Depressive Disorders

Patients may appear miserable, with tearful eyes, furrowed brows, down-turned corners of the mouth, slumped posture, poor eye contact, lack of facial expression, little body movement, and speech changes (eg, soft voice, lack of prosody, use of monosyllabic words). Appearance may be confused with Parkinson disease Parkinson Disease Parkinson disease is a slowly progressive, degenerative disorder characterized by resting tremor, stiffness (rigidity), slow and decreased movement (bradykinesia), and eventually gait and/or... read more . In some patients, depressed mood is so deep that tears dry up; they report that they are unable to experience usual emotions and feel that the world has become colorless and lifeless.

Nutrition may be severely impaired, requiring immediate intervention.

Some depressed patients neglect personal hygiene or even their children, other loved ones, or pets.

For diagnosis of major depression, ≥ 5 of the following must have been present nearly every day during the same 2-week period, and one of them must be depressed mood or loss of interest or pleasure:

Depressive symptoms that persist for ≥ 2 years without remission are classified as persistent depressive disorder (PDD), a category that consolidates disorders formerly termed chronic major depressive disorder and dysthymic disorder.

Symptoms typically begin insidiously during adolescence and may persist for many years or decades. The number of symptoms often fluctuates above and below the threshold for major depressive episode.

Affected patients may be habitually gloomy, pessimistic, humorless, passive, lethargic, introverted, hypercritical of self and others, and complaining. Patients with PDD are also more likely to have underlying anxiety disorders Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more , substance use disorders Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more , or personality (ie, borderline personality) disorders Overview of Personality Disorders Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more .

For diagnosis of persistent depressive disorder, patients must have had a depressed mood for most of the day for more days than not for ≥ 2 years plus ≥ 2 of the following:

Premenstrual dysphoric disorder involves mood and anxiety symptoms that are clearly related to the menstrual cycle, with onset during the premenstrual phase and a symptom-free interval after menstruation. Symptoms must be present during most menstrual cycles during the past year.

Manifestations are similar to those of premenstrual syndrome Premenstrual Syndrome (PMS) Premenstrual syndrome (PMS) is a recurrent luteal-phase disorder characterized by irritability, anxiety, emotional lability, depression, edema, breast pain, and headaches, occurring during the... read more but are more severe, causing clinically significant distress and/or marked impairment of social or occupational functioning. The disorder may begin any time after menarche; it may worsen as menopause approaches but ceases after menopause. Prevalence is estimated at 2 to 6% of menstruating women in a given 12-month interval.

For diagnosis of premenstrual dysphoric disorder, patients must have ≥ 5 symptoms during the week before menstruation. Symptoms must begin to remit within a few days after onset of menses and become minimal or absent in the week after menstruation. Symptoms must include ≥ 1 of the following:

In addition, ≥ 1 of the following must be present:

Prolonged grief is persistent sadness following the loss of a loved one. It is distinct from depression in that the sadness relates to the specific loss rather than the more general feelings of failure associated with depression. In contrast to normal grief this condition may be highly disabling and require therapy specifically designed for prolonged grief disorder.

Prolonged grief is considered present when the grief response (typified by persistent longing or yearning and/or preoccupation with the deceased) lasts a year or longer and is persistent, pervasive, and exceeding cultural norms. It also must be accompanied by ≥ 3 of the following for the last month to a degree that causes distress or disability:

Some useful screening tools include the Inventory of Complicated Grief and the Brief Grief Questionnaire.

Clusters of symptoms with characteristics of a depressive disorder that do not meet the full criteria for other depressive disorders but that cause clinically significant distress or impairment of functioning are classified as other depressive (specified or unspecified) disorder.

Included are recurrent periods of dysphoria with ≥ 4 other depressive symptoms that last < 2 weeks in people who have never met criteria for another mood disorder (eg, recurrent brief depression) and depressive periods that last longer but that include insufficient symptoms for diagnosis of another depressive disorder.

Major depression and persistent depressive disorder may include one or more specifiers that describe additional manifestations during a depressive episode:

Depressive disorders must be distinguished from demoralization and grief. Other mental disorders (eg, anxiety disorders Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more ) can mimic or obscure the diagnosis of depression. Sometimes more than one disorder is present. Major depression (unipolar disorder) must be distinguished from bipolar disorder Bipolar Disorders Bipolar disorders are characterized by episodes of mania and depression, which may alternate, although many patients have a predominance of one or the other. Exact cause is unknown, but heredity... read more .

In older patients, depression can manifest as dementia of depression (formerly called pseudodementia), which causes many of the symptoms and signs of dementia Dementia Dementia is chronic, global, usually irreversible deterioration of cognition. Diagnosis is clinical; laboratory and imaging tests are usually used to identify treatable causes. Treatment is... read more such as psychomotor retardation and decreased concentration. However, early dementia may cause depression. In general, when the diagnosis is uncertain, treatment of a depressive disorder should be tried.

Differentiating chronic depressive disorders, such as dysthymia, from substance use disorders Substance Use Disorders Substance use disorders involve a pathologic pattern of behaviors in which patients continue to use a substance despite experiencing significant problems related to its use. Diagnosis of substance... read more may be difficult, particularly because they can coexist and may contribute to each other.

Physical disorders must also be excluded as a cause of depressive symptoms. Hypothyroidism Hypothyroidism Hypothyroidism is thyroid hormone deficiency. Symptoms include cold intolerance, fatigue, and weight gain. Signs may include a typical facial appearance, hoarse slow speech, and dry skin. Diagnosis... read more often causes symptoms of depression and is common, particularly among older patients. Parkinson disease Parkinson Disease Parkinson disease is a slowly progressive, degenerative disorder characterized by resting tremor, stiffness (rigidity), slow and decreased movement (bradykinesia), and eventually gait and/or... read more , in particular, may manifest with symptoms that mimic depression (eg, loss of energy, lack of expression, paucity of movement). A thorough neurologic examination Introduction to the Neurologic Examination The neurologic examination begins with careful observation of the patient entering the examination area and continues during history taking. The patient should be assisted as little as possible... read more is needed to exclude this disorder.

Several brief questionnaires are available for screening for depression. They help elicit some depressive symptoms but cannot be used alone for diagnosis. However, many of these tools are useful in identifying at-risk people who need more detailed evaluation. Some of the more widely used screening tools include the Patient Health Questionnaire-9 (PHQ-9) and the Beck Depression Inventory (BDI).

No laboratory findings are pathognomonic for depressive disorders. However, laboratory testing is necessary to exclude physical conditions that can cause depression (see table Some Causes of Depression Some Causes of Symptoms of Depression and Mania* ). Tests include complete blood count, thyroid-stimulating hormone levels, and routine electrolyte, vitamin B12, and folate levels and, in older men, testosterone levels. Testing for illicit drug use is sometimes appropriate.

Until definite improvement begins, a physician may need to see patients weekly or biweekly to provide support and education and to monitor progress. Telephone calls may supplement office visits.

Patients and loved ones may be worried or embarrassed about the idea of having a mental disorder. The physician can help by explaining that depression is a serious medical disorder caused by biologic disturbances and requires specific treatment and that the prognosis with treatment is good. Patients and loved ones should be reassured that depression does not reflect a character flaw (eg, laziness, weakness). Telling patients that the path to recovery often fluctuates helps them put feelings of hopelessness in perspective and improves adherence.

Encouraging patients to gradually increase simple activities (eg, taking walks, exercising regularly) and social interactions must be balanced with acknowledging their desire to avoid activities. The physician can suggest that patients avoid self-blame and explain that dark thoughts are part of the disorder and will go away.

Numerous controlled trials have shown that psychotherapy, particularly cognitive-behavioral therapy and interpersonal therapy, is effective in patients with major depressive disorder, both to treat acute symptoms and to decrease the likelihood of relapse. Patients with mild depression tend to have better outcomes than those with more severe depression, but the magnitude of improvement is greater in those with more severe depression.

Several drug classes and drugs can be used to treat depression:

Choice of drug Drug Choice and Administration of Antidepressants Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more may be guided by past response to a specific antidepressant. Otherwise, SSRIs are often the initial drugs of choice. Although the different SSRIs are equally effective for typical cases, certain properties of the drugs make them more or less appropriate for certain patients (see table Antidepressants ).

ECT involves the electrical induction of a seizure under controlled conditions. Its mechanism of action is uncertain but the production of seizure activity appears to be integral to its antidepressant effects. Modern ECT, delivered under heavy sedation/general anesthesia, is typically well tolerated but confusion and memory impairment may occur acutely. Much of this improves and is resolved by 6 months following a course of ECT, but retrograde amnesia may persist for the long term. This is particularly so for memories from the several months preceding ECT. Patients with baseline cognitive deficits, those receiving bilateral treatments, older patients, and patients receiving lithium are at higher risk for memory impairment and confusion.

The following are often treated with ECT if drugs are ineffective:

Patients who have stopped eating may need ECT to prevent death. ECT is particularly effective for psychotic depression.

Response to 6 to 10 ECT treatments is usually dramatic and may be lifesaving. Relapse after ECT is common, and drug therapy is often maintained after ECT is stopped.

Phototherapy is best known for its effects on seasonal depression but appears to be equally effective for nonseasonal depression.

Treatment can be provided at home with a special light unit that provides 2500 to 10,000 lux at a distance of 30 to 60 cm that patients look at for 30 to 60 minutes/day (longer with a less intense light source).

In patients who go to sleep late at night and rise late in the morning, phototherapy is most effective in the morning, sometimes supplemented with 5 to 10 minutes of exposure between 3 PM and 7 PM. For patients who go to sleep and rise early, phototherapy is most effective between 3 PM and 7 PM.

Psychostimulants (eg, dextroamphetamine, methylphenidate) are sometimes used, often with antidepressants. A number of controlled trials support their use in depressive disorders (1 Treatment references Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more ).

Medicinal herbs are used by some patients. St. John’s wort St. John’s Wort The flowers of St. John’s wort (Hypericum perforatum) (SJW) contain its biologically active ingredients, hypericin and hyperforin. SJW may increase central nervous system serotonin and... read more may be effective for mild depression, although data are contradictory. St. John’s wort may interact with other antidepressants and other drugs. Some placebo-controlled studies of omega-3 supplementation, used as augmentation or as monotherapy, have suggested that eicosapentaenoic acid 1 to 2 g once a day has useful antidepressant effects.

Vagus nerve stimulation involves intermittently stimulating the vagus nerve via an implanted pulse generator. It may be useful for depression refractory to other treatments but usually takes 3 to 6 months to be effective.

The use of repetitive transcranial magnetic stimulation (rTMS) for the acute treatment of major depressive disorder has substantial support from controlled trials. Low-frequency rTMS may be applied to the right dorsolateral prefrontal cortex (DLPC), and high-frequency rTMS can be applied to the left DLPC. The most common adverse effects are headaches and scalp discomfort; both occur more often when high-frequency rather than low-frequency rTMS is used.

Deep brain stimulation using implanted electrodes that target the subgenual cingulate or the anterior ventral internal capsule/ventral striatum has had promising results in uncontrolled case series (2 Treatment references Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more ). Controlled trials are underway.

Support groups (eg, the Depression and Bipolar Support Alliance [DBSA] ) can help patients by providing a forum to share their common experiences and feelings.