Depression, major

Also known as unipolar disorder, major depression is a syndrome of persistently sad, dysphoric mood accompanied by disturbances in sleep and appetite, lethargy, and an inability to experience pleasure (anhedonia). Major depression occurs in 3% to 5% of adults, affecting all racial, ethnic, and socioeconomic groups. It affects both sexes but is more common in women. (See Depression.)

About half of all depressed patients experience a single episode and recover completely; the rest have at least one recurrence.  Major depression can profoundly alter social, family, and occupational functioning.

However, suicide is the most serious complication of major depression, resulting when the patient’s feelings of worthlessness, guilt, and hopelessness are so overwhelming that he no longer considers life worth living. Nearly twice as many women as men attempt suicide, but men are far more likely to succeed.

Causes

The multiple causes of depression aren’t completely understood. Current research suggests possible genetic, familial, biochemical, physical, psychological, and social causes.

Psychological factors

Such causes may include feelings of helplessness and vulnerability, anger, hopelessness and pessimism, and low self-esteem; they may be related to abnormal character and behavior patterns and troubled personal relationships.

In many patients, the history identifies a specific personal loss or severe stressor that probably interacts with the person’s predisposition to provoke major depression.

Medical conditions

Depression may be secondary to a specific medical condition — for example, metabolic disturbances, such as hypoxia and hypercalcemia; endocrine disorders, such as diabetes and Cushing’s disease; neurologic diseases, such as Parkinson’s and Alzheimer’s disease; and cancer, especially of the pancreas.

Other medical conditions that may underlie depression include viral and bacterial infections, such as influenza and pneumonia; cardiovascular disorders such as heart failure; pulmonary disorders such as chronic obstructive pulmonary disease; musculoskeletal disorders such as degenerative arthritis; GI disorders such as irritable bowel syndrome; genitourinary problems such as incontinence; collagen vascular diseases such as lupus; and anemias.

Drugs

Drugs prescribed for medical and psychiatric conditions as well as many commonly abused substances, can also cause depression. Examples include antihypertensives, psychotropics, narcotic and nonnarcotic analgesics, antiparkinsonian drugs, numerous cardiovascular medications, oral antidiabetics, antimicrobials, steroids, chemotherapeutic agents, cimetidine, and alcohol.

Signs and symptoms

The primary features of major depression are a predominantly sad mood and a loss of interest or pleasure in daily activities. Symptoms tend to be more severe than those caused by dysthymic disorder, which is a milder, chronic form of depression. (See Dysthymic disorder: A chronic affective disorder.) 

The depressive patient may complain of feeling “down in the dumps,” express doubts about his self-worth or ability to cope, or simply appear unhappy and apathetic. He may also report feeling angry or anxious.

Other common signs include difficulty concentrating or thinking clearly, distractibility, and indecisiveness. Take special note if the patient reveals suicidal thoughts, a preoccupation with death, or previous suicide attempts.

The psychosocial history may reveal life problems or losses that can account for the depression. Alternatively, the patient’s medical history may implicate a physical disorder or the use of prescription, nonprescription, or illegal drugs that can cause depression.

The patient may report an increase or a decrease in appetite, sleep disturbances (for example, insomnia or early awakening), a lack of interest in sexual activity, constipation, or diarrhea. Other signs that you may note during a physical examination include agitation (such as hand wringing or restlessness) and reduced psychomotor activity (for example, slowed speech).

Diagnosis

The DSM-IV-TR describes specific characteristics of patients with this condition. (See Diagnosing major depression.)

The diagnosis of major depression is supported by psychological tests, such as the Beck Depression Inventory, which may help determine the onset, severity, duration, and progression of depressive symptoms. A toxicology screening may suggest drug-induced depression.

Treatment

Depression is difficult to treat, especially in children, adolescents, elderly patients, and those with a history of chronic disease. The primary treatment methods are drug therapy, electroconvulsive therapy (ECT), and psychotherapy.

Drug therapy

In depression, drug therapy includes tricyclic antidepressants (TCAs) such as amitriptyline, serotonin reuptake inhibitors such as fluoxetine, and monoamine oxidase (MAO) inhibitors, such as isocarboxazid, maprotiline, and trazodone.

❑ The most widely used class of antidepressant drugs, TCAs prevent the reuptake of norepinephrine or serotonin (or both) into the presynaptic nerve endings, resulting in increased synaptic concentrations of these neurotransmitters. They also cause a gradual loss in the number of beta-adrenergic receptors.

❑ After resolution of the acute episode, patients with a history of recurrent depression may be maintained on low doses of antidepressants as a preventive measure.

❑ Selective serotonin reuptake inhibitors, including fluoxetine, paroxetine, and sertraline, are increasingly becoming the drugs of choice. They are effective and produce fewer adverse effects than the TCAs; however, they’re associated with sleep and GI problems and alterations in sexual desire and function.

❑ MAO inhibitors block the enzymatic degradation of norepinephrine and serotonin. These agents are commonly prescribed for patients with atypical depression (for example, depression marked by an increased appetite and need for sleep, rather than anorexia and insomnia) and for some patients who fail to respond to TCAs.

MAO inhibitors are associated with a high risk of toxicity; patients treated with one of these drugs must be able to comply with the necessary dietary restrictions. Conservative doses of an MAO inhibitor may be combined with a TCA for patients refractory to either drug alone.

Maprotiline is a potent blocker of norepinephrine uptake, whereas trazodone is a selective serotonin uptake blocker. The mechanism of action of bupropion is unknown.

ECT

When a depressed patient is incapacitated, suicidal, or psychotically depressed, or when antidepressants are contraindicated or ineffective, ECT is commonly the treatment of choice. Six to 12 treatments usually are needed, although improvement is usually evident after only a few treatments. Researchers hypothesize that ECT affects the same receptor sites as antidepressants.

Psychotherapy

Short-term psychotherapy is also effective in treating major depression. Many psychiatrists believe that the best results are achieved with a combination of individual, family, or group psychotherapy and medication. Therapeutic interventions focus on identifying the patient’s negative thoughts and interpretations and substituting adaptive responses.

Special considerations

❑ Share your observations of the patient’s behavior with him. For instance, you might say, “You’re sitting all by yourself, looking very sad. Is that how you feel?” Because the patient may think and react sluggishly, speak slowly and allow ample time for him to respond.

❑ Avoid feigned cheerfulness. However, don’t hesitate to laugh with the patient and point out the value of humor.

❑ Show the patient that he’s important by listening attentively and respectfully, preventing interruptions, and avoiding judgmental responses.

❑ Provide a structured routine, including noncompetitive activities, to build the patient’s self-confidence and encourage interaction with others. Urge him to join group activities and to socialize.

❑ Inform the patient that he can help ease depression by expressing his feelings, participating in pleasurable activities, and improving grooming and hygiene.

❑ Ask the patient if he thinks of death or suicide. Such thoughts signal an immediate need for consultation and assessment. Failure to detect suicidal thoughts early may encourage the patient to attempt suicide.

Clinical tip  The risk of suicide increases as the depression lifts.

❑ While tending to the patient’s psychological needs, don’t forget his physical needs. If he’s too depressed to take care of himself, help him with personal hygiene. Encourage him to eat, or feed him if necessary. If he’s constipated, add high-fiber foods to his diet; offer small, frequent meals; and encourage physical activity and fluid intake. Offer warm milk or back rubs at bedtime to improve sleep.

❑ If the patient is taking an antidepressant, monitor him for evidence of seizures. Some antidepressants significantly lower the seizure threshold. (See Guidelines for antidepressant therapy.) 

❑ Teach the patient about depression. Emphasize that effective methods are available to relieve his symptoms. Help him to recognize distorted perceptions that may contribute to his depression. Once the patient learns to recognize depressive thought patterns, he can consciously begin to substitute self-affirming thoughts.

❑ Instruct the patient about prescribed medications. Stress the need for compliance and review adverse effects. For drugs that produce strong anticholinergic effects, such as amitriptyline and amoxapine, suggest sugarless gum or hard candy to relieve dry mouth.

❑ Many antidepressants are sedating (for example, amitriptyline and trazodone); warn the patient taking one of these drugs to avoid activities that require alertness, including driving and operating mechanical equipment, until the central nervous system (CNS) effects of the drug are known.

❑ Caution the patient taking a TCA to avoid drinking alcoholic beverages or taking other CNS depressants during therapy.

❑ If the patient is taking an MAO inhibitor, emphasize that he must avoid foods that contain tyramine, caffeine, or tryptophan. The ingestion of tyramine can cause a hypertensive crisis. Examples of foods that contain these substances are cheese, sour cream, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, yeast extracts, meat tenderizers, coffee, colas, and beer, chianti, and sherry.

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Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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