Quest for Answers: A Primer of Understanding and Treating Severe Personality Disorders

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DSM-IV-TR excludes cases where the symptoms are a result of bereavement , although it is possible for normal bereavement to evolve into a depressive episode if the mood persists and the characteristic features of a major depressive episode develop. Excluded are a range of related diagnoses, including dysthymia , which involves a chronic but milder mood disturbance; [] recurrent brief depression , consisting of briefer depressive episodes; [] [] minor depressive disorder , whereby only some symptoms of major depression are present; [] and adjustment disorder with depressed mood , which denotes low mood resulting from a psychological response to an identifiable event or stressor.

The DSM-5 recognizes six further subtypes of MDD, called specifiers , in addition to noting the length, severity and presence of psychotic features:. In , the United States Preventive Services Task Force USPSTF recommended screening in the adult populations with evidence that it increases the detection of people with depression and with proper treatment improves outcomes.

A Cochrane review from found screening programs do not significantly improve detection rates, treatment, or outcome.

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To confirm major depressive disorder as the most likely diagnosis, other potential diagnoses must be considered, including dysthymia, adjustment disorder with depressed mood, or bipolar disorder. Dysthymia is a chronic, milder mood disturbance in which a person reports a low mood almost daily over a span of at least two years.

The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to secondary episodes of major depression sometimes referred to as double depression. Although depression is currently categorized as a separate disorder, there is ongoing debate because individuals diagnosed with major depression often experience some hypomanic symptoms, indicating a mood disorder continuum.

Other disorders need to be ruled out before diagnosing major depressive disorder. They include depressions due to physical illness, medications , and substance abuse. Depression due to physical illness is diagnosed as a mood disorder due to a general medical condition. This condition is determined based on history, laboratory findings, or physical examination.

When the depression is caused by a medication, drug of abuse, or exposure to a toxin , it is then diagnosed as a specific mood disorder previously called substance-induced mood disorder in the DSM-IV-TR. Behavioral interventions, such as interpersonal therapy and cognitive-behavioral therapy , are effective at preventing new onset depression. However, an earlier meta-analysis found preventive programs with a competence-enhancing component to be superior to behavior-oriented programs overall, and found behavioral programs to be particularly unhelpful for older people, for whom social support programs were uniquely beneficial.

In addition, the programs that best prevented depression comprised more than eight sessions, each lasting between 60 and 90 minutes, were provided by a combination of lay and professional workers, had a high-quality research design, reported attrition rates , and had a well-defined intervention. The Netherlands mental health care system provides preventive interventions, such as the "Coping with Depression" course CWD for people with sub-threshold depression.

The three most common treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice over medication for people under The UK National Institute for Health and Care Excellence NICE guidelines indicate that antidepressants should not be used for the initial treatment of mild depression, because the risk-benefit ratio is poor.

The guidelines recommend that antidepressants treatment in combination with psychosocial interventions should be considered for:. The guidelines further note that antidepressant treatment should be continued for at least six months to reduce the risk of relapse , and that SSRIs are better tolerated than tricyclic antidepressants. American Psychiatric Association treatment guidelines recommend that initial treatment should be individually tailored based on factors including severity of symptoms, co-existing disorders, prior treatment experience, and patient preference.

Options may include pharmacotherapy, psychotherapy, exercise, electroconvulsive therapy ECT , transcranial magnetic stimulation TMS or light therapy. Antidepressant medication is recommended as an initial treatment choice in people with mild, moderate, or severe major depression, and should be given to all patients with severe depression unless ECT is planned. Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy is often difficult. Development of mental health services is minimal in many countries; depression is viewed as a phenomenon of the developed world despite evidence to the contrary, and not as an inherently life-threatening condition.

Physical exercise is recommended for management of mild depression, [] and has a moderate effect on symptoms. There is a small amount of evidence that skipping a night's sleep may improve depressive symptoms, with the effects usually showing up within a day. This effect is usually temporary. Besides sleepiness, this method can cause a side effect of mania or hypomania.

In observational studies, smoking cessation has benefits in depression as large as or larger than those of medications. Besides exercise, sleep and diet may play a role in depression, and interventions in these areas may be an effective add-on to conventional methods.

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Psychotherapy can be delivered to individuals, groups, or families by mental health professionals. A review found that cognitive behavioral therapy appears to be similar to antidepressant medication in terms of effect. Psychotherapy has been shown to be effective in older people. Cognitive behavioral therapy CBT currently has the most research evidence for the treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy IPT are preferred therapies for adolescent depression.

The most-studied form of psychotherapy for depression is CBT, which teaches clients to challenge self-defeating, but enduring ways of thinking cognitions and change counter-productive behaviors. Research beginning in the mids suggested that CBT could perform as well as or better than antidepressants in patients with moderate to severe depression.

Cognitive behavioral therapy and occupational programs including modification of work activities and assistance have been shown to be effective in reducing sick days taken by workers with depression. Several variants of cognitive behavior therapy have been used in those with depression, the most notable being rational emotive behavior therapy , [] and mindfulness-based cognitive therapy.

Psychoanalysis is a school of thought, founded by Sigmund Freud , which emphasizes the resolution of unconscious mental conflicts. It also tends to focus more on the person's immediate problems, and has an additional social and interpersonal focus. Conflicting results have arisen from studies that look at the effectiveness of antidepressants in people with acute, mild to moderate depression. While small benefits were found, researchers Irving Kirsch and Thomas Moore state they may be due to issues with the trials rather than a true effect of the medication.

In the U. Food and Drug Administration published a systematic review of all antidepressant maintenance trials submitted to the agency between and To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. SSRIs are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants. For children, some research has supported the use of the SSRI antidepressant fluoxetine.

Irreversible monoamine oxidase inhibitors , an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions. They are still used only rarely, although newer and better-tolerated agents of this class have been developed. For children, adolescents, and probably young adults between 18 and 24 years old, there is a higher risk of both suicidal ideations and suicidal behavior in those treated with SSRIs.

One review found no connection; [] another an increased risk; [] and a third no risk in those 25—65 years old and a decreased risk in those more than There is some evidence that omega-3 fatty acids fish oil supplements containing high levels of eicosapentaenoic acid EPA to docosahexaenoic acid DHA are effective in the treatment of, but not the prevention of major depression. Electroconvulsive therapy ECT is a standard psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses.

Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia. A usual course of ECT involves multiple administrations, typically given two or three times per week, until the patient is no longer suffering symptoms. ECT is administered under anesthesia with a muscle relaxant. These three forms of application have significant differences in both adverse side effects and symptom remission.

After treatment, drug therapy is usually continued, and some patients receive maintenance ECT. ECT appears to work in the short term via an anticonvulsant effect mostly in the frontal lobes , and longer term via neurotrophic effects primarily in the medial temporal lobe.

References

Transcranial magnetic stimulation TMS or deep transcranial magnetic stimulation is a noninvasive method used to stimulate small regions of the brain. Bright light therapy reduces depression symptom severity, with benefit for both seasonal affective disorder and for nonseasonal depression, and an effect similar to those for conventional antidepressants. For nonseasonal depression, adding light therapy to the standard antidepressant treatment was not effective.

There is insufficient evidence for Reiki [] and dance movement therapy in depression. Major depressive episodes often resolve over time whether or not they are treated. A high proportion of people who experience full symptomatic remission still have at least one not fully resolved symptom after treatment.

People experiencing repeated episodes of depression require ongoing treatment in order to prevent more severe, long-term depression. In some cases, people must take medications for the rest of their lives. Cases when outcome is poor are associated with inappropriate treatment, severe initial symptoms including psychosis, early age of onset, previous episodes, incomplete recovery after one year of treatment, pre-existing severe mental or medical disorder, and family dysfunction. Depressed individuals have a shorter life expectancy than those without depression, in part because depressed patients are at risk of dying of suicide.

Depression is often associated with unemployment and poverty. In the year , it is predicted to be the second-leading cause of disease burden worldwide after HIV , according to the WHO. People are most likely to develop their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and The Ancient Greek physician Hippocrates described a syndrome of melancholia as a distinct disease with particular mental and physical symptoms; he characterized all "fears and despondencies, if they last a long time" as being symptomatic of the ailment.

The term depression itself was derived from the Latin verb deprimere , "to press down". It was used in in English author Richard Baker's Chronicle to refer to someone having "a great depression of spirit", and by English author Samuel Johnson in a similar sense in An early usage referring to a psychiatric symptom was by French psychiatrist Louis Delasiauve in , and by the s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function. Although melancholia remained the dominant diagnostic term, depression gained increasing currency in medical treatises and was a synonym by the end of the century; German psychiatrist Emil Kraepelin may have been the first to use it as the overarching term, referring to different kinds of melancholia as depressive states.

Sigmund Freud likened the state of melancholia to mourning in his paper Mourning and Melancholia. He theorized that objective loss, such as the loss of a valued relationship through death or a romantic break-up, results in subjective loss as well; the depressed individual has identified with the object of affection through an unconscious , narcissistic process called the libidinal cathexis of the ego. Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively but the ego itself is compromised.

In the midth century, researchers theorized that depression was caused by a chemical imbalance in neurotransmitters in the brain, a theory based on observations made in the s of the effects of reserpine and isoniazid in altering monoamine neurotransmitter levels and affecting depressive symptoms. The term "unipolar" along with the related term " bipolar " was coined by the neurologist and psychiatrist Karl Kleist , and subsequently used by his disciples Edda Neele and Karl Leonhard.

The term Major depressive disorder was introduced by a group of US clinicians in the mids as part of proposals for diagnostic criteria based on patterns of symptoms called the "Research Diagnostic Criteria", building on earlier Feighner Criteria , [] and was incorporated into the DSM-III in The new definitions of depression were widely accepted, albeit with some conflicting findings and views. There have been some continued empirically based arguments for a return to the diagnosis of melancholia.

The term "depression" is used in a number of different ways. It is often used to mean this syndrome but may refer to other mood disorders or simply to a low mood. People's conceptualizations of depression vary widely, both within and among cultures. What we call it—'disease,' 'disorder,' 'state of mind'—affects how we view, diagnose, and treat it. The diagnosis is less common in some countries, such as China.

It has been argued that the Chinese traditionally deny or somatize emotional depression although since the early s, the Chinese denial of depression may have modified. Australian professor Gordon Parker and others have argued that the Western concept of depression "medicalizes" sadness or misery. Historical figures were often reluctant to discuss or seek treatment for depression due to social stigma about the condition, or due to ignorance of diagnosis or treatments.

Nevertheless, analysis or interpretation of letters, journals, artwork, writings, or statements of family and friends of some historical personalities has led to the presumption that they may have had some form of depression. Watson , [] dealt with their own depression. There has been a continuing discussion of whether neurological disorders and mood disorders may be linked to creativity , a discussion that goes back to Aristotelian times.

Social stigma of major depression is widespread, and contact with mental health services reduces this only slightly. Public opinions on treatment differ markedly to those of health professionals; alternative treatments are held to be more helpful than pharmacological ones, which are viewed poorly. Depression is especially common among those over 65 years of age and increases in frequency beyond this age.

As with many other diseases, it is common among the elderly not to present with classical depressive symptoms. Problem solving therapy was, as of , the only psychological therapy with proven effect, and can be likened to a simpler form of cognitive behavioral therapy. The risks involved with treatment of depression among the elderly as opposed to benefits are not entirely clear. MRI scans of patients with depression have revealed a number of differences in brain structure compared to those who are not depressed. Meta-analyses of neuroimaging studies in major depression reported that, compared to controls, depressed patients had increased volume of the lateral ventricles and adrenal gland and smaller volumes of the basal ganglia , thalamus , hippocampus , and frontal lobe including the orbitofrontal cortex and gyrus rectus.

Trials are looking at the effects of botulinum toxins on depression. The idea is that the drug is used to make the person look less frowning and that this stops the negative facial feedback from the face. Models of depression in animals for the purpose of study include iatrogenic depression models such as drug-induced , forced swim tests, tail suspension test , and learned helplessness models. Criteria frequently used to assess depression in animals include expression of despair, neurovegetative changes, and anhedonia, as many other criteria for depression are untestable in animals, such as guilt and suicidality.

From Wikipedia, the free encyclopedia. For other types of depression, see Mood disorder. Not to be confused with Depression mood.

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