Major depressive episode
|Major depressive episode|
|Classification and external resources|
A major depressive episode is a period characterized by the symptoms of major depressive disorder: primarily severely depressed mood and a loss of interest or pleasure in everyday activities, accompanied by other symptoms such as feelings of emptiness, hopelessness, anxiety, worthlessness, guilt and/or irritability, changes in appetite, problems concentrating, remembering details or making decisions, and thoughts of or attempted suicide. Insomnia or hypersomnia, aches, pains, or digestive problems that are resistant to treatment may also be present. The description has been formalised in psychiatric diagnostic criteria such as the DSM-IV and ICD-10
In addition to the emotional pain endured by those suffering from depression, significant economic costs are associated with depression. Data gathered from the United States and Canada reveal that the costs associated with Major Depression are comparable to those related to heart disease, diabetes, and back problems and are greater than the costs of hypertension.
According to the Nordic Journal of Psychiatry, there is a direct correlation between major depressive episode and unemployment.
Depressive disorders are illnesses in the brain. There are many theories as to how depression occurs. One interpretation is that neurotransmitters in the brain are out of balance and this results in feelings of worthlessness and despair. Brain imaging from magnetic resonance imaging show that brains of people who have depression look different than normal brains. Depression can also be inherited through genetics. Studies show that family histories of depression increase the likeliness of being diagnosed.
The criteria below are based on the formal DSM-IV criteria for a Major Depressive Episode. A diagnosis of major depressive episode requires that the patient has—over a two-week period—experienced five or more of the symptoms below, and these must be outside the patient's normal behaviour. Either depressed mood or decreased interest or pleasure must be one of the five (although both are frequently concomitant).
Mood/Anhedonia and loss of interest
For the better part of nearly every day, the patient reports a depressed mood or appears depressed to others. The patient may state that he or she has been feeling sad or empty, hopeless, etc. Patients may also report feeling indifferent, anxiety or even having no feelings. If others report that the patient appears to be on the verge of tearfulness, manifests a depressed facial expression and disposition, or appears to be overly irritable, these may also indicate the presence of depressed mood. Children and adolescents may be irritable rather than expressing a depressed mood. If there are persistent feelings of sadness, anxiety, or "empty" feelings on an everyday basis for two weeks or longer then the patient is exhibiting a symptom of major depressive disorder and could be exhibiting a major depressive episode. Feelings of hopelessness or pessimism as well as an increase in irritability. Restlessness is a symptom for major depressive episode as well. For most of nearly every day, interest or pleasure is markedly decreased in nearly all activities (noted by the patient or by others). The Diagnostic Statistical Manual for Mental Disorders (DSM) states that people suffering with depression tend to lose interest in things they once found enjoyable. Activities are no longer enjoyable and there is often a loss of interest in or desire for sex. Friends and family of the depressed person may notice that he/she has withdrawn from friends, or has neglected or quit doing activities that were once a source of enjoyment.
Change in eating, appetite, or weight
Although the person experiencing a depressive episode is not dieting, there is a marked loss or gain of weight (such as 5% of their body weight in one month) or their appetite is markedly decreased or increased nearly every day. Changes in appetite take on two manifestations: under- or over-eating. In the first instance, some people never feel hungry, can go long periods without wanting to eat, may forget to eat, or if they do eat a small amount of food may be sufficient. A reduction in weight is often associated with a melancholic type of depression. In the second instance, some people tend toward an increase in appetite and may gain significant amounts of weight. They may tend to crave certain types of food such as sweets or carbohydrates. People with seasonal affective disorder (SAD) often crave foods high in carbohydrates. Weight gain is often associated with atypical depression. In children, failure to make expected weight gains may be counted towards this criteria.
A major symptom is if the patient sleeps excessively, known as hypersomnia, or not enough, known as insomnia. Insomnia is the most common type of sleep disturbance for people who are clinically depressed. According to the Sleep Foundation, "having difficulty falling asleep at night is known as "initial" insomnia; waking in the middle of the night and being unable to go back to sleep as "middle insomnia", and; waking too early as "terminal insomnia". Insomnia is often associated with a melancholic type of depression." The British Journal of Psychiatry states that about 60 million Americans suffer from insomnia. A less frequent sleeping problem is oversleeping. The Sleep Foundation indicates that "hypersomnia may occur in the form of sleeping for prolonged periods at night or increased sleeping during the daytime. Even with excess sleep, a person may still feel tired and sluggish during the day." This impacts their everyday activities and increases their inability to focus at home or work. According to the United States National Library of Medicine, people with seasonal affective disorder (SAD) may sleep longer during the winter months. Hypersomnia is often associated with an atypical depression. Hypersomnia is not as common as insomnia and up to 40% of people exhibits hypersomnia from time to time.
Nearly every day others can see that the patient's activity is agitated or slow. People suffering from depression may be either quite agitated (psychomotor agitation), or very lethargic (psychomotor retardation) in their mannerisms and behaviour. If a person is agitated, he or she may find it difficult to sit still, may pace the room, wring his/her hands, or fidget with clothes or objects. Someone with psychomotor retardation tends to move sluggishly, may move across a room very slowly, avert his/her eyes, sit slumped in a chair and speak slowly, saying little. In terms of diagnosis, the agitation or slowing down of one's demeanour must be to the degree that it can be observed by others. Subjective personal reports of the patient feeling restless or feeling as if they are moving more slowly do not count towards the diagnostic criteria.
Nearly every day the patient will experience extreme fatigue/tiredness or loss of energy. A person may feel tired without having engaged in any physical activity, and day-to-day tasks become increasingly difficult. Job tasks or housework become very tiring, and the patient finds that their work begins to suffer. The patient is indecisive or has trouble thinking or concentrating, especially in school or the workplace. They may also experience uncharacteristic indecisiveness. A person with depression frequently experiences negative, pessimistic thoughts and problems with memory and distraction are common. The person remains unfocused and finds it hard to engage in everyday activities. These issues cause significant difficulty in functioning for those involved in intellectually demanding activities, such as school and work; especially in difficult fields.
Thoughts of death and suicide
The patient has had repeated thoughts about death (other than the fear of dying), suicide (with or without a plan) or has made a suicide attempt. The frequency and intensity of thoughts about suicide can range from believing that friends and family would be better off if one were dead, to frequent thoughts about committing suicide (generally related to wishing to stop the emotional pain), to detailed plans about how the suicide would be carried out. Less severely suicidal people may have regular thoughts of suicide, while those who are more severely suicidal may have made specific plans and decided upon a day and location for the suicide attempt.Thoughts of suicide occur mostly when events that trigger a depressive state occur in a more frequent or severe manner than usual. Nearly every day the patient feels worthless or excessively and/or inappropriately guilty. These feelings are "not merely self-reproach or guilt about being sick", they may be delusional. Depressed people may think of themselves in very negative, unrealistic ways such as manifesting a preoccupation with past "failures", personalisation of trivial events, or believing that minor mistakes prove their inadequacy. They also may have an unrealistic sense of personal responsibility and see things beyond their control as being their fault. Additionally, self-loathing is common in clinical depression, and can lead to a downward spiral when combined with other symptoms.
In diagnosing the symptoms a trained therapist must take the following into account:
- That the symptoms do not meet the criteria for a mixed episode.
- These symptoms must cause considerable distress or impair functioning at work, in social settings or in other important areas in order to qualify as an episode.
- The symptoms are not due to the direct physiological effects of a substance (e.g., abuse of a drug or medication) or a general medical condition (e.g., hypothyroidism).
- Other than in the case of severe symptoms (severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations or psychomotor retardation), the episode should not have begun within two months of the loss of a loved one. (See Bereavement)
There are many places a person can go for help. If exhibiting at least five of the nine symptoms as listed in the Diagnostic and Statistical Manual of Mental Disorders for at least two consecutive weeks, there are many mental health resources once can seek. Resources include, but are not limited to, mental health specialists (i.e. psychologist, psychiatrists, social workers, counselors, etc), mental health centers or organizations, hospitals, outpatient clinics, social service agencies, private clinics, peer support groups, clergy, and employee assistance programs.
If left untreated, a typical major depressive episode may last for about six months, while about 20% of these episodes can last two years or more, with 50% of depressive episodes ending spontaneously. However, even after the major depressive episode is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability.
Regarding the treatment of major depressive episodes of severe intensity (multiple symptoms, minimal mood reactivity, severe functional impairment), combined psychotherapy plus antidepressant medications are more effective than psychotherapy alone. Patients with severe symptoms may require outpatient treatment or hospitalization.
Psychotherapy, also known as talk therapy, counseling or psychosocial therapy, is characterized by a patient talking about their condition and mental health issues with a trained therapist. Different types of psychotherapy can be effective for depression, such as cognitive behavioral therapy, interpersonal therapy, dialectical behavior therapy, acceptance and commitment therapy, and mindfulness techniques.
Medications used to treat depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine-dopamine reuptake inhibitors (NDRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and atypical antidepressants, which do not fit neatly into any of the other categories. Different antidepressants work better for different individuals and it is often necessary to try several before finding one that works best for a specific patient. Some people may find it necessary to combine medications, which could mean two antidepressants or an antipsychotic medication in addition to an antidepressant, in order to effectively treat their depression. If a patient's close relative has responded well to a certain medication, it indicates that that treatment will likely work well for him or her. Although they are not truly addictive, sometimes a patient may become physically dependent on an antidepressant, which means that suddenly stopping treatment or missing several doses may cause withdrawal-like symptoms. Side effects of medications are one of the main reasons people stop taking them, although they often become less severe over time. One of the worst side effects of antidepressants is increased suicidal thoughts or actions, especially in children, adolescents, and young adults. However, antidepressants are more likely to reduce a person's risk of suicide in the long run.
Estimates of the numbers of people suffering from major depressive episodes and Major Depressive Disorder (MDD) vary significantly. Between 10% and 25% of women, and between 5% and 12% of men will suffer a major depressive episode. Fewer people, between 5% and 9% of women and between 2% and 3% of men, will have MDD, or full-blown depression. Depression occurs nearly twice as often in adolescent and adult females as in males, with the greatest differences found in the United States and Europe. The peak period of development is between the ages of 25 and 44 years. Onset of major depressive episodes or MDD often occurs to people in their mid-20s, and less often to those over 65. Prepubescent girls and boys are affected equally. The symptoms of depression are the same in both children and adolescents though there is evidence that their expression within an individual may change as he or she ages.
In a National Institute of Mental Health study, researchers found that more than 40 percent of people with Post Traumatic Stress Disorder suffered from depression 4 months after the traumatic event they experienced.
Cultural factors can influence the symptoms displayed by a person experiencing a Major Depressive Episode. The values of a specific culture may also influence which symptoms are more concerning to the patient and their friends and family. It is essential that a trained professional knows not to dismiss specific symptoms as merely being the "norm" of a culture. However, socio-economic and environmental factors do not appear to have any bearing on the incidence of a major depressive episode or MDD.
Major depressive episodes often express comorbidity with other physical and mental health conditions. Over 84% of cases occur alongside other illnesses and 20-25% of individuals with a chronic general medical condition will develop Major Depression. Common comorbid disorders include: eating disorders, substance-related disorders, panic disorder, and obsessive-compulsive disorder. Up to 25% of people who experience a major depressive episode have a pre-existing dysthymic disorder.
- Depression and Bipolar Support Alliance (DBSA) website from the Depression and Bipolar Support Alliance
- Depression information from the National Institutes of Health
- The Truth About Depression
- Diagnostic and Statistical Manual of Mental Disorders, fourth Edition.
- Medscape (subscription required)
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