Depressive disorder, major clinical presentation

The classic symptoms of depression are listed in Table 12.1, which is based on DSM-IV criteria. For a diagnosis of major depressive disorder, most of these symptoms must be present, including the first two (APA, 2000). These symptoms should be of sufficient intensity and chronic duration (at least 2 weeks) to cause clinically significant distress and impairment in social or economic functioning. However, they should not be a result of another psychiatric or somatic illness, nor of drug misuse or bereavement. For a diagnosis of mania, the symptoms are a mirror image of those for depression (Table... 

The differential diagnosis of depression is organized along both symptomatic and causative lines. Symptomatically, major depression is differentiated from other disorders by its clinical presentation or its long-term history. This is, of course, the primary means of distinguishing psychiatric disorders in DSM-1V. The symptomatic differential of major depression includes other mood disorders such as dysthymic disorder and bipolar disorder, other disorders that frequently manifest depressed mood including schizoaffective disorder, schizophrenia, dementia, adjustment disorder, and post-traumatic stress disorder, and, finally, other nonpsychiatric conditions that resemble depression such as bereavement and medical illnesses like cancer or AIDS. 

It is still debated whether patients with two previous episodes should receive maintenance treatment. Overall, maintenance treatment has been recommended for adult depressed patients with two episodes who have one or more of the following criteria (Depression Guideline Panel, 1993) (1) a family history of bipolar disorder or recurrent depression, (2) early onset of the first depressive episode (before age 20), and (3) both episodes were severe or life threatening and occurred during the past 3 years. Given that depression in youth has similar clinical presentation, sequelae, and natural course as in adults, these guidelines should probably be applied for youth with two previous major depressive episodes. 

The philosophy of evidence-based practice is widely accepted, although operational and implementation issues represent major barriers. One of the significant barriers is a shortage of evidence reports on topics of critical interest, and the lack of a national infrastructure to prepare such reports. In response to this need, AHRQ has funded 12 Evidence-based Practice Centers to conduct systematic, comprehensive analyses and syntheses of the scientific literature to develop evidence reports and technology assessments on clinical topics that are common, expensive, and present challenges to decision makers. Since December 1998, 11 evidence reports have been released on topics that include sleep apnea, traumatic brain injury, alcohol dependence, cervical cytology, urinary tract infection, depression, dysphasia, sinusitis, stable angina, testosterone suppression, and attention deficit hyperactivity disorder. 

Currently, the benzodiazepines and the SSRIs are the most commonly employed pharmacotherapies for common clinical anxiety disorders see Chapter 16). Benzodiazepines sometimes are given to patients presenting with anxiety mixed with symptoms of depression, although their efficacy in altering the core features of severe major depression has not been demonstrated. 

LF sometimes is used as an alternative or adjunct to antidepressants in severe, especially melancholic, recurrent depression, as a supplement to antidepressant treatment in acute major depression, including in patients who present clinically with only mild mood elevations or hypomania (bipolar II disorder), or as an adjunct when later response to an antidepressant alone is unsatisfactory. In major affective disorders, LT has stronger evidence of reduction of suicide risk than any other treatment. Clinical experience also suggests the utility of IF in the management of childhood disorders that are marked by adult-like manic depression or by severe changes in mood and behavior, which are probable precursors to bipolar disorder in adults. Evidence of efficacy of Li in many additional episodic disorders (e.g., premenstrual dysphoria, episodic alcohol abuse, and episodic violence) is unconvincing. 

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