Major Depressive Disorder

Happy Monday, and welcome to Medical Mondays! Since this week is National Suicide Prevention Week, with World Suicide Prevention Day in 3 days (September 10), this week’s topic is on Major Depressive Disorder.

Major Depressive Disorder (MDD) is a mood disorder that’s characterized by recurrent episodes of sadness, anhedonia (loss of interest in things that the person previously found enjoyable), and other symptoms.

Diagnosis

A major depressive episode must have at least 5 of the following, with either depressed mood or anhedonia, to be diagnosed (“SIG E CAPS“):

• Sleep disturbance (increased or decreased)
• Interest (decreased, aka anhedonia)
• Guilt (or thoughts of worthlessness)
• Energy (fatigue or low energy)
• Concentration (decreased)
• Appetite (decreased or increased, also notable weight loss or gain)
• Psychomotor (retardation or agitation)
• Suicidal (recurrent ideation or attempt)

In severe cases, MDD can occur with psychotic features, which may make it difficult to differentiate from schizoaffective disorder. It may manifest as irritability and anger in children and adolescents, and a notable differential of behavioral change in adolescents is drug abuse.

Major depression is associated with an increased all-cause mortality, completed suicide, homicidal death, and accidental death. It is episodic, and patients generally tend to have a 50% recurrence rate within 2 years of their first episode of MDD.

MDD Secondary to Medical Cause

MDD must be differentiated from MDD secondary to a medical cause, which is when a medical illness causes the mood disorder). Some medical causes include:

• Hypothyroidism
• Parkinson disease
• Cushing syndrome
• Stroke
• Cancer

Substance-Induced MDD

As certain substances can cause depression, certain pharmaceuticals + illicit drugs/substances must be ruled out, including:

• Alcohol
• Beta-blockers (especially propanolol)
• Corticosteroids
• Levodopa

Treatment

Treatment of MDD generally involves pharmacotherapy, psychotherapy, and in severe or refractory cases, electroconvulsive therapy (ECT). The first-line treatment for major depression is SSRIs (serotonin s- reuptake inhibitors).

Antidepressants should be continued for ~6 months after response to treating a single episode of major depression.

Assessment of Suicide Risk

The “SAD PERSONS” mnemonic is used to help assess suicide risk in patients.

• Sex (male)
• Age
• Depression
• Previous attempt
• Excess alcohol or substance use/abuse
• Rational thinking loss
• Social supports (lacking)
• Organized plan
• No spouse
• Sickness

The risk assessment scale is as follows: 0-4 (low), 5-6 (medium), 7-10 (high).

The #1 risk factor for suicide is previous attempt.

Successful prevention involves careful risk assessment and a high index of suspicion. Management involves hospitalization for stabilization and mental recovery. For a patient who isn’t actively suicidal but has multiple risk factors, close follow-up is necessary.

Persistent depressive disorder (PDD), formerly known as dysthymic disorder, involves a chronic depressed mood that occurs almost continuously for 2+ years.

Symptoms

• Sleep disturbance
• Appetite disturbance
• Fatigue, decreased energy
• Low self-esteem
• Cognitive difficulties (poor concentration, problems making decisions)
• Feelings of hopelessness or pessimism

They may describe “feeling sad for as long as they can remember,” possibly due to negative situations in their lives (e.g. losing a job, chronic medical condition), but they have activities that they enjoy despite their “baseline” sadness.

Patients with PDD may meet the diagnostic requirement for MDD during these periods (“double depression”), but will never have symptoms of mania or psychosis. The most effective treatment for PDD is psychotherapy, although antidepressants (e.g. SSRIs) can be used.

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Disclaimer: The information in this post was gleaned from UpToDate articles and other med school resources. This is where I reiterate that I am merely a medical student struggling through the world that is her clinical rotations. The statements made on this blog should not be taken as medical advice to treat, cure or prevent any disease. Please contact your own physician or health care provider before starting a health or fitness/wellness program. (See full disclaimer here.)