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22.03.2015

Symptoms of severe depression with psychotic features, major depressive disorder diagnosis dsm-iv - Review

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The other major mood disorder is bipolar disorder, formerly called manic-depressive illness, which is characterized by periods of depression alternating with episodes of excessive energy and activity. In major, or acute, depression, at least five of the symptoms listed below must occur for a period of at least 2 weeks, and they must represent a change from previous behavior or mood. The symptoms listed above do not follow or accompany manic episodes (such as in bipolar disorder or other disorders). Dysthymia, or chronic depression, afflicts 3 - 6% of the general population and is characterized by many of the same symptoms that occur in major depression. Seasonal affective disorder (SAD) is characterized by annual episodes of depression during fall or winter that improve in the spring or summer. Other neurotransmitters possibly involved in depression include acetylcholine and catecholamines, a group of neurotransmitters that consists of dopamine, norepinephrine, and epinephrine (also called adrenaline). Women, regardless of nationality, race, ethnicity, or socioeconomic level, have twice the rate of depression than men. Depression is less reported in the male population, but this may be caused by male tendency to mask emotional disorders with behavior such as alcohol abuse. Adolescents who have depression are at significantly higher risk for substance abuse, recurring depression, and other emotional and mental health problems in adulthood.
Studies suggest that 3 - 5% of children and adolescents suffer from clinical depression, and 10 - 15% have some depressive symptoms. Any chronic or serious illness, such as diabetes, that is life-threatening or out of a person's control can lead to depression. Hypothyroidism (a condition caused when the thyroid gland does not produce enough hormone) can cause depression. Studies have reported a strong association between depression and headaches, including chronic tension-type and migraine.
There is a significant association between cigarette smoking and a susceptibility to depression.
Children, adolescents, and young adults who are prescribed antidepressant medication should be carefully monitored by both their parents and doctor, especially during the first few months of treatment, for any worsening of depression symptoms or changes in behavior.
Major depression in the elderly or in people with serious illness may reduce survival rates, even independently of any accompanying illness. Data suggest that depression itself may be a risk factor for heart disease as well as its increased severity.
While the evidence is less conclusive, studies also indicate that depression in healthy people may increase the risk for developing heart disease. Studies are now showing that depression may contribute to poor outcomes for patients with heart disease. Depression does not increase the risk for cancer, but cancer can physically trigger depression by affecting chemicals in the brain. Many people with major depression also have an alcohol use disorder or drug abuse problems. Depression is a well-known risk factor for smoking, and many people with major depression are nicotine dependent. Individuals who have certain factors might ask their doctor if they should be screened for depression. Mental health professionals may administer a screening test such as the Beck Depression Inventory or the Hamilton Rating Scale, both of which consist of about 20 questions that assess the individual for depression. Symptoms of depression can vary depending on a person’s cultural and ethnic background, For example, people from non-Western countries are more apt to report physical symptoms (such as headache, constipation, weakness, or back pain) related to the depression, rather than mood-related symptoms. Unfortunately, many Americans with major depression receive either inadequate treatment or no treatment at all. Brain stimulation techniques, such as electroconvulsive therapy (ECT), are options for treatment-resistant depression.
Patients with minor depression (fewer than five symptoms that persist for fewer than 2 years) may respond well to watchful waiting to see if antidepressants are necessary. Depression can worsen many medical conditions and may even increase mortality rates from some disorders, such as heart attack and stroke. Treating depression in patients who abuse alcohol or drugs is important and can sometimes help patients quit. Most people with depression can be treated in an office setting by a psychiatrist, psychologist, or other therapist. Although other mental health professionals cannot prescribe drugs, most therapists have arrangements with a psychiatrist for providing medications to their patients. Psychoanalysts tend to have a degree in psychiatry, psychology, or social work as well as several years of training at a psychoanalytic institute.
Between 14 - 23% of women experience depressive symptoms during pregnancy, and some women develop full-blown postpartum depression following delivery.
The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women with depression receive care from a multidisciplinary team that includes the patient’s obstetrician, primary care physician, and mental health clinician. The use of antidepressants during pregnancy is controversial, especially for women with major depression who regularly take antidepressant medication.
ACOG and the American Psychiatric Association (APA) recommend that women who are pregnant or thinking about becoming pregnant should not stop taking antidepressants without first talking to their doctors. In terms of non-drug treatment of postpartum depression, doctors recommend that women with signs of postpartum depression receive intensive and individualized psychotherapy within a month after giving birth. Studies suggest that when children or adolescents are treated for depression, a large majority recover. It is important to recognize that childhood depression differs from adult depression and that children may respond differently than adults to antidepressant medication. The pediatrician may want to monitor a child with mild depression for 6 - 8 weeks before deciding whether to prescribe psychotherapy, antidepressant medication, or a referral to a mental health professional.
The American Academy of Child and Adolescent Psychiatry recommends an SSRI antidepressant for children and adolescents with very severe depression that does not respond to psychotherapy. These drugs are effective but can have severe adverse effects, particularly in older people. If no improvement occurs within 6- 8 weeks of starting drug treatment, the doctor may either increase the dosage or switch to an alternative drug. In general, patients are asked to continue taking antidepressants for at least 4 - 9 months after symptom relief to help prevent relapse.
Patients with at least two episodes of major depression or major depression that lasts for 2 years or longer before initial treatment.
Patients who continue to have low-level depression for 7 months after starting antidepressant treatments.
There is no risk for addiction with current antidepressants, and many of the common antidepressants, including most standard SSRIs, have been proven safe when taken for a number of years.
No matter how well a drug treats depression, the ability of patients to tolerate its side effects strongly influences their compliance with therapy. An increased risk of oral health problems caused by dry mouth is associated with long-term use of many antidepressants, particularly tricyclics. Virtually all antidepressants have complicated interactions with other drugs; some are very important.
Nearly all antidepressants are metabolized in the liver, so anyone with liver abnormalities should use them with caution.
Abrupt withdrawal from many antidepressants can produce severe side effects; no antidepressant should be stopped abruptly without consultation with a doctor. The FDA recommends that caregivers monitor children, adolescents, and young adults being treated with antidepressants for sudden behavioral changes, and immediately notify their doctor if such changes occur. Selective serotonin-reuptake inhibitors (SSRIs) are now the first-line treatment for major depression.
At this time, fluoxetine and escitalopram are the only antidepressants approved for treatment of major depressive disorder in adolescents (ages 12 - 17).
SSRIs can interact with other antidepressants such as tricyclics and, in particular, monoamine oxidase inhibitors (MAOIs). Cognitive problems, sleep disturbances, increase in depressive symptoms, and electric shock-like symptoms have been known to occur with sudden discontinuation of SSRIs. Some of these drugs may be helpful for additional problems -- such as insomnia, fibromyalgia and similar chronic pain syndromes, or smoking -- that affect some people with depression.
These drugs do share some side effects with other antidepressants, including dizziness and dry mouth. In 2009, the FDA warned that bupropion products may cause symptoms such as changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide. They tend to cause disturbances in heart rhythm, which can pose a danger for some patients with certain heart diseases.
Because these drugs can have very severe side effects, they are usually prescribed only for severe depression or when other types of antidepressants do not help (treatment-resistant depression).
The most serious side effect is severe hypertension (high blood pressure), which can be brought on by eating certain foods having high tyramine content.
In a major analysis, cognitive behavioral therapy (CBT) worked as well as antidepressants in treating severe depression for many patients. Children of parents with the depression -- in this case, therapy should involve the whole family. First, the patient must learn to recognize depressive reactions and thoughts as they occur, usually by keeping a journal of feelings about, and reactions to, daily events. As the patient begins to understand the underlying falseness of the assumptions that cause depression, they can begin substituting new ways of coping. Based in part on psychodynamic theory, interpersonal therapy acknowledges the childhood roots of depression, but focuses on symptoms and current issues that may be causing problems. The intent of supportive psychotherapy or attention intervention is to provide the patient with a nonjudgmental environment by offering advice, attention, and sympathy. An implantable deep brain stimulation device (Reclaim), similar to a pacemaker and devices used for treating movement disorders like Parkinson’s disease, has been approved for treatment of severe obsessive-compulsive disorder. Studies report response rates of 35 - 46% in appropriate candidates with treatment-resistant depression.


Side effects include headache, eye strain, and irritability, although these symptoms tend to disappear within a week. Some people report relief from depression by eating foods or diet supplements that boost levels of tryptophan, an amino acid involved in the production of serotonin. Some studies have suggested that an imbalance in the ratio of specific fatty acids (omega-6 to omega-3) may increase the risk for depression.
Omega-3 fatty acids, found in oily fish and flaxseed and canola oils, may be beneficial to people with depression.
Vitamin B-12 and calcium supplements may help reduce depression that occurs before menstruation.
A strong network of social support is important for both prevention and recovery from depression.
The primary subtypes are major depression, dysthymia (longstanding but milder depression), and atypical depression.
Atypical depression refers to a subtype of depression characterized by mood reactivity, which is the ability to temporarily respond to positive experiences. Other SAD symptoms include fatigue and a tendency to overeat (particularly carbohydrates) and oversleep in winter.
The basic biologic causes of depression are strongly linked to abnormalities in the delivery of certain key neurotransmitters (chemical messengers in the brain).
Corticotropin-releasing factor (CRF), a stress hormone and neurotransmitter, may be involved in depression and anxiety disorders.
For example, researchers have identified a defect in the gene known as SERT, which regulates serotonin and has been linked to depression. Risk FactorsAccording to major surveys, major depressive disorder affects nearly 15 million Americans (nearly 7% of the adult population) in a given year. While both boys and girls have similar rates of depression before puberty, girls have twice the risk for depression once they reach puberty. PMDD is a specific psychiatric syndrome that includes severe depression, irritability, and tension before menstruation. Hormonal fluctuations that occur during and after pregnancy, especially when combined with relationship stresses and anxiety, can contribute to depression.
Risk factors for depression in young people include having parents with depression, particularly if it is the mother who is depressed. Fibromyalgia, arthritis, and other chronic pain syndromes are also associated with depression. Also, neurological conditions that impair movement or thinking are associated with depression. Patients with heart failure or patients who have suffered a heart attack may also be at increased risk for depression. Sleep abnormalities are a hallmark of depressive disorders, with many depressed patients experiencing insomnia. People who are prone to depression face a 25% chance of becoming depressed when they quit smoking, and this increased risk persists for at least 6 months. Possible ComplicationsDepression is often chronic, with episodes of recurrence and improvement. Decreased physical activity and social involvement certainly play a role in the association between depression and illness severity. Patients with heart disease who are depressed tend to have more severe cardiac symptoms than those who are not depressed, and a poorer quality of life.
Conversely, obese people are about 25% more likely than non-obese people to develop depression or other mood disorders. Depression in the elderly is associated with a decline in mental functioning, regardless of the presence of dementia. Studies on the connections between alcohol dependence and depression have still not resolved whether one causes the other or if they both share some common biologic factor.
Nicotine may stimulate receptors in the brain that improve mood in some people with depression. Guidelines now recommend that family doctors screen for depression adults and adolescents (ages 12 - 18), as long as these doctors have appropriate systems in place to ensure accurate diagnosis, treatment, and follow-up of their patients.
However, most mental health professionals generally diagnose depression based on symptoms and other criteria.
Reasons may include treatment by providers who may not have sufficient information or training on dosages or specific drugs that would be best suited for individual cases, lack of recognition of depression symptoms by providers, poor access to health care services, lack of health insurance, and poor compliance with medications.
Although some people may feel better after taking antidepressants for a few weeks, most people need to take medication for at least 4 - 9 months to ensure a full response and to prevent depression from recurring. For patients with severe depression who are not helped by SSRIs or SNRIs, other types of antidepressants are available. If patients also suffer from anxiety, treating the depression first often relieves both problems. However, absence from substance abuse is considered essential for adequate treatment of depression. Although a mother's depression during and after pregnancy can have serious effects on her child, researchers are still trying to determine the best methods for preventing and treating pregnancy-related depression. Any woman who has suicidal or psychotic symptoms during depression should immediately seek treatment from a psychiatrist. Women who have mild or no depressive symptoms for at least 6 months before becoming pregnant may be able to taper off or discontinue antidepressant medication, under supervision of their doctor. Still, up to a half of these young people have a recurrence of depression within 2 years of their first episode of depression.
MAOIs are the most effective antidepressants for atypical depression, but have some severe side effects and require restrictive dietary rules and care to avoid drug interactions.
Patients who have had at least 2 episodes of depression may need to continue drug treatment for longer than 9 months. About a third of patients will relapse after a first episode within a year of ending treatment, and more than half will experience a recurring bout of depression at some point during their lives. These symptoms may be particularly problematic in patients who also suffer from anxiety, sleeplessness, or both. The symptoms are more likely to occur with antidepressants with shorter half-lives as compared with fluoxetine, which has a long half-life.
In addition to depression, bupropion is also approved for treating seasonal affectiveness disorder (SAD) and, under the tradename Zyban, for smoking cessation. They may offer benefits for many people with dysthymia, who generally do not respond to SSRIs.
Very dangerous side effects, such as serotonin syndrome, can occur from interactions with other antidepressants, including SSRIs.
Ketamine, an anesthetic drug, may be helpful for patients with severe treatment-resistant depression. PsychotherapyAmong the various psychotherapeutic "talk therapies," cognitive-behavioral therapy appears to be the most effective approach. VNS is approved by the FDA for long-term treatment of chronic depression in adults who have not responded to typical treatments for their major depressive episode.
A variation of this procedure using MRI scans to guide the surgeon has been shown to produce long-term improvement in patients with severe intractable depression. Although its efficacy has not been clearly shown, it may help some patients with mild-to-moderate depression. John's wort is believed to be helpful in relieving mild-to-moderate depression, but should only be taken under a doctor's supervision. Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults.
Atypical antipsychotic augmentation in major depressive disorder: a meta-analysis of placebo-controlled randomized trials.
Screening for depression in adult patients in primary care settings: a systematic evidence review. Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians.
Dietary restrictions and drug interactions with monoamine oxidase inhibitors: the state of the art. Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement.
Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force.
The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists.
However, when sadness persists and impairs daily life, it may be an indication of a depressive disorder. Other depressive disorders include premenstrual dysphoric disorder (PDD or PMDD) and seasonal affective disorder (SAD). The symptoms of dysthymia have been described as a "veil of sadness" that covers most activities. It is accompanied by two or more associated symptoms such as sensitivity to rejection, hypersomnia (oversleeping), overeating (usually related to carbohydrate craving), and leaden paralysis (feelings of heaviness in the arms and legs). Living in a northern country with long winter nights does not guarantee a higher risk for depression. Studies have found that close relatives of patients with depression are two to six times more likely to develop the problem than individuals without a family history. Imbalances in the brain’s serotonin levels can trigger depression and other mood disorders.
While depression is an illness that can afflict anyone at any time in their life, the average age of onset is 32 (although adults age 49 - 54 years are the age group with the highest rates of depression.).


In addition to hormonal factors, sociocultural factors may also affect the development of depression in girls in this age group. Post-partum depression is a severe depression (sometimes accompanied by psychosis) that occurs within the first year after giving birth. Early negative experiences and exposure to stress, neglect, or abuse also pose a risk for depression.
Depression also occurs in some elderly people who require home healthcare or hospitalization. Likewise, insomnia or other changes in waking and sleeping patterns can have significant effects on a person's mood, and perhaps worsen or draw out an underlying depression. About a third of patients with a single episode of major depression will have another episode within 1 year after discontinuing treatment, and more than half will have a recurrence at some point in their lives. Suicide is most commonly associated with depression in young people but it is also linked with anxiety, psychosis, substance abuse, or impulsivity. Feeling connected with parents and family can help protect young people with depression from suicide. TreatmentDepression is a treatable illness, with many therapeutic options available including psychotherapy, antidepressants, or both.
Research indicates that patients respond better to medications when drug therapy is combined with CBT. Sometimes an atypical antipsychotic drug may be given in combination with an antidepressant for patients with severe major depressive disorder.
More severe psychiatric problems, such as bipolar disorder or schizophrenia, require specialized treatments. But, women with depression who stop taking antidepressants during pregnancy may be likely to have a relapse of depression, which can have negative consequences for prenatal care and subsequent mother-child bonding.
Stopping medication may be more difficult for women with a history of severe recurrent depression.
Medication may need to be continued for 1 year after the symptoms have resolved, and the doctor should continue to monitor the child on a monthly basis for 6 months after full remission of depression. Many are proving to be effective in patients who do not respond to standard antidepressants or in specific patients, such as smokers who want to quit or patients with chronic pain. While depression is itself the major risk factor for suicide, and antidepressant medication may revitalize suicidal attempts in patients who were too despondent before treatment to make the effort, evidence suggests that in some cases the medication itself can cause suicidal thoughts and behavior (suicidality). They should be aware that some of the weight-loss medications, notably sibutramine (Meridia), can have serious interactions with SSRIs. Patients with narrow-angle glaucoma or patients with liver or kidney diseases should not take duloxetine. In particular, desipramine (Norpramin) has been associated with dangerous heart rhythm abnormalities in patients who have a family history of these problems. A skin patch form of selegiline (Emsam) is also available for treatment of major depressive disorder in adults.
Two atypical antipsychotics, aripiprazole (Abilify) and quetiapine (Seroquel), are currently approved in combination with antidepressant therapy for treatment of adults with major depressive disorder. In a small preliminary study, a single intravenous dose of ketamine helped patients quickly recover from depression within 2 hours, and some patients sustained benefits for up to a week. If psychotherapy is used alone without medications, benefits should be evident within 8 weeks and symptoms should be fully resolved by 12 weeks. Many studies suggest that combining cognitive therapy with antidepressants offer the greatest benefits.
These perceptions, known as schemas, are negative assumptions developed in childhood that can precipitate and prolong depression.
The therapist seeks to redirect the patient's attention, which has been distorted by depression, toward the daily details of social and family interaction.
Since its introduction in the 1930s, ECT has been significantly refined, and is now considered an effective and safe treatment for severe depression in the appropriate situation. Patients who use VNS may continue to show improvement in both their depression symptoms and quality of life.
Long-term studies on patients with epilepsy have reported no serious adverse side effects, although the treatment may cause lung function deterioration in some people with existing lung disease.
If no improvement is experienced after that, depressive symptoms will be unlikely to respond to phototherapy. This herb may also interact with other types of medications and increase or decrease their potency. Researchers are studying whether eating fish or taking fish oil supplements can reduce depression. Severity, duration, and the presence of other symptoms are the factors that distinguish normal sadness from clinical depression. Possibly because of the duration of the symptoms, patients who suffer from chronic minor depression do not exhibit marked changes in mood or in daily functioning, although they have low energy, a general negativity, and a sense of dissatisfaction and hopelessness. Other major risk factors for depression include being female, being African-American, and living in poverty. The rapid decline of reproductive hormones that accompany childbirth may play the major role in postpartum depression in susceptible women, particularly first-time mothers. In addition, older people often have to contend with significant stressful life changes such as the loss of a spouse. Smokers with a history of depression are not encouraged to continue smoking, but rather to keep a close watch on recurrence of depressive symptoms if they do stop smoking. Depression is more likely to recur if the first episode was severe or prolonged, or if there have been prior recurrences. In general, the treatment choice depends on the degree and type of depression and other accompanying conditions. In general, the more treatment strategies that patients need, the less likely they are to recover completely from depression. The risks for negative outcomes are highest when depression occurs during the late second or early third trimester.
Psychotherapy (preferably cognitive behavioral therapy or interpersonal therapy) may be helpful in addition to, or in replacement of, antidepressant medication. For psychotherapy, cognitive therapy may be the best approach for children and adolescents with depression. For optimal results, SSRIs should be combined with either cognitive-behavioral or interpersonal psychotherapies. In general, the fewer drug treatment strategies required, the better a patient's chances of recovering completely from depression.
Paroxetine (Paxil) appears to have the strongest association with increased suicidal risk, particularly in younger adults.
There do not appear to be significant differences among SSRI brands in effectiveness for treating major depressive disorder, although individual drugs may have different side effects or benefits for specific patients. Some of the newer SSRIs or other antidepressants may cause less severe impairment of sexual function. People who take SSRIs may drink alcohol in moderation, although the combination may compound any drowsiness experienced with SSRIs, and some SSRIs increase the effects of alcohol. The drug can increase blood pressure and heart rate and should be used with caution in patients with high blood pressure or heart disease. CBT works on the principle that these schemas can be recognized and altered, thereby changing the response and eliminating the depression. The goals of this treatment method are improved communication skills and increased self-esteem within a short period (3 - 4 months of weekly appointments) of time. It is especially effective for patients with severe depression who experience delusions and hallucinations. In many seizures disorders, electrical stimulation of the vagus nerves may help relieve symptoms. Studies suggest that women who are more sensitive to hormone fluctuations are at greater risk for postpartum depression if they have a personal or family history of depression. To date, even newer antidepressants have failed to achieve permanent remission in many patients with major depression, although the standard medications are very effective in treating and preventing acute episodes.
Depression during pregnancy may also increase the risk of developing postpartum depression. Electroconvulsive therapy (ECT) may be an option for pregnant women with severe depression. Other types of psychotherapy, such as family therapy and supportive therapy, may also be effective. Patients who become symptom-free have the best chance for complete recovery compared to patients whose symptoms merely improve.
Pregnant women who are being treated for major depression should not stop taking antidepressants without first talking to their doctors.
Cognitive behavioral therapy has been shown to help prevent future suicide attempts in patients with a history of suicidal behavior. Among the forms of depression best served by IPT are those caused by distorted or delayed mourning, unexpressed conflicts with people in close relationships, major life changes, and isolation. Recent research has also indicated that the Mediterranean Diet, which is high in omega-3 rich foods as well as vegetables and fruit and low in saturated fats from meat, may help reduce the risk of developing depression. Men account for the majority of these suicides, with divorced or widowed men at highest risk. MAOIs can have serious interactions with other drugs as well, including some common over-the-counter cough medications.
It is important that patients discuss with their doctors any other medications they are taking.



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