Major Depressive Disorder (MDD)

 

Major Depressive Disorder (MDD) is a serious mental illness characterized by persistent feelings of sadness, hopelessness, and a lack of interest in activities that were once enjoyable. It is a mood disorder that affects a person’s ability to function in daily life, causing significant distress and impairment in social, occupational, and other areas of functioning.

 

Diagnostic Criteria

 

To be diagnosed with MDD, an individual must experience five or more of the following symptoms during the same 2-week period, representing a change from previous functioning:

 

• Depressed mood most of the day, nearly every day
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
• Significant weight loss or gain (e.g., 5% or more of body weight in a month) or decrease or increase in appetite
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• Diminished ability to think or concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death, recurrent suicidal ideation without a plan, or a suicide attempt or a specific plan for committing suicide

 

Symptoms:

 

• Depressed mood: feeling sad, empty, or hopeless
• Anhedonia: loss of interest or pleasure in activities that were once enjoyable
• Changes in appetite or weight: significant weight loss or gain, or changes in appetite
• Sleep disturbances: insomnia or hypersomnia
• Psychomotor changes: agitation or retardation
• Fatigue or loss of energy: feeling tired, sluggish, or lacking energy
• Feelings of worthlessness or guilt: feelings of inadequacy, self-blame, or shame
• Cognitive changes: difficulty thinking, concentrating, or making decisions
• Suicidal thoughts or behaviors: recurrent thoughts of death, suicidal ideation, or suicide attempts

 

Subtypes and Specification

Melancholic Depression

This subtype is characterized by:

• Loss of pleasure in most or all activities
• Failure of reactivity to pleasurable stimuli
• Depressed mood more pronounced than that of grief or loss
• Worsening of symptoms in the morning
• Early-morning waking
• Psychomotor retardation
• Excessive weight loss or guilt.

 

Atypical Depression

Atypical depression is marked by:

• Mood reactivity (improvement in mood in response to positive events)
• Increased appetite or weight gain
• Hypersomnia (excessive sleep)
• Leaden paralysis (a sensation of heaviness in the limbs)
• Long-term social impairment due to hypersensitivity to perceived interpersonal rejection.

 

Psychotic Depression

This severe form of depression includes symptoms of psychosis, such as:

• Hallucinations
• Delusions
• Paranoia

It is automatically rated as severe due to the presence of psychotic features.

 

Catatonic Depression

A rare and severe form characterized by disturbances in motor behavior, such as:

• Mutism
• Immobility or purposeless and bizarre movements.

 

Depression with Anxious Distress

This specifier is used when there is significant anxiety present, such as:

• Feeling tense and restless
• Trouble concentrating due to worry
• Fear of losing control
• Increased risk of suicide.

 

Postpartum Depression

This type occurs in women after childbirth and can include symptoms similar to those of major depression, along with anxiety and obsessive thoughts about the baby.

Seasonal Affective Disorder (SAD)

While not exclusively a subtype of MDD, SAD is a type of depression that follows a seasonal pattern, typically occurring during the winter months and improving in the spring and summer. Symptoms include lack of energy, excessive sleep, overeating, and cravings for carbohydrates.

 

Persistent Depressive Disorder (PDD)

Although not a subtype of MDD but related, PDD involves less severe symptoms of depression that last for at least two years. It was previously known as dysthymia or chronic major depression.

 

Each of these subtypes and specifiers helps in tailoring the treatment approach to the specific needs and symptoms of the individual.

 

Treatment:

Antidepressant Medications

Antidepressants are a cornerstone in the treatment of MDD and can be categorized into several types:

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Examples include fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), and fluvoxamine.
• SSRIs are generally the first line of treatment due to their relatively favorable side-effect profile and ease of use.

 

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

• Examples include venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), levomilnacipran (Fetzima), and milnacipran (Savella).
• SNRIs are often used for patients with comorbid pain disorders or when SSRIs are not effective.

 

Tricyclic Antidepressants (TCAs)

• Examples include amitriptyline, imipramine (Tofranil), clomipramine (Anafranil), doxepin, nortriptyline, and desipramine.
• TCAs are less commonly used today due to their higher incidence of side effects and potential lethality in overdose.

 

Monoamine Oxidase Inhibitors (MAOIs)

• Examples include tranylcypromine (Parnate), phenelzine (Nardil), selegiline, and isocarboxazid (Marplan).
• MAOIs are typically reserved for patients who have not responded to other treatments due to dietary restrictions and potential interactions with other medications.

 

Atypical Antidepressants

• Examples include bupropion (Wellbutrin), mirtazapine (Remeron), vilazodone (Viibryd), and vortioxetine (Trintellix).
• These medications are often used as monotherapy or as augmenting agents when patients experience side effects from SSRIs or SNRIs.

 

 N-Methyl-D-Aspartate (NMDA) Antagonists

• Examples include esketamine (Spravato) and dextromethorphan/bupropion.
• These medications are FDA-approved for treatment-resistant depression and work more rapidly than traditional antidepressants, with effects seen within hours or a week.

 

Psychotherapy

 

Psychotherapy is a crucial component of MDD treatment and can be used alone or in combination with medications.

 

Cognitive-Behavioral Therapy (CBT)

• Focuses on identifying and changing negative thought patterns and behaviors that contribute to depression.

 

 Interpersonal Therapy (IPT)

Concentrates on improving interpersonal relationships and communication skills to help manage depressive symptoms.

 

Psychodynamic Therapy

Explores the unconscious thoughts and feelings that underlie an individual’s depression, often focusing on past experiences and relationships.

 

Other Forms of Therapy

Includes problem-solving therapy, behavior therapy, and supportive therapy, each with its own approach to addressing depressive symptoms.

 

Electroconvulsive Therapy (ECT)

 

ECT is a highly effective treatment for severe, treatment-resistant MDD, particularly when there is a high risk of suicide or significant impairment in daily functioning.

It involves the use of electrical impulses to induce controlled seizures in the patient.

 

Lifestyle Changes

 

Lifestyle modifications can complement pharmacological and psychotherapeutic treatments.

 

Regular Exercise

Moderate exercise has been shown to improve symptoms of mild to moderate depression by releasing endorphins and other neurotransmitters that enhance mood.

 

Healthy Diet

A balanced diet rich in fruits, vegetables, whole grains, and lean proteins can help stabilize mood and energy levels.

 

Stress Management Techniques

Techniques such as mindfulness, meditation, and relaxation exercises can help reduce stress and improve overall mental health.

 

Interdisciplinary Approach

 

An effective treatment plan for MDD often involves an interdisciplinary team, including primary care physicians, psychiatrists, nurses, therapists, social workers, and case managers. This collaborative approach ensures comprehensive care and better outcomes.

 

Screening and Early Intervention

Regular screening for depression in primary care settings using tools like the Patient Health Questionnaire-9 (PHQ-9) is crucial for early diagnosis and intervention

 

Prognosis:

 

The prognosis for MDD varies depending on the individual and the severity of symptoms. With proper treatment, many people with MDD can experience significant improvement in symptoms and quality of life. However, some people may experience recurrent episodes or chronic symptoms. Early diagnosis and treatment can improve outcomes and reduce the risk of complications, such as suicide.

 

 

 

 

 

The treatment of Major Depressive Disorder (MDD) is multifaceted and often involves a combination of medications, psychotherapy, and lifestyle modifications. Here is a brief discussion of the common treatment approaches: