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Major Depression

HOW COMMON IS MAJOR DEPRESSION?

Major depression, the most common psychiatric illness occurs in children, adolescents, adults and the elderly; it is more common in females, regardless of culture. In Australia, 1 in 4 women and 1 in 6 men at sometime experience major depression. Current evidence suggests that the incidence of major depression is increasing.

COURSE AND EPISODES

Onset of major depression may occur at any age; the average age of adult onset is the mid twenties, an age that may be decreasing. Prior to onset, periods of transient anxiety and depressive symptoms often occur that, while distressing, have little impact on functioning. Following an episode, a fear of relapse often emerges; a justified fear, as only one in ten that recover will not experience further episodes. If the first episode is severe, the risk of future episodes increases. If not treated, up to 50% will relapse after the first episode, in contrast only 15% will relapse when treated effectively. When depression becomes recurrent, some experience isolated episodes separated by years of wellness; for others, frequent occurrences are the norm with the duration between episodes shortened as frequency increases.

THE SYMPTOMS OF DEPRESSION

Table 1 lists the symptoms of major depression. Symptoms and severity can change within an episode; different symptoms can emerge if the illness is recurrent. Under - recognition is often the consequence of symptom diversity, moreover, the symptoms may masquerade as other conditions thus at times the diagnosis of major depression becomes a challenge. Table 2 highlights the diversity in which the specific symptoms may present.

MAKING THE DIAGNOSIS

The diagnosis of major depression is made if five or more of the symptoms in Table 1 are present. One of the symptoms must be the presence of a depressed mood or loss of interest and pleasure in aspects of daily life. These symptoms must be present during the same two - week period, be associated with distress, a change in mental and physical function and cause impairment. The symptoms must not stem from a medical condition or be the effects of substance abuse. Some suffer symptoms of depression but the symptoms are not sufficient in total for the diagnosis. This depression known as subsyndromal depression is today considered clinically significant necessitating treatment.

TABLE 1 Symptoms of major depression
  1. A depressed mood most of the day or nearly every day
  2. A markedly diminished interest or pleasure in all or almost all activities
  3. Changes in appetite
  4. Sleep disturbance
  5. Agitation or slowness in movement everyday
  6. Fatigue or loss of energy nearly everyday
  7. Feelings of worthlessness, excessive or inappropriate guilt
  8. Diminished ability to think or concentrate
  9. Recurrent thoughts about death or thoughts and plans of suicide
TABLE 2 The diversity of symptoms in depression

Mood

  • Mood may be low, irritable, flat, angry, sad, frustrated, discouraged or despondent.
Appetite
  • Appetite maybe decreased, food may no longer be enjoyed and a loss in body weight may occur.
  • Overeating, comfort eating, binge eating, having food cravings for sugary or fatty foods may occur leading to weight gain.
Movement
  • Normal body movement, speech and gestures may be slowed or accelerated. Agitation and restlessness may arise.
Loss of interest
  • A loss of pleasure in activities once enjoyed, a loss of interest in self and others occurs with the withdrawal from loved ones and family. Loss of libido is also common.
Sleep

  • Depressed people sleep lightly, they experience initial insomnia, interrupted sleep, hypersomnia and daytime sleepiness. Awakening unrefreshed is also common.
Energy
  • A deficit in energy occurs as well as a lack of motivation and a loss of drive to initiate. Rest periods are often sought.
Thinking
  • Thoughts may race, be confused, difficult to control, and focus on the negative and past distressing times. Short - term memory and concentration may falter, absent - mindedness is experienced and decision - making may become impaired.
Feelings
  • Some complain of an absence of feelings and view life as meaningless and negative. Negative feelings towards self and others emerge, as does a magnification of guilt over past failings.
Thoughts about death
  • Preoccupation with death occurs, some feel that others would benefit if death did occur. Thoughts about committing suicide may be transient or constant and a specific plan for suicide may be formulated.

RISK FACTORS FOR MAJOR DEPRESSION

We are all at risk of suffering depression particularly if stress becomes chronic and unmanageable; other risk factors for depression are listed in Table 3.

TABLE 3 Risk factors for depression
Genetic
  • Major depression is often genetic in etiology; first - degree relatives of a depressed person have double the risk for developing depression.
Sex
  • Regardless of culture, females are at greater risk
Marital status
  • Depression is higher in the divorced and the unhappily married
Physical illness
  • If a disabling physical illness develops with or without pain, depression is more probable
Childhood trauma
  • Children who experience sexual, physical and mental abuse, physical impairment, a severe illness or loss of their mother early in life are more vulnerable to developing depression.
Parent bonding
  • Poor attachment to mother during childhood is associated with depression
Social class
  • Poverty and unemployment are common with depression
Parental alcoholism
  • Adult children of alcoholics report more symptoms of depression
Age
  • Some studies suggests an increase of risk as one ages, others disagree. It is becoming accepted that often age does not bring on depression but depression may stem from changes occurring with age, such as the onset of a chronic impairing physical illness or adjustment to the loss of a partner.

DEPRESSION AND CO - OCCURRING ILLNESSES

Those who suffer major depression invariably suffer other psychiatric illnesses. When this happens, the other illnesses are termed comorbid. The most common comorbid illnesses with depression are the anxiety disorders listed in Table 4. When depression and an anxiety disorder occur comorbiditly, the onset of the anxiety disorder generally precedes the onset of depression. As highlighted in Table 5, the symptoms of depression and the anxiety disorders often overlap.

Depression co - occurs with a range of other psychiatric illnesses including schizophrenia and the eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder. Co - occurring also are personality disorders defined as when a person experiences a number of personality traits that are maladaptive causing impairment and distress. Depression also occurs comorbiditly with alcoholism and drug abuse.

TABLE 4 The anxiety disorders

PANIC DISORDER –

The experience of recurrent panic attacks
SOCIAL ANXIETY DISORDER – The avoidance of social situations for fear of negative evaluation
GENERALISED ANXIETY DISORDER (GAD) – An illness characterised by constant worrying
OBSESSIVE COMPULSIVE DISORDER (OCD) – Characterised by obsessions and compulsions
POST TRAUMATIC STRESS DISORDER (PTSD) – Emerges following exposure to a life - threatening situation
SPECIFIC PHOBIA – A fear of and /or avoidance of specific situations
Return to the Panic Anxiety Mood Guide page to learn more about the above anxiety disorders.
TABLE 5 Overlap of depression and anxiety symptoms

SUICIDE AND DEPRESSION

For many years, suicide has been ranked among the top ten causes of death in the western world. It is a distressing and tragic phenomenon. Recent evidence suggests that suicide in those who are depressed is associated with lowered serotonin levels in the brain. It is a myth to say that most who are depressed commit suicide, they don’t. Studies suggest that 30% of depressed patients will attempt suicide and half will succeed. Successful suicide is more common in men than women but women attempt suicide more often. Over recent decades, the suicide rate among males 15 - 26 years of age has been increasing. Risk factors for suicide are listed in Table 6.

TABLE 6 Risk factors for suicide
  • Prior attempts of suicide
  • Hopelessness
  • Involvement in antisocial behaviour
  • Family history of suicide
  • Social Isolation
  • Substance Abuse
  • Worthlessness
  • Major Depression
  • Unemployment
  • Divorced/Widowed

MAJOR DEPRESSION IS OFTEN RECURRENT

Up to 60% of those who experience one episode of depression will experience another and 70% of those who experience a second will experience a third. Recurrent is defined when an episode of depression occurs six months after a person has been asymptomatic (free of depressive symptoms). Facts that increase the risk for depression are listed in Table 7.

TABLE 7 Facts that increase the risk for recurrent depression
  • Early age of onset
  • Comorbid substance abuse
  • Relapse after medication withdrawal
  • Family history of major depression
  • A higher prior rate of recurrence
  • Previous episodes of depression in the last year
  • Comorbid anxiety disorders
  • A history of severe depression

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