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Diagnostic assessment of major depressive disorder, adrenal fatigue symptoms and treatment - Reviews

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Objectives: To assess the prevalence of major depressive disorder and subsyndromal depression in patients with first episode of myocardial infarction (MI) and to compare the socio-demographic, clinical and coronary risk factors in patients with and without depression.
Conclusion: Unrecognized and untreated major depressive disorder and sub-syndromal symptoms were frequent in patients of MI. Depression, anxiety, suppressed anger and type A personality have been shown to be risk factors for developing coronary artery disease.
These prevalence rates of depression in MI population are higher than the possibly conservative rates of major depression in the general population of 5% as reported by the National Co-Morbidity study, 5-10% in primary care, or in 6 to14% in other inpatient medical settings.4,5 There is scarcity of data on this topic in Indian population. The design of the study was a single point cross-sectional, non invasive study of patients after first episode of Acute MI involving administration of diagnostic and assessment tools in those who had come four to six weeks after the index event.
A total of 44.6% patients had symptoms of depression at 4 to 6 weeks after first episode of acute MI.
In our study we used stringent criteria according to DSM-IV-TR in terms of symptom duration and number of symptoms for Major Depressive Disorder. All the previous studies, have compared patients with depressive illness and patients without depressive illness post-MI.3 None has compared patients with diagnosable Major Depressive Disorder with patients having sub-syndromal depressive symptoms. Major Depressive Disorder and sub-syndromal depressive symptoms in 44.5% of patients in our study was largely unrecognized. It was a time bound cross-sectional study, so follow up of cases after one time assessment could not be done. In conclusion, unrecognized and untreated Major Depressive Disorder and sub-syndromal symptoms were frequent in patients of MI attending OPD at 4 to 6 weeks after the index event. American Psychiatric Association: Diagnosis and statistical Manual of Mental Disorder, 4th Edition, Test revision. Had at least 2 weeks of a major depressive episode which caused significant distress or disability. Major Depressive Disorder is a condition characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes.
Completed suicide occurs in up to 15% of individuals with severe Major Depressive Disorder. Disorder, Obsessive-Compulsive Disorder, Anorexia Nervosa, Bulimia Nervosa, and Borderline (Emotionally Unstable) Personality Disorder. There is a greater likelihood of developing additional episodes of this disorder if: (1) there was pre-existing Persistent Depressive Disorder, (2) the individual has made only a partial recovery, (3) the individual has a chronic general medical condition. Manic Episode never disappears completely, however many Major Depressive Episodes have been experienced. Stressors may play a more significant role in the precipitation of the first or second episode of this disorder and play less of a role in the onset of subsequent episodes. First-degree biological relatives of individuals with this disorder are 2-4 times more likely to develop Major Depressive Disorder. Treatment refractory depressions may respond to a combination of an antidepressant plus lithium or electroconvulsive therapy (ECT).
Although almost two-thirds of individuals with major depressive disorder respond to current therapies; at least one-third of those entering remission relapse back into depression 18 months posttreatment.
In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. A disorder characterized by repeated episodes of depression as described for depressive episode (F32.-), without any history of independent episodes of mood elevation and increased energy (mania).
A disorder characterized by repeated episodes of depression, the current episode being mild, as in F32.0, and without any history of mania. A disorder characterized by repeated episodes of depression, the current episode being of moderate severity, as in F32.1, and without any history of mania. A disorder characterized by repeated episodes of depression, the current episode being severe without psychotic symptoms, as in F32.2, and without any history of mania. A disorder characterized by repeated episodes of depression, the current episode being severe with psychotic symptoms, as in F32.3, and with no previous episodes of mania. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. Over 5 years (2005-2011) I studied my outpatient psychiatric patients that had a DSM-IV diagnosis of Major Depressive Disorder.

Fatigue, sleep disturbance, appetite disturbance, occupational impairment and social impairment are all part of the diagnostic criteria for major depressive disorder.
Depressed mood, guilt, self-harm, agitation, distractibility, apathy, and impaired executive functioning are all part of the diagnostic criteria for major depressive disorder.
The most striking finding was the extent to which depression had impaired my patients' social functioning. When you watch the video of this caveman experiment, you can see practically all of the symptoms of major depressive disorder appear. This disorder can be triggered by exposure to any major physical, psychological, or social adversity.
The average major depressive episode lasts less than one year, but up to 15% of severely depressed individuals commit suicide because they prematurely give up any hope of recovery. During a depression, self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. Summary Of Practice Guideline For The Treatment Of Patients With Major Depressive Disorder. An antidepressant medication is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder [I] and definitely should be provided for those with severe major depressive disorder unless ECT is planned [I].
Bright light therapy might be used to treat seasonal affective disorder as well as nonseasonal depression [III]. In women who are pregnant, wish to become pregnant, or are breastfeeding, a depression-focused psychotherapy alone is recommended [II] and depending on the severity of symptoms, should be considered as an initial option [I]. Marital and family problems are common in the course of major depressive disorder, and such problems should be identified and addressed, using marital or family therapy when indicated [II]. The combination of psychotherapy and antidepressant medication may be used as an initial treatment for patients with moderate to severe major depressive disorder [I].
Combining psychotherapy and medication may be a useful initial treatment even in milder cases for patients with psychosocial or interpersonal problems, intrapsychic conflict, or co-occurring personality disorder [II]. Diagnoses of Major Depressive Disorder were established according to Diagnostic and Statistical Manual for Mental Disorders fourth edition Test Revision (DSN-IV-TR) criteria.
Established coronary factors were more commonly present in these groups as compared to no depressive symptom group. Depression and Cardiovascular diseases (CVD) are both highly prevalent disorders and both of them cause a significant decrease in quality of life of the patient. The present study was planned to assess the prevalence of depression in patients with first episode of post-myocardial infarction and to compare the socio-demographic profile, clinical variables and risk factors of the patients with and without depression. The patients were divided into three groups on the basis of presence or absence of depressive symptoms. Somatic symptoms of depression can be difficult to distinguish from symptoms secondary to medical illness or its treatment.12,13 The DSM-IV states that symptoms “accounted for by a general medical condition” should not be counted towards a diagnosis of major depression. Patients who had symptoms of depression but could not fulfill criteria for disorder were kept as a separate group (Sub-syndromal) and were not mixed in the disorder group which could have altered the results. Although no relation was found between gender and psychiatric symptomatology, earlier study has found a relation between female gender and depression i.e. Similarly even those who had sub-syndromal symptoms had significantly poorer level of functioning indicating that not only diagnosable disorder but even minimal symptoms of depression have significant impact on the functional status post MI.
The prevalence of sub-syndromal symptoms was almost equal to prevalence of Major Depressive Disorder in our study. The course of illness of the patients with sub-syndromal depression could not be determined.
Prevalence of depression in survivors of acute myocardial infarction and review of evidence. These Major Depressive Episodes are not due to a medical condition, medication, abused substance, or Psychosis.
Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment. There is a fourfold increase in deaths in individuals with this disorder who are over age 55.
Persistent Depressive Disorder often precedes the onset of this disorder for 10%-25% of individuals.
These vascular depressions are associated with greater neuropsychological impairments and poorer responses to standard therapies.

About 5%-10% of individuals with Major Depressive Disorder eventually convert into Bipolar Disorder.
Major Depressive Disorder, particularly with psychotic features, may also convert into Schizophrenia, a change that is much more frequent than the reverse. St John's wort and regular exercise appear mildly effective in the treatment of depression (but their effect size is small). Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. If such an episode does occur, the diagnosis should be changed to bipolar affective disorder (F31.-).
During major depressive disorder, individuals lack the essential social skills of self-confidence, optimism, belonging, and sociability.
In this way, I could statistically determine which symptoms were elevated in major depressive disorder.
As expected, these classical symptoms of major depression decreased as my patients recovered.
Thus suicide is a tragic waste of life; especially when major depressive disorder is so time-limited. So depression can be triggered by a physical illness or stress, an addiction to alcohol or drugs, or a significant psychological or social stress. The following shows which items on this scale would be rated as abnormal for Major Depressive Disorder.
Schedule for Affective Disorder and Schizophrenia changed version modified for Bipolar disorder (SADS-CB) was applied to detect cases with depressive symptoms not amounting to major depressive disorder (sub-syndromal). This emphasizes the need for routine screening for depression in post MI phase in our population. Depressed individuals are more likely to develop angina, or fatal or non-fatal MI than their non-depressed counterparts.1,2 Prevalence of depression in patients of MI ranges from 16 to 45 % in studies using a standardized interview for the diagnosis of depression.
Severity of MI, complications and intervention post-MI were not related to presence or absence of depressive symptoms. Evaluating patients 4 to 6 weeks after index MI ruled out reactionary depressive symptoms so that true depression in such patients could be detected.
Significantly higher number of patients with Major Depressive Disorder and sub-syndromal symptoms had hypertension and diabetes mellitus. This emphasizes the need for routine screening for depression in post MI phase in this population. The patients having depressive symptoms were further divided into patients with Major Depressive Disorder as group B and patients having depressive symptoms but not amounting to a Major Depressive Disorder (sub-syndromal) were kept in group C. Thus, whether to attribute them to depression or not is typically left to interviewer judgement.
The 2008 American Heart Association Science Advisory concluded that depression is commonly present in patients with coronary heart disease and is independently associated with increased cardiovascular morbidity and mortality. Apprehension about their family members being left helpless in their absence (lack of support system) was their major concern. Therefore, screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment.19,20 In view of adverse outcome of depression associated with Coronary Heart Disease and the availability of easy-to-administer and reasonably accurate screening tools, it is reasonable to screen for depression to improve outcomes.
Malfunctioning of this self-control function is seen in Eating Disorders and Substance Use Disorders.
Published studies have not found a relation between smoking and post-MI depression.14,16 No relation was found between family history of premature CHD, physical inactivity and Type A personality and depressive symptomatology.
The possible reason was that the patients in the educated group could easily differentiate minor changes in their life before MI and life post-MI and hence fell in the sub-syndromal category, whereas illiterate group could only identify major changes and hence fell in the Major Depressive Disorder category.
In Schizophrenia and related disorders, there is malfunctioning of the brain's "detachment" function. Similarly major risk factors like hypertension, diabetes mellitus and lipids were similar in both the groups except smoking.

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