Major depression/depressive disorder course

The essential feature of major depressive disorder is a clinical course that is characterized by one or more major depressive episodes without a history of manic, mixed, or hypomanic episodes. Dysthymic disorder is a chronic disturbance of mood involving depressed mood and at least two other symptoms, and it is generally less severe than major depressive disorder. This chapter focuses exclusively on the diagnosis and treatment of major depressive disorder. 

It also seems likely that some mental disorders (perhaps major depressive disorder) in their present form will fail to show evidence of taxonicity, but definitional refinement would help elucidate underlying taxa (e.g., melancholia). Thus, taxometrics may be able to serve as an impetus and a guide for revising the diagnostic system. Of course, taxometric methods alone are not sufficient to tackle this task and should be used in conjunction with dimensional methods, such as exploratory factor analysis. Dimensions provide the building blocks for construction of taxa, and research on the structure of psychopathology should integrate dimensional and taxometric methods. 

D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium). 

Strober, M., Lampert, C., Schmidt, S., and Mottell, W. (1993) The course of major depressive disorder in adolescents I. Recovery and risk of manic switching in a follow-up of psychotic and nonpsychotic subtypes. J Am Acad Child Adolesc Psychiatry 32 34 2. 

Keller MB, Hanks DL Course and outcome in panic disorder and depression. J Clin Psychopharmacol Biol Psychiatry 17 551-570, 1993 Keller MB, Shapiro RW Double depression superimposition of acute depressive episodes on chronic depressive disorders. Am J Psychiatry 139 438-442, 1982 Keller MB, Shapiro RW, Lavori PW, et al Recovery in major depressive disorder analysis with the life table and regression models. Arch Gen Psychiatry 39 905-910, 1982a... 

Preventing relapse is of critical importance in the life course of major depressive disorder, and every effort should be made to ensure patient compliance. 

Depression and Diabetes Mellitus. Patients with chronic medical illness have a high prevalence of major depressive disorder [59], Depression may be three times more prevalent in the diabetic population when compared with its occurrence in nondiabetic individuals [60], In addition, microalbuminuria, hypertension, and hyperinsulinemia are another three independent risk factors for cardiac disease in non-insulin-dependent diabetes mellitus (NIDDM) [61], Nosadini et al. showed that peripheral insulin resistance, hypertension, microalbuminuria, and lipid abnormalities are associated with NIDDM [61], Further, Helkala et al. determined that cognitive and memory dysfunction are associated with NIDDM and explored the disease s relationship with depression, metabolic control, and serum lipids. The results showed that the NIDDM patients had impaired control of their learning processes [62], Obviously, future research examining the causal relationship of depression to the onset on diabetes and the effect of depression on the natural course of diabetes is needed [60]. 

The worst complication of major depressive disorder, of course, is suicide. Persons with major depressive disorder have a lifetime risk of suicide of about 15% (Guze and Robins, 1970). This highlights the fact that major depressive disorder is a potentially lethal illness. Also, this represents one of the major sources of preventable death. 

Other psychiatric illnesses, particularly the anxiety disorder, are also risk factors for development of major depressive disorder. Persons with anxiety disorders (panic disorder, obsessive compulsive cUsorder, social phobia, generalized anxiety disorder, and posttrauma tic stress disorder) go on to develop major depressive cUsorder over the course of 5-20 years in over 50% of cases. 

Acute mania as part of bipolar I disorder is supposed to result from overexcitation of limbic neurons. This can arise either from loss of inhibitory tonic orbitofrontal control of limbic neurons or from various intra- and intercellular alterations (the full mechanism is unknown as yet). Manic episodes are often classified into euphoric (classical), dysphoric, mixed (along with clinical manifestations of major depressive disorder), mania with psychotic/catatonic features, and mania with a rapid cycling course of the disease. 

Major depressive episodes also occur in the context of bipolar disorder. The key difference is that persons with bipolar disorder also experience manic, hypomanic, and/or mixed episodes (see Chap. 36) during the course of their illness, whereas persons with MDD experience only major depressive episodes.3... 

Bipolar disorder is a mood disorder characterized by one or more episodes of mania or hypomania, often with a history of one or more major depressive episodes.1 It is a chronic illness with a course characterized by relapses and improvements or remissions. Mood episodes can be manic, depressed, or mixed. They can be separated by long periods of stability or can cycle... 

Major depression varies greatly from person to person. Therefore, DSM-IV uses course and descriptive specifiers to further describe the disorder in each individual. The course specifiers quantitatively describe the long-term history of the illness. Patterns of episode recurrence and remission are delineated by these specifiers. 

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. 

When treating mild-to-moderate panic disorder, we recommend avoiding benzodiazepines in favor of CBT or antidepressants. Because CBT and antidepressants are both effective for panic disorder and major depression (commonly comorbid with panic disorder), the choice between the two largely rests on patient preference. Antidepressants are preferred for those who are pessimistic regarding the potential benefit of CBT, cannot afford CBT, or are unable (or unwilling) to invest the time necessary to complete a course of CBT. In our experience, some patients may accrue significant beneht from the combined treatment, particularly those with more moderate symptoms who struggle with the exposure aspects of therapy. 

The primary indication for ECT in adolescents is the short-term treatment of mood symptoms, depressive or manic (Walter et al., 1999). Mood symptoms in the course of major depression, psychotic depression, bipolar disorder, organic mood disorders, schizophrenia, and schizoaffective disorder respond well to ECT. Psychotic symptoms in mood disorders also respond well to ECT whereas the effectiveness of ECT in the treatment of psychotic symptoms in schizophrenia is doubtful. There are suggestions that other uncommon clinical conditions in adolescents such as catatonia and neuroleptic malignant syndrome also benefit from ECT. The effectiveness of ECT seems to lessen when there is a comorbid personality disorder or drug and/or alcohol problems. There are very few data about usefulness on prepubertal children. 

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