Case Study of Major Depression
Muhammad Zafar Iqbal1* and Sadaf un Nisa Awan2
1Hypnotherapist and Psychotherapist, Islamabad, Pakistan
2M.Phil Psychology, Gujarat, Pakistan
- *Corresponding Author:
- Muhammad Zafar Iqbal
Hypnotherapist and Psychotherapist
Therapist, Private Psychology
House 39, Street 3, Park Avenue
Park Road, Islamabad 44000, Pakistan
Received date: May 07, 2016; Accepted date: Jun 04, 2016; Published date: Jun 11, 2016
Citation: Iqbal MZ, un Awan SN (2016) Case Study of Major Depression. J Med Diagn Meth 5:214. doi:10.4172/2168-9784.1000214
Copyright: © 2016 Iqbal MZ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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This document pertains to the case study of Major Depression. The subject of the disorder was Mrs. RJ (Initial instead of real name), 43 years old housewife and mother of four children. She visited my clinic along with her husband who informed that she feels burden on shoulder and at the back of her head most of time, feel weakness, facing lack of concentration on her daily work, disturbance with loud voices of anyone specially loud voice of males, shivering of body without any reason. He also informed about her weak memory, negative dreaming which disturb her sleep, fidgety and restless most of the time, aggressive behaviour and sometime weeping and shouting without any reason. Before visiting my clinic she visited some psychiatrists for treatment because she had become very aggressive and started to throw things and whatever was in her physical approach. One of those psychiatrists recommended ECT for treatment but ECT only affected her memory badly. Assessment made after taking semi-structured interviews from Mrs. RJ and her husband. In light of assessment and DSM-IV, Mrs. RJ was diagnosed by Major Depression Disorder.
Major depression; Fear stimuli identification therapy (FSIT); Assessment; Treatment
Major purpose of this particular case study was to reaffirm and prove the efficacy of Fear-Stimuli Identification Therapy (FSIT) on empirical grounds. It was also intended to use FSIT in order to eliminate the symptoms of Major Depression Disorder in which Mrs. RJ was suffering from as the therapy was already successfully used to remove the symptoms of various disorders in different cases [1,2].
Hypotheses: "It is expected that the FSIT method would effectively cure the Major Depression Disorder from which the above referred person Mrs. RJ is suffering."
Fear Stimuli Identification Therapy (FSIT): Fear-Stimuli Identification Therapy (FSIT) is based upon the perception that some of the incidents (mostly the sudden incidents) in the early age of a child become stimuli for fear instinct which cast negative effects over the personality of a child and become reason for one or the other type of disorder. FSIT investigates and digs out such events from a person’s unconscious which play as stimuli for fear instinct. Whenever effected person encounters the events in his/her life resembling to the stimulus/ stimuli the specific incident which has stimulated the fear instinct previously is recalled.
Participants: Mrs. RJ (client)
Materials: No any specific material used in this case study.
Procedure: In the first two sessions semi-structured interviews were conducted with Mrs. RJ and her husband. Assessment was made in the light of these interviews and reasons/causes for disorder were dig out. DSM-IV was consulted to decide the nature or type of disorder.
In the subsequent of fifty sessions Mrs. RJ was asked to write on specific topics. Cross-questioning was carried out over the ideas mentioned in the writings.
Results and Discussions
Results: After diagnosis of Major Depression Disorder, treatment was started in the light of FSIT method. Five sessions per week were taken, total of fifty sessions were conducted. In the course of treatment, her husband reported about Positive behavioural change in different spheres of Mrs. RJ’s life. Clinical observations during treatment also indicated a gradual positive change in his personality. The difference between pre-assessment and post- assessment confirmed precision of hypotheses and efficacy of FSIT. Feedback was obtained on weekly basis for a period of one month from Mrs. RJ’s husband about any possible reappearance of symptoms of Mrs. RJ Disorder and this was confirmed that there was no reoccurrence of disorder’s symptoms anymore.
Discussions: Before visited to the clinic, Mrs. RJ had already consulted a psychiatrist and was mostly treated by means of antidepressants and ECT. This had no significant effects upon client’s disorder. Anyhow this medication helped Mrs. M RJ to sleep little well, as she was not able to sleep before .
Prior to write about intervention/treatment, a brief description of patient’s social and family environment is necessary in order to understand the main causes of Mrs. RJ’s disorder.
Family history: Her father was employed in Pakistan Army in lower staff with low income level. Their family always faced financial problems but despite of their low level of income, her father spend most of his income on himself and his own entertainments and ignored the necessities and basic needs of his family. Her grandfather and an uncle usually supported her family but as they were also not financially well off so her family has been remained in financially crisis throughout her life till she had to depend on her father’s income. This scenario was somehow changed after her marriage because his husband was a teacher and she also started to teach in a school and income of both life partners helped them to fulfil their basic requirements of life. Her father always behaved badly, strict and harsh to client like traditional behaviour of most of the males to females in that backward area. Even her mother had also been facing her father’s behaviour since her marriage with his father. Mrs. RJ remembers that she saw her mother mostly weeping and unhappy with her life and due to her own problems she also never tried to give due attention, love and care to her daughter (Client) and she also behaved badly to Mrs. RJ. Whenever her father visits his home after a month or more from his job, he never tried to spend his time with his family (client and her mother) and never tried to understand their basic needs and always like to spend his time outside the home as well as spend his money outside the home without considering the basic need of his family. On his visit to home, how much time he spend his home was a tough time for both of these females i.e., client and her mother because he behaved badly, strict and always looked in a mood to taunt them, yelling at them, scolding them loudly and insulting them. This behaviour of her father and even her mother towards her made her deprived personality. And feelings of being deprived and ignorance effected badly in her personality and sense of deprivation was developing in her mind. This sense of deprivation was increasing in her mind when she started to make comparison between her own father’s behaviour with them and other families that how their father deal with their family. She thought that her father had worst behaviour as compared to others. Mrs. RJ has a younger brother who was also effected person of this atmosphere but as he was a male so he could go out and managed to have catharsis for his depression little bit although he has also a submissive behaviour.
Although after her marriage she had a happy life with a loving husband. She have not financially problems after her marriage as both, her husband and she, doing jobs and have enough income for their basic needs. Her husband is a loving person and both have been happy with each other. Her husband cares for her and tries to make her happy. When they got their first baby girl, her husband was also very happy to have a female child despite of traditional approach to have baby boy. He loves her daughter and very much caring for both of them. He usually spends time with them, plays with her daughter. Although her husband is a loving, caring and nice person but he has a bad habit that he also speaks loudly as this is the traditional habit of most of the males of their area so he also do the same. And his habit of speaking loudly again reminds her past life, before marriage in her own home, specifically pertaining to her father that how he speaks loudly. So, this was miserable position for her unconscious level of mind and her psychological problem kept increasing instead of being removed as to her husband behaves with her and their kids very nicely and in loving and caring manners.
Social History: Mrs. RJ belonged to a small village which was a backward area with low population and mostly people have very traditional and low mentality. They have strong religious believes. Most of the females of that village spend their time in their home without any entertainment and refreshing activities. Their males were very strict about going out alone and without covers for females. Most of the people were against the education of their females. So as the trend of her village she was also compel to act like that. She was never allowed to go out to meet her friends alone so her feelings from her childhood were lonely. But her uncle fully supported her so she was sent to school for education. She had just two friends in school but this relation were also limited to school and after school she had to spend her time in her home only. Due to low population of the village, there were lesser gatherings or social events. Whenever there was any social gathering like marriage or any funerals, she went there with her parents or any elder family member. She never participated in any social activities.
Medical / Past psychiatric history: She has been using antidepressant medicines since 10 years from different physiatrists and one of those physiatrists recommended E.C.T which effected very badly to her memory even she lost her some memory for a specific period of one months.
Assessment: Since her childhood she was facing lots of psychological problem with behaviour of her father who used to behave badly, strict and harsh to client. Even her mother had also been facing her father’s behaviour since her marriage with his father. Mrs. RJ remembers that she saw her mother mostly weeping and unhappy with her life and due to her own problems she also never tried to give due attention, love and care to her daughter (Client) and she also behaved badly to Mrs. RJ. On his visit to home from job as he was an army person, how much time he spend his home was a tough time for both of these females i.e., client and her mother because he behaved badly, strict and always looked in a mood to taunt them, yelling at them, scolding them loudly and insulting them. This behaviour of her father and even her mother towards her made her deprived personality. And feelings of being deprived and ignorance effected badly in her personality and sense of deprivation was developing in her mind. She was scared of loud voices and feels fidgety and uncomfortable whenever she hear loud voice and by some time her this problem started occurring to hear any loud voice of any male even except her father. An association of loud voice with cruelty was developed in her unconscious level of mind and loud voice became stimulus for fear instinct. She thought that her father had worst behaviour as compare to others.
Treatment: In first 7 sessions, I made cross questioning with her about her past history of her childhood and I focused behaviour of her father specially in her childhood (1 year to 7 years) and it was clearly known that her father had much insulting and harsh behaviour with her mother and even with my patient also which affected my patient’s personality and she started to face some psychological problem since her early childhood. It was also explored that whenever her father used to come back from his duty, patient was much conscious (careful) till her father remained present in home. During the period of her father’s presence in home, my patient was extra conscious and careful, definitely, this consciousness increased pressure on her nervous system and she felt burden on her shoulder although she felt much relax after her father again go to his duty. So the problem just occur only when her father remain present at home.
In next 7 session I analyzed her behaviour during presence of her father in home and emotional effects during her father’s presence in routine as well as due to scolding, snubbing (in loud voice) or harsh behaviour of her father with her or her mother. I also analyzed that how her unconscious level of mind perceives her father’s behaviour and how it affected her unconscious level of mind. After cross questioning and analyzing it was found that her father’s harsh, insulting behaviour and scolding them in loud voice was become a stimulus for her fear instinct. Although this has become a stimulus for her fear instinct but as well as it created the sense of deprivation, humiliation and indignity for which her unconscious level of mind reacted due to her feelings of anger and being humiliated but her these feelings was suppressed by her conscious level of mind due to same stimulus so she could never be able to express her anger and used to sob and weep in low voice when she was alone.
In next 7 sessions I asked her to write about two topics specifically, one is her father and loud voice of males. So initially I asked her to write about her father and while she was writing, she felt very difficult to write about her father because her all symptoms were appeared like burden on her shoulder which showing resistance of her unconscious level of mind. Next day when I made cross questioning after analyzing her writing and her behaviour, during this session of cross questioning, her all symptoms were again strongly appeared although consciously she tried to avoid any negative remarks about her father (this because of traditions, customs and religiously most people can’t be able to say anything negatively about their parents). In next session, I continued cross questioning with her about her father and at last she admitted that she did not like her father at all since her childhood. She also admitted that she disliked her father since her childhood and she has been keeping negative feelings and hate about her father since childhood even sometimes she had in her mind some abuses in very bad wording but she never expressed these sought of feeling to anyone else tried to get rid of these negative feelings consciously. After this I asked her to write about loud voice of males specifically. During writing the about loud voice of males, same symptoms were appeared as appeared during writing about her father. After analyzing her writing, I made cross questioning to her in next session and it was known that the loud voice of males has been associated with her father being a stimulus by her unconscious level of mind because her father used to scold and humiliate her in loud voice so whenever she hear any male speaking anything in loud voice her symptoms were appeared. Her husband is very loving and caring husband for her and father for their kids but unfortunately her husband also use to speak in loud voice in routine not to show any anger but even he speaks in loud during normal and routine conversation. So loud voice of males has become a reference for her stimulus and her unconscious level of mind always used to associate every loud voice of any male with her stimulus. The loud voice of any other male, except her father, at any place even on road has become a reference for her stimulus. This reference also brings all symptoms which are associated with stimulus.
Whatever has been happening with my patient since her childhood lead her defence mechanism of unconscious level of mind to make a shelter against fear instinct and this shelter is over consciousness about cleanness. She always remain over conscious about cleanness for example if she has cleaned her kitchen and after some time when she visits kitchen next time she was usually of the view that may be there is some incest in kitchen so she again started to clean everything in kitchen unnecessarily and if she has cleaned her home but she sees any little piece of litter/dust or garbage on anywhere in floor she must clean whole house anyway although her mother was not much conscious about cleanliness so she never try to instruct her about cleanliness and never ask her to clean her house or anything else since her childhood. When I asked her to write about cleanliness and make cross questioning, she feel all problems and appears all symptoms as appeared during writing about references. During last 9 session of first stage, I made cross questioning in broad view repeatedly about stimulus, references and shelter to strike her fear instinct again and again. Her behaviour was getting rude and harsh and aggression level was much increased even in a session her unconscious level of mint resisted as much that her some senses like sense to hear and talk was suspended for almost 1 minute. She was not been able to listen and talk anything during this minute and this was a clear sign that when I tried to repeat it during cross questioning that her all problem/ symptoms caused by her stimulus, references and shelter and when I insisted to make her realize the fact, her unconscious level of mind resisted much forcefully and halted her senses for a while.
In next twenty sessions, I asked her to write about her stimulus, references and shelter again but this time I asked her to write only positive possibilities about her stimulus and references as there are many other reasons why a person can speak in loud voices so I tried to make her understand and write that what can be other possibilities of her stimulus and references and on the other side I asked her to write some negative aspects about her shelter that why she was so conscious about cleanliness and what happened if she does not repeat this practice again and again and why she felt so uncomfortable with a little bit dust on floor and what if she just clean that part of floor not the whole floor or when she sees an incest on any item in kitchen so what happens if she only clean that item not the whole kitchen. Basically these negative associations with stimulus and reference, associated with the stimulus, are the main cause which suppressed her real personality and when with the help of writing and cross questioning, she explored the all other positive possibilities and her conscious level of mind have griped the positive aspects of stimulus and reference, the negative associations of stimulus and reference were removed from unconscious level of mind and when her unconscious level of mind became realistic about stimulus and references then automatically her unconscious level of mind don’t need any shelter anymore which it has made against those stimulus and reference and this scenario made her personality at normal.
There was no extra factor occur or create problem during the assessment or treatment process it was only resistance of unconscious level of mind.
Follow up was made during the time of treatment and after treatment for feedback and about progress of the client from her and her husband. It was good during the entire course of treatment and after treatment.
Mrs. RJ was a patient of Major Depression Disorder.
Basic reason was behaviour of her father (Specially speaking in loud voice which became stimulus for her fear instinct).
Loud voice of any male became reference for her stimulus.
Unconscious level of mind (defence mechanism) made a shelter against stimulus and reference that is “over conscious about cleanliness”.
Treatment could not be possible without deep analysis of her unconscious level of mind that what was the stimulus and references for fear instinct.
It was necessary to explore all positive possibilities about her stimulus and references (loud voice) to make her personality unsuppressed and make it at normal.
When all other positive possibilities were realized by her unconscious level of mind and negative association with stimulus and reference removed so there was no need of any shelter so the role of shelter was also wiped out.
Minimum 5 sessions per week required for treatment because if there was gap between each session and next session may not be conducted on consecutive day, the fear which was explored in one session may again suppressed and resistance level of the client may also again suppressed. So continuity in sessions without having gap is very important in treatment for proper cure.
Access and Barriers to Care
Only resistance of unconscious level of mind was a barrier but when it was sought out by free writing and cross questioning that barrier was also removed successfully.
• It is recommended that study should be done on Fear instinct.
• FSIT should be used for the treatment when the patients problem led to the fear instinct.
• Therapist should focus on the reason of the problem for the treatment.
- (2000) American Psychiatric Association. Diagnostic and statistical manual of mentaldisorders (5thEdn.).
- Ejaz M, Iqbal MZ (2016) Case Study of Major Depressive Disorder. J ClinCase Rep 6:698
- Iqbal MZ, Ejaz M (2016) Case Study of Functional Neurological Disorder (Aphonic). J PsycholPsychother 6:243
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For other types of depression, see Mood disorder.
|Major depressive disorder|
|Synonyms||Clinical depression, major depression, unipolar depression, unipolar disorder, recurrent depression|
|Vincent van Gogh's 1890 painting|
Sorrowing old man ('At Eternity's Gate')
|Symptoms||Low mood, low self-esteem, loss of interest in normally enjoyable activities, low energy, pain without a clear cause|
|Duration||> 2 weeks|
|Causes||Genetic, environmental, and psychological factors|
|Risk factors||Family history, major life changes, certain medications, chronic health problems, substance abuse|
|Treatment||Counseling, antidepressant medication, electroconvulsive therapy|
|Frequency||216 million (2015)|
[edit on Wikidata]
Major depressive disorder (MDD), also known simply as depression, is a mental disorder characterized by at least two weeks of low mood that is present across most situations. It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause. People may also occasionally have false beliefs or see or hear things that others cannot. Some people have periods of depression separated by years in which they are normal while others nearly always have symptoms present. Major depressive disorder can negatively affect a person's personal, work, or school life, as well as sleeping, eating habits, and general health. Between 2–7% of adults with major depression die by suicide, and up to 60% of people who die by suicide had depression or another mood disorder.
The cause is believed to be a combination of genetic, environmental, and psychological factors. Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance abuse. About 40% of the risk appears to be related to genetics. The diagnosis of major depressive disorder is based on the person's reported experiences and a mental status examination. There is no laboratory test for major depression. Testing, however, may be done to rule out physical conditions that can cause similar symptoms. Major depression should be differentiated from sadness, which is a normal part of life and is less severe. The United States Preventive Services Task Force (USPSTF) recommends screening for depression among those over the age 12, while a prior Cochrane review found that the routine use of screening questionnaires have little effect on detection or treatment.
Typically, people are treated with counseling and antidepressant medication. Medication appears to be effective, but the effect may only be significant in the most severely depressed. It is unclear whether medications affect the risk of suicide. Types of counseling used include cognitive behavioral therapy (CBT) and interpersonal therapy. If other measures are not effective electroconvulsive therapy (ECT) may be tried. Hospitalization may be necessary in cases with a risk of harm to self and may occasionally occur against a person's wishes.
Major depressive disorder affected approximately 216 million people (3% of the world's population) in 2015. The percentage of people who are affected at one point in their life varies from 7% in Japan to 21% in France. Lifetime rates are higher in the developed world (15%) compared to the developing world (11%). It causes the second most years lived with disability after low back pain. The most common time of onset is in a person in their 20s and 30s. Females are affected about twice as often as males. The American Psychiatric Association added "major depressive disorder" to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. It was a split of the previous depressive neurosis in the DSM-II which also encompassed the conditions now known as dysthymia and adjustment disorder with depressed mood. Those currently or previously affected may be stigmatized.
Signs and symptoms
Major depression significantly affects a person's family and personal relationships, work or school life, sleeping and eating habits, and general health. Its impact on functioning and well-being has been compared to that of other chronic medical conditions such as diabetes.
A person having a major depressive episode usually exhibits a very low mood, which pervades all aspects of life, and an inability to experience pleasure in activities that were formerly enjoyed. Depressed people may be preoccupied with, or ruminate over, thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness, and self-hatred. In severe cases, depressed people may have symptoms of psychosis. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant. Other symptoms of depression include poor concentration and memory (especially in those with melancholic or psychotic features), withdrawal from social situations and activities, reduced sex drive, irritability, and thoughts of death or suicide. Insomnia is common among the depressed. In the typical pattern, a person wakes very early and cannot get back to sleep.Hypersomnia, or oversleeping, can also happen. Some antidepressants may also cause insomnia due to their stimulating effect.
A depressed person may report multiple physical symptoms such as fatigue, headaches, or digestive problems; physical complaints are the most common presenting problem in developing countries, according to the World Health Organization's criteria for depression. Appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice that the person's behavior is either agitated or lethargic. Older depressed people may have cognitive symptoms of recent onset, such as forgetfulness, and a more noticeable slowing of movements. Depression often coexists with physical disorders common among the elderly, such as stroke, other cardiovascular diseases, Parkinson's disease, and chronic obstructive pulmonary disease.
Depressed children may often display an irritable mood rather than a depressed mood, and show varying symptoms depending on age and situation. Most lose interest in school and show a decline in academic performance. They may be described as clingy, demanding, dependent, or insecure. Diagnosis may be delayed or missed when symptoms are interpreted as normal moodiness.
Major depression frequently co-occurs with other psychiatric problems. The 1990–92 National Comorbidity Survey (US) reports that half of those with major depression also have lifetime anxiety and its associated disorders such as generalized anxiety disorder. Anxiety symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability and increased suicide attempts. There are increased rates of alcohol and drug abuse and particularly dependence, and around a third of individuals diagnosed with ADHD develop comorbid depression.Post-traumatic stress disorder and depression often co-occur. Depression may also coexist with attention deficit hyperactivity disorder (ADHD), complicating the diagnosis and treatment of both. Depression is also frequently comorbid with alcohol abuse and personality disorders.
Depression and pain often co-occur. One or more pain symptoms are present in 65% of depressed patients, and anywhere from 5 to 85% of patients with pain will be suffering from depression, depending on the setting; there is a lower prevalence in general practice, and higher in specialty clinics. The diagnosis of depression is often delayed or missed, and the outcome can worsen if the depression is noticed but completely misunderstood.
Depression is also associated with a 1.5- to 2-fold increased risk of cardiovascular disease, independent of other known risk factors, and is itself linked directly or indirectly to risk factors such as smoking and obesity. People with major depression are less likely to follow medical recommendations for treating and preventing cardiovascular disorders, which further increases their risk of medical complications. In addition, cardiologists may not recognize underlying depression that complicates a cardiovascular problem under their care.
The cause of major depressive disorder is unknown. The biopsychosocial model proposes that biological, psychological, and social factors all play a role in causing depression. The diathesis–stress model specifies that depression results when a preexisting vulnerability, or diathesis, is activated by stressful life events. The preexisting vulnerability can be either genetic, implying an interaction between nature and nurture, or schematic, resulting from views of the world learned in childhood.
Childhood abuse, either physical, sexual or psychological are all risk factors for depression, among other psychiatric issues that co-occur such as anxiety and drug abuse. Childhood trauma also correlates with severity of depression, lack of response to treatment and length of illness. However, some are more susceptible to developing mental illness such as depression after trauma, and various genes have been suggested to control susceptibility.
The 5-HTTLPR, or serotonin transporter promoter gene's short allele has been associated with increased risk of depression. However, since the 1990s results have been inconsistent, with three recent reviews finding an effect and two finding none. Other genes that have been linked to a gene-environment interaction include CRHR1, FKBP5 and BDNF, the first two of which are related to the stress reaction of the HPA axis, and the latter of which is involved in neurogenesis.
Other health problems
Depression may also come secondary to a chronic or terminal medical condition such as HIV/AIDS, or asthma and may be labeled "secondary depression". It is unknown if the underlying diseases induce depression through effect on quality of life, of through shared etiologies (such as degeneration of the basal ganglia in parkinson's disease or immune dysregulation in asthma). Depression may also be iatrogenic (the result of healthcare), such as drug induced depression. Therapies associated with depression include interferon therapy, beta-blockers, Isotretinoin, contraceptives, cardiac agents, anticonvulsants, antimigraine drugs, antipsychotics, and hormonal agents agents such as gonadotropin-releasing hormone agonist. Drug abuse in early age is also associated with increased risk of developing depression later in life. Depression that occurs as a result of pregnancy is called postpartum depression, and is thought to be the result of hormonal changes associated with pregnancy. Seasonal affective disorder, a type of depression associated with seasonal changes in sunlight, is thought to be the result of decreased sunlight.
Further information: Biology of depression
The pathophysiology of depression is not yet understood, but the current theories center around monoaminergic systems, the circadian rhythm, immunological dysfunction, HPA axis dysfunction and structural or functional abnormalities of emotional circuits.
The monoamine theory, derived from the efficacy of monoaminergic drugs in treating depression, was the dominant theory until recently. The theory postulates that insufficient activity of monoamine neurotransmitters is the primary cause of depression. Evidence for the monoamine theory comes from multiple areas. Firstly, acute depletion of tryptophan, a necessary precursor of serotonin, a monoamine, can cause depression in those in remission or relatives of depressed patients; this suggests that decreased serotonergic neurotransmission is important in depression. Secondly, the correlation between depression risk and polymorphisms in the 5-HTTLPR gene, which codes for serotonin receptors, suggests a link. Third, decreased size of the locus coeruleus, decreased activity of tyrosine hydroxylase, increased density of alpha-2 adrenergic receptor, and evidence from rat models suggest decreased adrenergic neurotransmission in depression. Furthermore, decreased levels of homovanillic acid, altered response to dextroamphetamine, responses of depressive symptoms to dopamine receptor agonists, decreased dopamine receptor D1 binding in the striatum, and polymorphism of dopamine receptor genes implicate dopamine in depression. Lastly, increased activity of monoamine oxidase, which degrades monoamines, has been associated with depression. However, this theory is inconsistent with the fact that serotonin depletion does not cause depression in healthy persons, the fact that antidepressants instantly increase levels of monoamines but take weeks to work, and the existence of atypical antidepressants which can be effective despite not targeting this pathway. One proposed explanation for the therapeutic lag, and further support for the deficiency of monoamines, is a desensitization of self-inhibition in raphe nuclei by the increased serotonin mediated by antidepressants. However, disinhibition of the dorsal raphe has been proposed to occur as a result of decreased serotonergic activity in tryptophan depletion, resulting in a depressed state mediated by increased serotonin. Further countering the monoamine hypothesis is the fact that rats with lesions of the dorsal raphe are not more depressive that controls, the finding of increased jugular 5-HIAA in depressed patients that normalized with SSRI treatment, and the preference for carbohydrates in depressed patients. Already limited, the monoamine hypothesis has been further oversimplified when presented to the general public.
Immune system abnormalities have been observed, including increased levels of cytokines involved in generating sickness behavior (which shares overlap with depression). The effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) and cytokine inhibitors in treating depression, and normalization of cytokine levels after successful treatment further suggest immune system abnormalities in depression.
HPA axis abnormalities have been suggested in depression given the association of CRHR1 with depression and the increased frequency of dexamethasone test non-suppression in depressed patients. However, this abnormality is not adequate as a diagnosis tool, because its sensitivity is only 44%. These stress-related abnormalities have been hypothesized to be the cause of hippocampal volume reductions seen in depressed patients. Furthermore, a meta-analysis yielded decreased dexamethasone suppression, and increased response to psychological stressors. Further abnormal results have been obscured with the cortisol awakening response, with increased response being associated with depression.
Theories unifying neuroimaging findings have been proposed. The first model proposed is the "Limbic Cortical Model", which involves hyperactivity of the ventral paralimbic regions and hypoactivity of frontal regulatory regions in emotional processing. Another model, the "Corito-Striatal model", suggests that abnormalities of the prefrontal cortex in regulating striatal and subcortical structures results in depression. Another model proposes hyperactivity of salience structures in identifying negative stimuli, and hypoactivity of cortical regulatory structures resulting in a negative emotional bias and depression, consistent with emotional bias studies.
Further information: Rating scales for depression
A diagnostic assessment may be conducted by a suitably trained general practitioner, or by a psychiatrist or psychologist, who records the person's current circumstances, biographical history, current symptoms, and family history. The broad clinical aim is to formulate the relevant biological, psychological, and social factors that may be impacting on the individual's mood. The assessor may also discuss the person's current ways of regulating mood (healthy or otherwise) such as alcohol and drug use. The assessment also includes a mental state examination, which is an assessment of the person's current mood and thought content, in particular the presence of themes of hopelessness or pessimism, self-harm or suicide, and an absence of positive thoughts or plans. Specialist mental health services are rare in rural areas, and thus diagnosis and management is left largely to primary-care clinicians. This issue is even more marked in developing countries. The mental health examination may include the use of a rating scale such as the Hamilton Rating Scale for Depression or the Beck Depression Inventory or the Suicide Behaviors Questionnaire-Revised. The score on a rating scale alone is insufficient to diagnose depression to the satisfaction of the DSM or ICD, but it provides an indication of the severity of symptoms for a time period, so a person who scores above a given cut-off point can be more thoroughly evaluated for a depressive disorder diagnosis. Several rating scales are used for this purpose.
Primary-care physicians and other non-psychiatrist physicians have more difficulty with underrecognition and undertreatment of depression compared to psychiatric physicians, in part because of the physical symptoms that often accompany depression, in addition to the many potential patient, provider, and system barriers that the authors describe. A review found that non-psychiatrist physicians miss about two-thirds of cases, though this has improved somewhat in more recent studies.
Before diagnosing a major depressive disorder, in general a doctor performs a medical examination and selected investigations to rule out other causes of symptoms. These include blood tests measuring TSH and thyroxine to exclude hypothyroidism; 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. Adverse affective reactions to medications or alcohol misuse are often ruled out, as well. Testosterone levels may be evaluated to diagnose hypogonadism, a cause of depression in men.Vitamin D levels might be evaluated, as low levels of vitamin D have been associated with greater risk for depression.
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.Cognitive testing and brain imaging can help distinguish depression from dementia. A CT scan can exclude brain pathology in those with psychotic, rapid-onset or otherwise unusual symptoms. In general, investigations are not repeated for a subsequent episode unless there is a medical indication.
No biological tests confirm major depression. Biomarkers of depression have been sought to provide an objective method of diagnosis. There are several potential biomarkers, including Brain-Derived Neurotrophic Factor and various functional MRI techniques. One study developed a decision tree model of interpreting a series of fMRI scans taken during various activities. In their subjects, the authors of that study were able to achieve a sensitivity of 80% and a specificity of 87%, corresponding to a negative predictive value of 98% and a positive predictive value of 32% (positive and negative likelihood ratios were 6.15, 0.23, respectively). However, much more research is needed before these tests could be used clinically.
DSM-IV-TR and ICD-10 criteria
The most widely used criteria for diagnosing depressive conditions are found in the American Psychiatric Association's revised fourth edition of the 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), which uses the name depressive episode for a single episode and recurrent depressive disorder for repeated episodes. The latter system is typically used in European countries, while the former is used in the US and many other non-European nations, and the authors of both have worked towards conforming one with the other.
Both DSM-IV-TR and ICD-10 mark out typical (main) depressive symptoms. ICD-10 defines three typical depressive symptoms (depressed mood, anhedonia, and reduced energy), two of which should be present to determine depressive disorder diagnosis. According to DSM-IV-TR, there are two main depressive symptoms—depressed mood and anhedonia. At least one of these must be present to make a diagnosis of major depressive episode.
Major depressive disorder is classified as a mood disorder in DSM-IV-TR. The diagnosis hinges on the presence of single or recurrent major depressive episodes. 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 very 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.
Major depressive episode
Main article: Major depressive episode
A major depressive episode is characterized by the presence of a severely depressed mood that persists for at least two weeks. 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. Depression without mania is sometimes referred to as unipolar because the mood remains at one emotional state or "pole".
DSM-IV-TR 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. 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. 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: Excluded are a range of related diagnoses, including dysthymia, which involves a chronic but milder mood disturbance;recurrent brief depression, consisting of briefer depressive episodes;minor depressive disorder, whereby only some symptoms of major depression are present; and adjustment disorder with depressed mood, which denotes low mood resulting from a psychological response to an identifiable event or stressor.
The DSM-IV-TR recognizes five further subtypes of MDD, called specifiers, in addition to noting the length, severity and presence of psychotic features:
- 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.
- 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.
- 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 stuporous, 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.
- Postpartum depression, or mental and behavioral disorders associated with the puerperium, not elsewhere classified, refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression has an incidence rate of 10–15% among new mothers. The DSM-IV mandates that, in order to qualify as postpartum depression, onset occur within one month of delivery. It has been said that postpartum depression can last as long as three months.
- Seasonal affective disorder (SAD) 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.
In 2016, the United States Preventive Services Task Force (USPSTF) recommended screening in the adult populations with evidence that it increases the detection of people with depression and with proper treatment improves outcomes. They recommend screening in those between the age of 12 to 18 as well.
A Cochrane review from 2005 found screening programs do not significantly improve detection rates, treatment, or outcome.
Main article: Depression (differential diagnoses)
To confer major depressive disorder as the most likely diagnosis, other potential diagnoses must be considered, including dysthymia, adjustment disorder with depressed mood, or bipolar disorder. 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).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.Bipolar disorder, also 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. Further differential diagnoses involve chronic fatigue syndrome.
Other disorders need to be ruled out before diagnosing major depressive disorder. They include depressions due to physical illness, medications, and substance abuse. Depression due to physical illness is diagnosed as a Mood disorder due to a general medical condition. This condition is determined based on history, laboratory findings, or physical examination. When the depression is caused by a medication, drug of abuse, or exposure to a toxin, it is then diagnosed as a specific mood disorder (previously called Substance-induced mood disorder in the DSM-IV-TR).
Preventative efforts may result in decreases in rates of the condition of between 22 and 38%. Eating large amounts of fish may also reduce the risk.
Behavioral interventions, such as interpersonal therapy and cognitive-behavioral therapy, are effective at preventing new onset depression. Because such interventions appear to be most effective when delivered to individuals or small groups, it has been suggested that they may be able to reach their large target audience most efficiently through the Internet.
However, an earlier meta-analysis found preventive programs with a competence-enhancing component to be superior to behavior-oriented programs overall, and found behavioral programs to be particularly unhelpful for older people, for whom social support programs were uniquely beneficial. In addition, the programs that best prevented depression comprised more than eight sessions, each lasting between 60 and 90 minutes, were provided by a combination of lay and professional workers, had a high-quality research design, reported attrition rates, and had a well-defined intervention.
The Netherlands mental health care system provides preventive interventions, such as the "Coping with Depression" course (CWD) for people with sub-threshold depression. The course is claimed to be the most successful of psychoeducational interventions for the treatment and prevention of depression (both for its adaptability to various populations and its results), with a risk reduction of 38% in major depression and an efficacy as a treatment comparing favorably to other psychotherapies.
Main article: Management of depression
The three most common treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice (over medication) for people under 18. The UK National Institute for Health and Care Excellence (NICE) 2004 guidelines indicate that antidepressants should not be used for the initial treatment of mild depression, because the risk-benefit ratio is poor. The guidelines recommend that antidepressants treatment in combination with psychosocial interventions should be considered for:
- People with a history of moderate or severe depression
- Those with mild depression that has been present for a long period
- As a second line treatment for mild depression that persists after other interventions
- As a first line treatment for moderate or severe depression.
The guidelines further note that antidepressant treatment should be continued for at least six months to reduce the risk of relapse, and that SSRIs are better tolerated than tricyclic antidepressants.
American Psychiatric Association treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and patient preference. Options may include pharmacotherapy, psychotherapy, exercise, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS) or light therapy. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all patients with severe depression unless ECT is planned.
Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy is 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. A 2014 Cochrane review found insufficient evidence to determine the effectiveness of psychological versus medical therapy in children.
Further information: Neurobiological effects of physical exercise § Major depressive disorder
Physical exercise is recommended for management of mild depression, and has a moderate effect on symptoms. Exercise has also been found to be effective for (unipolar) major depression. It is equivalent to the use of medications or psychological therapies in most people. In older people it does appear to decrease depression. Exercise may be recommended to people who are willing, motivated, and physically healthy enough to participate in an exercise program as treatment.
There is a small amount of evidence that skipping a night's sleep may improve depressive symptoms, with the effects usually showing up within a day. This effect is usually temporary. Besides sleepiness, this method can cause a side effect of mania or hypomania.
In observational studies smoking cessation has benefits in depression as large as or larger than those of medications.
Besides exercise, sleep and diet may play a role in depression, and interventions in these areas may be an effective add on to conventional methods.
Psychotherapy can be delivered, to individuals, groups, or families by mental health professionals. A 2015 review found that cognitive behavioral therapy appears to be similar to antidepressant medication in terms of effect. A 2012 review found psychotherapy to be better than no treatment but not other treatments. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used. A 2014 Cochrane review found that work-directed interventions combined with clinical interventions helped to reduce sick days taken by people with depression.
Psychotherapy has been shown to be effective in older people. Successful psychotherapy appears to reduce the recurrence of depression even after it has been terminated or replaced by occasional booster sessions.
Cognitive behavioral therapy
See also: Behavioral theories of depression
Cognitive behavioral therapy (CBT) currently has the most research evidence for the treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy (IPT) are preferred therapies for adolescent depression. In people under 18, according to the National Institute for Health and Clinical Excellence, medication should be offered only in conjunction with a psychological therapy, such as CBT, interpersonal therapy, or family therapy. Cognitive behavioral therapy has also been shown to reduce the number of sick days taken by people with depression, when used in conjunction with primary care.
The most-studied form of psychotherapy for depression is CBT, which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. Research beginning in the mid-1990s suggested that CBT could perform as well as or better than antidepressants in patients with moderate to severe depression. CBT may be effective in depressed adolescents, although its effects on severe episodes are not definitively known. Several variables predict success for cognitive behavioral therapy in adolescents: higher levels of rational thoughts, less hopelessness, fewer negative thoughts, and fewer cognitive distortions. CBT is particularly beneficial in preventing relapse.
Cognitive behavioral therapy and occupational programs (including modification of work activities and assistance) have been shown to be effective in reducing sick days taken by workers with depression.
Several variants of cognitive behavior therapy have been used in those with depression, the most notable being rational emotive behavior therapy, and mindfulness-based cognitive therapy. Mindfulness based stress reduction programs may reduce depression symptoms. Mindfulness programs also appear to be a promising intervention in youth.
Psychoanalysis is a school of thought, founded by Sigmund Freud, which emphasizes the resolution of unconscious mental conflicts. Psychoanalytic techniques are used by some practitioners to treat clients presenting with major depression. A more widely practiced therapy, called psychodynamic psychotherapy, is in the tradition of psychoanalysis but less intensive, meeting once or twice a week. It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus. In a meta-analysis of three controlled trials of Short Psychodynamic Supportive Psychotherapy, this modification was found to be as effective as medication for mild to moderate depression.
Conflicting results have arisen from studies that look at the effectiveness of antidepressants in people with acute, mild to moderate depression. Stronger evidence supports the usefulness of antidepressants in the treatment of depression that is chronic (dysthymia) or severe.
While small benefits were found, researchers Irving Kirsch and Thomas Moore state they may be due to issues with the trials rather than a true effect of the medication. In a later publication, Kirsch concluded that the overall effect of new-generation antidepressant medication is below recommended criteria for clinical significance. Similar results were obtained in a meta analysis by Fornier.
A review commissioned by the National Institute for Health and Care Excellence concluded that there is strong evidence that SSRIs have greater efficacy than placebo on achieving a 50% reduction in depression scores in moderate and severe major depression, and that there is some evidence for a similar effect in mild depression. Similarly, a Cochrane systematic review of clinical trials of the generic tricyclic antidepressantamitriptyline concluded that there is strong evidence that its efficacy is superior to placebo.
In 2014 the U.S. FDA published a systematic review of all antidepressant maintenance trials submitted to the agency between 1985 and 2012. The authors concluded that maintenance treatment reduced the risk of relapse by 52% compared to placebo, and that this effect was primarily due to recurrent depression in the placebo group rather than a drug withdrawal effect.
To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. Response rates to the first antidepressant administered range from 50–75%, and it can take at least six to eight weeks from the start of medication to remission. Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to one year of continuation is recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.
Selective serotonin reuptake inhibitors (SSRIs) are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants. People who do not respond to one SSRI can be switched to another antidepressant, and this results in improvement in almost 50% of cases. Another option is to switch to the atypical antidepressant bupropion.Venlafaxine, an antidepressant with a different mechanism of action, may be modestly more effective than SSRIs. However, venlafaxine is not recommended in the UK as a first-line treatment because of evidence suggesting its risks may outweigh benefits, and it is specifically discouraged in children and adolescents.
For child and adolescent depression, fluoxetine is recommended if medication are used. Fluoxetine; however, appears to have only slight benefit in children, while other antidepressants have not been shown to be effective. There is also insufficient evidence to determine effectiveness in those with depression complicated by dementia. Any antidepressant can cause low serum sodium levels (also called hyponatremia); nevertheless, it has been reported more often with SSRIs. It is not uncommon for SSRIs to cause or worsen insomnia; the sedating antidepressant mirtazapine can be used in such cases.
Irreversible monoamine oxidase inhibitors, an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions. They are still used only rarely, although newer and better-tolerated agents of this class have been developed. The safety profile is different with reversible monoamine oxidase inhibitors such as moclobemide where the risk of serious dietary interactions is negligible and dietary restrictions are less strict.
For children, adolescents, and probably young adults between 18 and 24 years old, there is a higher risk of both suicidal ideations and suicidal behavior in those treated with SSRIs. For adults, it is unclear whether SSRIs affect the risk of suicidality. One review found no connection; another an increased risk; and a third no risk in those 25–65 years old and a decrease risk in those more than 65. A black box warning was introduced in the United States in 2007 on SSRI and other antidepressant medications due to increased risk of suicide in patients younger than 24 years old. Similar precautionary notice revisions were implemented by the Japanese Ministry of Health.
There is some evidence that omega-3 fatty acids fish oil supplements containing high levels of eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA) are effective in the treatment of, but not the prevention of major depression. However, a Cochrane review determined there was insufficient high quality evidence to suggest Omega-3 fatty acids were effective in depression. There is limited evidence that vitamin D supplementation is of value in alleviating the symptoms of depression in individuals who are vitamin D deficient. There is some preliminary evidence that COX-2 inhibitors have a beneficial effect on major depression.Lithium appears effective at lowering the risk of suicide in those with bipolar disorder and unipolar depression to nearly the same levels as the general population. There is a narrow range of effective and safe dosages of lithium thus close monitoring may be needed.