Clinical:Depression

Other Names

Clinical Depression, Major Depressive Disorder, Recurrent Depressive Disorder

Types

The DSM IV specify the following possible features for Major Depressive Disorder, recurrent:

Mild, Moderate

Severe with or without psychotic features

Chronic

With Catatonic features

With Melancholic features

With Atypical features

With Postpartum onset

Diagnosis

Based on the World Health Organization ICD 10

According to the World Health Organization ICD 10 Major Depressive Disorder is classified under the heading Mood (affective) disorders (F30-F39). The ICD 10 diagnostic recommendations for Major Depressive Disorder are:

F33 Recurrent depressive disorder

A disorder characterized by repeated episodes of depression as described for depressive episode (F32.-), without any history of independent episodes of mood elevation and increased energy (mania). There may, however, be brief episodes of mild mood elevation and overactivity (hypomania) immediately after a depressive episode, sometimes precipitated by antidepressant treatment. The more severe forms of recurrent depressive disorder (F33.2 and F33.3) have much in common with earlier concepts such as manic-depressive depression, melancholia, vital depression and endogenous depression. The first episode may occur at any age from childhood to old age, the onset may be either acute or insidious, and the duration varies from a few weeks to many months. The risk that a patient with recurrent depressive disorder will have an episode of mania never disappears completely, however many depressive episodes have been experienced. If such an episode does occur, the diagnosis should be changed to bipolar affective disorder (F31.-). Includes: recurrent episodes of: · depressive reaction · psychogenic depression · reactive depression seasonal depressive disorder Excludes: recurrent brief depressive episodes ( F38.1 ) F33.0 Recurrent depressive disorder, current episode mild

A disorder characterized by repeated episodes of depression, the current episode being mild, as in F32.0, and without any history of mania.

F33.1 Recurrent depressive disorder, current episode moderate

A disorder characterized by repeated episodes of depression, the current episode being of moderate severity, as in F32.1, and without any history of mania.

F33.2 Recurrent depressive disorder, current episode severe without psychotic symptoms

A disorder characterized by repeated episodes of depression, the current episode being severe without psychotic symptoms, as in F32.2, and without any history of mania. Endogenous depression without psychotic symptoms Major depression, recurrent without psychotic symptoms Manic-depressive psychosis, depressed type without psychotic symptoms Vital depression, recurrent without psychotic symptoms

F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms

A disorder characterized by repeated episodes of depression, the current episode being severe with psychotic symptoms, as in F32.3, and with no previous episodes of mania. Endogenous depression with psychotic symptoms Manic-depressive psychosis, depressed type with psychotic symptoms Recurrent severe episodes of: · major depression with psychotic symptoms · psychogenic depressive psychosis · psychotic depression · reactive depressive psychosis

F33.4 Recurrent depressive disorder, currently in remission

The patient has had two or more depressive episodes as described in F33.0-F33.3, in the past, but has been free from depressive symptoms for several months.

F33.8 Other recurrent depressive disorders

F33.9 Recurrent depressive disorder, unspecified Monopolar depression NOS

Differential Diagnosis

A number of medical and psychiatric conditions could mimic major depression.

Medical Conditions

Hypothyroidism

Diabetes

Anemia

Neurologic Conditions

Dementia

Psychiatric Disorders

Anxiety disorders - such as panic disorder or Generalized Anxiety Disorder

Post-traumatic Stress Disorder

Dissociative disorders

Epidemiology

Prevalence

Major Depressive Disorder has a high prevalence in the general population. Lifetime prevalence of major depressive episodes range from 5 to 17% of the population. In almost all samples the risk for women is double that of men. The mean age of onset for major depressive disorder is 40 years, and the majority of patients have an onset between 20 and 50. There are some indications that the incidence of depression is increasing among the younger generations.

Treatment

The treatment of depression has evolved significantly over the last decades, with the arrival of Selective Serotonin Reuptake Inhibitors (SSRIs) as a watershed event. The current consensus is that a combination of medication and psychotherapy is the more effective approach. There are a variety of psychotherapy modalities; regarding choice of antidepressants, SSRIs tend to be first choice today. If a patient fails an initial antidepressant trial a number of alternatives could be implemented: adjust the dose of the first antidepressant, combine antidepressants, augment or use adjunct medication, switch to another class of antidepressants, or try Electro-Convulsive Therapy (ECT).

The American Psychiatric Association Practice Guidelines for the treatment of Major Depressive Disorder can be found here.

There is overall consensus that all antidepressants have similar efficacy while presenting marked differences in terms of side effect profile. A recent metanalysis on the efficacy and acceptability of new antidepressants concluded that escitalopram and sertraline have a more favorable profile ^[1].

Screening Recommendations

The U.S. Preventive Services Task Force recommends that adolescents aged 12 to 18 be screened for major depression as long as accurate diagnosis, psychotherapy, and follow-up can be ensured. The point prevalence of major depression among teens in primary care ranges from 9% to 21% ^[2]

References

1. ↑ Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Cipriani A, Furukawa TA, Salanti G, Geddes JR, Higgins JP, Churchill R, Watanabe N, Nakagawa A, Omori IM, McGuire H, Tansella M, Barbui C. Lancet. 2009 Jan 28.
2. ↑ Screening for Child and Adolescent Depression in Primary Care Settings: A Systematic Evidence Review for the US Preventive Services Task Force. Selvi B. Williams, MD, MPH, Elizabeth A. O'Connor, PhD, Michelle Eder, PhD and Evelyn P. Whitlock, MD, MPH. PEDIATRICS Vol. 123 No. 4 April 2009, pp. e716-e735