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Depression and Major Depressive Disorders:
A brief overview of common myths and DSM-IV to DSM-5 changes in Major Depressive Disorder criteria and classification.
All rights reserved  Clinical Psychology Associates of North Central Florida  WWW.CPANCF.COM
                                2121 NW 40th Terrace Suite B, Gainesville FL 32605      352-336-2888
and Abimbola Farinde, Pharm.D., M.S.2
1. Clinical Psychology Associates of North Central Florida
2. Walden University, Minneapolis, MN
Depressive disorders, in general, and more specifically, major depressive disorder (MDD) are among the most common psychiatric disorders, affecting individuals across the lifespan.  During a one-year period, approximately 6.7% of the adult U.S. population will suffer major depressive disorder, with approximately 1/3 of the cases classified as severe.  Prevalence rates tend to be higher for women and can vary by age. There is also a 2-4 times higher rate of depression in individuals with first degree relatives with the disorder. While the one-year 12.4% prevalence rate of major depressive disorder for children and adolescents is greater than that of adults, a smaller percentage (3.3%) of children and adolescent suffer depression classified as severe (Kessler, Chiu, & Walters, 2005).
 
Far from benign, depression’s impact on children, adolescents, and adults in society is highlighted by the fact it comprises nearly a third of disabilities caused by neuropsychiatric disorders.  According to the World Health Organization (WHO), neuropsychiatric disorders by far account for the greatest proportion (28.47%) of diseases which cause disability.
 
The recent revision of the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has resulted in changes in the general classification of mood and depressive disorders and the specific diagnosis of MDD.  Bipolar disorders and cyclothymic disorders are now separated from the depressive disorders. What primarily differentiates the mood disorders are the duration of the disorders, timing, and their presumed causes or etiology.
 
The DSM-5 category of depressive disorders includes: MDD, a new diagnosis termed persistent depressive disorder (most closely resembling the prior diagnosis of dysthymic disorder), substance/medication-induced depressive disorder, and depressive disorder due to another medical condition. Premenstrual mood dysphoric disorder (PMDD), previously included in an Appendix within DSM-IV-TR (American Psychiatric Association, 2000), is now moved to the category of depressive disorders. Also, a somewhat constroversial diagnosis of disruptive mood dyregulation disorder was created and included in the category of depressive disorders.
 
As with other psychiatric categories in DSM-5, there are now two categories for depressive disorders which do not meet the criteria for the aforementioned diagnoses. These include “other specified depressive disorder“ and “unspecified depressive disorder.
 
In what was described as an effort to address concerns about overdiagnosis of bipolar disorder in children and adolescents, a somewhat controversial diagnosis of disruptive mood dysregulation disorder was created and included in the category of depressive disorders. Persisting depressive disorder, requires a minimum of two years of depressive symptoms in adults, and one year in children. This now entails previous DSM-IV symptoms of major depression and dysthymia.
 
Major Depressive Disorder consists of at least one two-week major depressive episode. The primary symptom of a major depressive episode is either depressed mood or loss of interest or pleasure. In children, this may more closely resemble irritability, rather than sadness.  Additionally, the symptoms must not be clearly attributable to another medical condition or to the physiological effects of a substance. The symptoms cannot be better explained by a range of psychotic, schizophrenic, or delusional disorders.
A major depressive episode is not diagnosed if there has ever been a manic or hypomanic episode. Symptoms that are clearly attributable to another medical condition are not counted in the required 5 symptoms minimum.  Additionally, as with most psychiatric conditions, the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The following is an abbreviated Summary of DSM-V Symptoms of Depression (at least 5 are needed for at least 2 weeks for a diagnosis of Major Depressive Episode). 
With the exception of suicidal ideation and weight change, symptoms must be present most of the day, nearly every day.  Clinical judgment is required as it is noted sadness may be denied at first and sadness may be elicited in clinical interview or inferred from expression and demeanor.
1.         Depressed mood most of the day, nearly every day (can be irritable mood in children and adolescents).
2.         Markedly diminished interest or pleasure, in all, or almost all, activities most of the day, nearly every day.
3.         Significant weight loss or gain when not dieting (i.e. 5% in a month), or decreased appetite nearly every day.  Failure to make appropriate weight gains is considered in children.
4.         Insomnia or hypersomnia nearly every day.
5.         Psychomotor agitation or retardation nearly every day (observable by others).
6.         Fatigue or loss of energy nearly every day.
7.         Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day.
8.         Diminished ability to think or concentrate or indecisiveness nearly every day.
9.         Recurrent thoughts of death, recurrent suicidal ideation without plan, or a suicide attempt or plan.
Major Depressive Episodes are classified as either single episode or recurrent and are also further specified with a variety of features listed below:
·        with anxious distress
·        with mixed features
·        with melancholic features
·        with atypical features
·        with mood congruent psychotic features
·        with mood incongruent psychotic features
·        with catatonia
·        with peripartum onset
·        with seasonal pattern
 
Proper assessment for depression requires consideration of medical and other factors that can mimic depression (e.g., sleep disorders, medical conditions, medical side effects alcohol or substance abuse, and normal bereavement), and should consider co-occurring conditions or stressors which may be exacerbating or maintaining the depression. For example, a child failing in school may develop depression, and become further withdrawn or unmotivated.  If only depression is considered, a co-occurring learning disability contributing to both the depression and school difficulties would be missed.
 
 
Generally, at least a current (within the past year) physical examination is advised with routine annual blood work.  Since thyroid disease can produce increased or reduced thyroid levels which can mimic depression or anxiety, lab testing should also include thyroid levels.  Further tests may be advisable per physician advice depending on family and personal medical history or other symptoms which may present on physical exam.
 
 
Psychological assessment approaches to the evaluation of depression typically involves review of the following: family history, childhood and developmental history, contributory medical history, psychosocial history and history of stressors, prior psychiatric diagnoses and treatment, alcohol, drug and medication history, work and marital history, history of trauma, occupational history and functioning, consideration of co-morbid conditions, and a formal mental status examination. In some, if not many, cases psychological testing that is appropriate to the person’s age, background and circumstance is warranted. 
 
 
Broad band personality and psychopathology measures assess not only depression, but response bias, personality, adaptive strengths, and weakness and help assess and rule out comorbid psychiatric conditions.  Simple rating scales often do not address other possible psychiatric disorders and tend to be susceptible to response bias, but do have their place. For instance, they can be used as “screeners” for more in depth assessment, can offer a quick way of estimating severity, and are useful for follow up attempts to gauge treatment response.
 
 
When there is hopelessness, suicidal threats, or history of suicidal acts, a more detailed assessment of factors associated with elevated suicidal risk as well as an assessment to potential inhibitors to suicidal attempts is conducted.  Close follow-up therapy is indicated when there has been suicidal threat or history, including close psychotherapeutic follow up and monitoring if starting antidepressant medication.
 
 
When it comes to prescribing medication, it should not be surprising that thorough medical, psychiatric and psychological assessment is important to avoid misdiagnosis (Schatzberg, Cole, & DeBattista, 2010).  Such assessment should include consideration of medical factors, ruling out medical conditions which mimic depression, sleep and weight issues, should evaluate patient concerns about sexual side effects, and should include assessment for common co-occurring conditions such as anxiety, posttraumatic stress disorder, and obsessive-compulsive disorder, or the presence of manifest or underlying potential for psychosis.  In some, if not many cases, psychological testing by a licensed psychologistprovides an objective method to help with diagnostic and treatment decisions and reduce risk of adverse psychiatric reactions.
 
 
Briefly, the pharmacological treatment of major depressive disorder can consist of selective serotonin reuptake inhibitors, selective serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, norepinephrine and dopamine inhibitors, serotonin-2 antagonist reuptake inhibitors, and monoamine oxidase inhibitors. In general, all antidepressant drugs have shown equal efficacy, but the various agents have different side-effect profiles that may lead to the selection of one over another (Hahn, 2008).

MYTHS ABOUT DEPRESSION
  • All depression is the same.  A cursory reading of this article should quickly dispel this common myth.  There are different types of depression, and depression varies in severity and can even produce psychotic features.

  • All it takes is some medication.  Medication can be effective in the treatment of depression, and when risks are high, and depression severe, medication should seriously be considered.  However, medication may take 3 to 6 weeks to become effective and some individuals may require medication increases or changes due to side effects or ineffectiveness.  Psychotherapy and exercise are also of some benefit, with most practitioners advocating for a combination of medication and psychotherapy as the most effective approach, resulting in better and more rapid resolution in most cases.  In fact, the National Institute of Mental Health (NIMH) reports that adolescents not responding to medication alone are more likely to improve if treatment involves both psychotherapy and medication.

  • If medication and therapy do not work, there is no hope.  There are some individuals who do not respond to medication, or combination of medication and psychotherapy.  These may be candidates for Electroconvulsive Treatment (ECT), which can be very effective in refractory depression despite some significant risks, or more recently developed approaches such as Transcranial Magnetic Stimulation (TMS).

  • Children do not suffer depression.  This may now sound silly, especially with increasing rates of depression and suicide among teens, but there was a time when this was the subject of debate in psychiatric circles. In fact, the NIMH estimates approximately 3% of children and 12% of adolescents are depressed in any given year.  Current diagnostic criteria emphasize symptoms of depression may differ in children and adolescents compared to adults.  Children who are depressed may complain of feeling sick, refuse to go to school, cling to a parent or caregiver, or worry excessively that a parent may die. Older children and teens may sulk, get into trouble at school, be negative or grouchy, or feel misunderstood.  Assessment by a child psychiatrist or a psychologist experienced in evaluation children and adolescents is important.

  • Depression is no big deal. Depression can last a lifetime for some, contributes to reduced productivity, lost work days, divorce, negative health effects, and suicide.  It is estimated to contribute to as much disability in the U.S. as cardiac disease.

  • Once you start medication or psychotherapy it will be needed for the rest of your life. Many people responds after a course of treatment lasting 4-6 months to a year and are able to discontinue therapy or medication without further episodes.  Others with recurrent depression may require additional courses of treatment, but few will require medication and therapy for the rest of their life.

  • Taking medication or seeing someone for treatment for depression is a sign of weakness. Recognizing a common condition which has a high rate of successful treatment is not a sign of weakness, but practical and wise.  A truly strong individual recognizes their own needs or ailments and takes effective measures to deal with them.  Therapy and medication are effective ways to do that.  Denying depression can have many adverse results on productivity, relationships, quality of life and even health.

first published 11/26/13 CPANCF.COM Articles, Tips, and Archives


See upcoming articles for further discussion and detail about psychotherapeutic and pharmacological approaches to treatment of depression.  Also see an article on this website about cognitive-behavioral and psychodynamic treatment approaches.

 


REFERENCES:
 
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of
Mental Disorders - TR (4th  Ed.). Washington, DC
 
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders - 5 (5th  ed). Washington, DC
 
Hahn, R.K, Albers, L.J., & Reist, C. (2008).Psychiatry. Blue Jay, California: Current Clinical Strategies Publishing.
 
Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun ;62 (6):617-27.)
 
 
Schatzberg, A.F., Cole, J.O., DeBattista, C. (2010). Manual of clinical  psychopharmacology (7th ed.). Washington, DC: American Psychiatric Publishing, Inc.


 
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