia nervosa and bulimia nervosa in young women who present with any mood disorder, especially those with amenorrhea.  If present, the eating disorder is the principal target of treatment.

For those depressed patients whose disorder has some obsessive features, the mood disorder is the

initial focus of treatment.  If full-blown OCD is present with depressive symptoms or manic-depressive disorder, the OCD is usually the initial objective of treatment.  Evidence from OCD medication treatment trials suggests that, if the OCD is treated successfully, the depressive symptoms usually abate.

Somatization is defined as the presentation of somatic symptoms by patients with underlying psychiatric illness or psychosocial distress.  These somatic symptoms have no, or insufficient, underlying organic cause.

Personality disorders are not uncommon among mood-disordered patients.  The presence of a personality disorder does not exclude diagnosis of a mood disorder,  if present.  When both a major depressive and personality disorder are present, more frequent and longer major depressive episodes, as well as poorer interepisode recovery (if untreated), may be anticipated.

The general medical disorder biological causes depression for example, hypothyroidism may cause depressive symptoms.

The general medical disorder triggers the onset of the depression in those who are genetically vulnerable to depressive disorders; for example, Cushing’s disease may precipitate a major depressive episode.

The general medical disorder psychologically causes the depression; for example, a patient with cancer may become clinically depressed as a psychological reaction to the prognosis, pain, and incapacity. The general medical disorder and the mood disorder are not causally related.

social isolation

recent losses

a tendency to pessimism

socioeconomic pressures

a history of mood disorder

alcohol or substance abuse

previous suicide attempt(s)

poorly controlled pain

Cardiovascular drugs

Hormones

Psychotropics

Anticancer Agents

Anti-inflammatory Anti-infective agents

assess the patient for the nine specific sings/symptoms of major depressive disorder

investigate the possibility of concurrent substance or alcohol abuse

detect the existence of medical disorders

detect the presence of another concurrent nonmood

psychiatric condition

exclude alternative causes

Maintain high index of suspicion and evaluate risk depressive factors

Detect depressive symptoms with clinical interview and/or self-report questionnaire

Define mood syndrome (clinical history, interview, report by spouse or significant other).

Define potential known cause of mood syndrome (medical medications, substance abuse, and other casual nonmood psychiatric disorders).

Treat potential causes

Reevaluate for mood syndromes

If mood syndrome is still present, treat as primary mood disorder  

to reduce and ultimately remove all signs and symptoms of the depressive syndrome

to restore occupational and psychosocial function to that  of the asymptomatic state

to reduce the likelihood of relapse and recurrence  

Need for repeated medical visits to monitor response and adjust dosage.

Unwanted side effects

More severe (but infrequent) medication reactions, such as allergic reaction

Potential use in suicide attempts

Failure of many patients (10 to 30 percent) to complete treatment

Lack of efficacy in some cases of major depressive disorder

Need for strict adherence to the medication schedule.

Need for continuation phase treatment  

Lack of physiologic side effects, such as those found with medication or ECT.

Logical possibility that psychotherapy is effective for some patient for whom medication are not effective.

Theoretical possibility that psychotherapy may make the depression less likely to recur once treatment stops because patients learn to cope with or avoid factors contributing to recurrence.

Psychotherapy has rarely been tested in patients with severe or psychotic depressions.

Many patients (10 to 40 percent) fail to follow through with the full treatment.

Many time-limited forms of psychotherapy, as well as all forms of longer term psychotherapy, have not been tested for efficacy in randomized controlled trials.

Psychotherapy is not effective for all patients with major depressive disorder.

The quality of the therapy affects outcome.

Therapy sessions are time-consuming and may be inconvenient.

Psychotherapy may be expensive, depending on the type of therapy and the provider.

Treatment effects are usually measurable later (6 to 8 weeks than with medication (4 to 6 weeks).