#14087 - Clinical Features Of A Depressive Episode - Psychology

What are the main clinical features of a depressive episode? What is the evidence base for current treatment approaches?

Clinical Features of depressive episode

Defining and classifying MDD is difficult: The symptoms exhibited vary massively from person to person and there are many confounding factors such as tragic events which also lead to similar symptoms.

The two most commonly used criteria for diagnosis are the

-DSM-5 – American psychiatric association diagnostic and statistical manual

-ICD-10.

Major depressive disorder is characterised by a history of one or more major depressive episodes and no history of mania

-Major depressive episode manifests with 5 or more of the following symptoms for at least 2 consecutive weeks; at least one symptom must be either depressed mood or loss of interest or pleasure

Depressed mood most the day, nearly every day

Loss of interest or pleasure in most or all activities, nearly every day

Insomnia or hypersomnia nearly every day

Significant weight loss or weight gain (eg, 5 percent within a month) or decrease or increase in appetite nearly every day.

Psychomotor retardation or agitation nearly every day that is observable by others

Fatigue or low energy, nearly every day

Decreased ability to concentrate, think, or make decisions, nearly every day

Thoughts of worthlessness or excessive or inappropriate guilt, nearly every day

Recurrent thoughts of death or suicidal ideation, or a suicide attempt

-In addition symptoms cause significant distress or psychosocial impairment

-There should be multiple “major depressive episodes” where these symptoms persist for 2 weeks or more.

-The DSM-IV-TR categorises MDD into 5 subtypes.

-Melancholic depression is the stereotypical MDD, and is particularly characterised by diurnal variations in mood

-Atypical depression seems to have quite different symptoms to melancholic. Patients cheer up temporarily, but the depressive state seems more chronic rather than episodic. Patients are also more likely to over-eat and be hypersomnic, and this is highly associated to anxiety disorders.

-Post partum depression affects women much more than men as it is associated with child birth.

- People with seasonal affective disorder seem to have more episodes in the winter more than the summer.

-Catatonic depression is rarer than the other forms, but also seems to affect motor systems.

-As well as these 5, there are other forms of depression such as dysthmia (less severe), manic-depressive disorder (bipolar) which must also be considered.

-A diagnosis of MDD can be thought of as exclusion of all other possible diagnoses.

- Blood tests must be carried out to exclude hypothyroidism, metabolic disturbances, systemic infections and substance abuse.

-If the symptoms are accompanied by cognitive impairment, dementia disorders such as Alzheimer’s must be considered, particularly in older patients.

Treatment options for depression

Cognitive behavioural therapy

Cognitive and behavioral therapies can be used individually or in combination as a program of interventions known as cognitive behavioral therapy or CBT. CBT often includes education, relaxation exercises, coping skills training, stress management, or assertiveness training [3].

In cognitive therapy, the therapist helps the patient identify and correct distorted, maladaptive beliefs. Behavioral therapy uses thought exercises or real experiences to facilitate symptom reduction and improved functioning. This may occur through learning, through decreased reactivity from repeated exposure to a stimulus, or through other mechanisms.

Individuals for whom cognitive behavioral therapy works best are generally highly motivated and value a problem-solving approach, because therapy requires that the patient learns the skills of self-observation. Patients learn cognitive and behavioral skills and practice them within and outside of the therapy setting.

Psychotherapy is efficacious for the initial treatment of mild to moderate unipolar major depression, based upon randomized trials [104,105]. As an example, a meta-analysis of 92 trials (n >6900 patients) compared psychotherapy (primarily CBT) with a control condition (eg, waiting list or usual care) [95]. The primary findings were as follows:

Response (reduction of baseline symptoms 50 percent) occurred in more patients who received psychotherapy than patients in the control groups (48 versus 19 percent)

Remission occurred in more patients treated with psychotherapy, compared with controls (41 versus 21 percent)

Heterogeneity across studies was large; subgroup analyses found that the benefits of psychotherapy were smaller in older patients, and for group therapies (compared with individual therapies)

Number of therapy sessions was not associated with the effect of psychotherapy

It is worth noting that meta-analyses appear to overestimate the clinical benefit of nearly all types of psychotherapy in treating depression [106,107]. These inflated effects may be due to low quality studies as well as publication bias.

Compared with antidepressants—For patients with mild to moderate unipolar major depression, the evidence indicates that the efficacy of psychotherapy compared with antidepressants at the end of treatment is generally comparable [111,112]. A meta-analysis of 30 randomized trials compared psychotherapy (primarily CBT or interpersonal psychotherapy) with antidepressants in 3178 patients with depressive disorders and found that improvement was comparable for both groups [113].

Anti-depressants

Selective serotonin reuptake inhibitors (SSRIs

Serotonin-norepinephrine reuptake inhibitors (

Atypical antidepressants

Serotonin modulators

Older, first-generation antidepressants

Tricyclic antidepressants

Monoamine oxidase inhibitors (MAOIs

Early improvement and response—Among patients with mild to moderate unipolar major depression who start antidepressants, improvement is often apparent within one to two weeks [51,52]:

A meta-analysis of 28 randomized trials (5872 patients with unipolar major depression) that compared SSRIs with placebo found that superior clinical improvement with SSRIs occurred within one week [53].

A pooled analysis of four randomized trials found that the mean time to improvement (reduction of baseline symptoms 20 percent) in 2532 patients treated with antidepressants was approximately 13 days [54].

However, meta-analyses based upon published randomized trials may overestimate the effect of antidepressants because of selective publication of trials (publication bias) [84]. A study of 12 second-generation antidepressants compared drug trials that were published with trials that were registered with the United States Food and Drug...