Braila

Cristiana
Grupa: 4
 Background
Major depression, also known as unipolar depression, is one of the more commonly
encountered psychiatric disorders. While many effective treatments are available,
this disorder is often underdiagnosed and undertreated. Primary care providers
should strongly consider the presence of depression in their patients; studies
suggest a high prevalence of affective disorders among patients seeking medical
attention in the office setting. Following is a case study.
A 30-year-old presented to her primary care doctor with symptoms of frequent
headaches, insomnia, feeling overwhelmed, and have low energy. Examination was
unremarkable and blood workup supported mild iron deficiency anemia. She
returned after one month with improvement in anemia but worsening of symptoms
stated earlier. A Physician Depression Questionnaire (PDQ-9) revealed that for
several weeks she was feeling sad and had little interest or pleasure in doing thing
she used to enjoy. She also had suicidal thoughts occasionally and could not
concentrate on tasks. She felt like a failure. There were no recognizable losses. She
stated that in the past she had similar feelings, but they were less intense and lasted
for shorter periods. She did not have any period of euphoria or overproductivity.
Her primary care physician prescribed antidepressants and referred her to a
psychiatrist
 Pathophysiology
The underlying pathophysiology of major depressive disorder (MDD) has not been
clearly defined. Clinical and preclinical trials suggest a disturbance in CNS serotonin
(ie, 5-HT) activity as an important factor. Other neurotransmitters implicated include
norepinephrine (NE) and dopamine (DA).1
The role of CNS serotonin activity in the pathophysiology of major depressive disorder
is suggested by the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the
treatment of major depressive disorder. Furthermore, studies have shown that an
acute, transient relapse of depressive symptoms can be produced in research subjects
in remission using tryptophan depletion, which causes a temporary reduction in CNS
serotonin levels. Serotonergic neurons implicated in affective disorders are found in
the dorsal raphe nucleus, the limbic system, and the left prefrontal cortex.
Clinical experience indicates a complex interaction between neurotransmitter
availability, receptor regulation and sensitivity, and affective symptoms in major
depressive disorder. Drugs that produce only an acute rise in neurotransmitter
availability, such as cocaine, do not have the efficacy over time that antidepressants
do. Furthermore, an exposure of several weeks' duration to an antidepressant is
usually necessary to produce a change in symptoms. This, together with preclinical
research findings, implies a role for neuronal receptor regulation over time in
response to enhanced neurotransmitter availability
 Frequency
United States
Lifetime incidence of major depressive disorder is 20% in women and 12%
in men. Prevalence is as high as 10% in patients observed in a medical
setting.
International
Cultural influences on the presentation of depression can be significant. The
practitioner should be aware of differences in the expression of
psychological distress in patients from other countries or cultures. Some
cultural patterns are mentioned in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR); for
example, major depressive disorder may be expressed as fatigue,
imbalance, or neurasthenia in patients of Asian origin
 Mortality/Morbidity
Major depressive disorder is a
disorder with significant
potential morbidity and
mortality, contributing as it does
to suicide, medical illness,
disruption in interpersonal
relationships, substance abuse,
and lost work time.
Suicide ranks as a leading cause of
death in the United States, with a
yearly rate of approximately
200,000 attempts. The number of
completed suicides for 2005 was
32,000.
 Depending on the gender of the
person
Major depressive disorder is
diagnosed more
commonly in women,
with a prevalence twice
that observed in men. In
prepubertal children,
boys and girls are
affected equally.
 Depends on age
The incidence of clinically significant depressive symptoms increases with
advancing age, especially when associated with medical illness or
institutionalization. However, depression might not meet criteria for major
depression because of somewhat atypical features of depression in elderly
persons. Elderly persons experience more somatic complaints, cognitive
symptoms, and fewer complaints of sad or dysphoric mood. Of particular
importance is the increasing risk of death by suicide, particularly among
elderly men. Rates in women and men are highest in those aged 25-44
years. For more information about childhood depression, see
Mood Disorder: Depression.
 Appearance and affect
 Most patients with major depressive disorder present to their physician
with a normal appearance.
 In patients with more severe symptoms, a decline in grooming and
hygiene can be observed, as well as a change in weight. Patients may
show psychomotor retardation, which is manifest as a slowing or loss
of spontaneous movement and reactivity. Together with this, major
depressive disorder often produces a flattening or loss of reactivity in
the patient's affect (ie, emotional expression).
 Psychomotor agitation or restlessness also can be observed in some
patients with major depressive disorder.
 Mood and thought process
 Patients report a dysphoric mood state, which may be expressed as
sadness, heaviness, numbness, or sometimes irritability and mood
swings. They often report a loss of interest or pleasure in their usual
activities, difficulty concentrating, or loss of energy and motivation.
Their thinking often is negative, frequently with feelings of
worthlessness, hopelessness, or helplessness. While it is not
uncommon for patients with major depressive disorder to show
ruminative thinking, it is important to evaluate each patient for
evidence of psychotic symptoms because this affects initial
management.
 Psychosis, when it occurs in the context of unipolar depression, usually
is congruent in its content with the patient's mood state; for example,
the patient may experience delusions of worthlessness or some
progressive physical decline. Symptoms of psychosis should prompt a
careful history evaluation to rule out a history of bipolar disorder,
schizophrenia or schizoaffective disorder, substance abuse, or organic
brain syndrome.
 Biological contributors
 Genetic susceptibility plays a role in the development of major
depressive disorder. Individuals with a family history of affective
disorders (7%), panic disorder, and alcohol dependence (8%) carry a
higher risk for major depressive disorder.
 Certain neurologic illnesses increase the risk of major depressive
disorder. Examples include Parkinson disease, stroke, multiple
sclerosis, and seizure disorders.
 Exposure to certain pharmacologic agents also increases the risk;
medications such as reserpine or beta-blockers, as well as abused
substances such as cocaine, amphetamine, narcotics, and alcohol are
associated with higher rates of major depressive disorder.
 Chronic pain, medical illness, and psychosocial stress also can play a
role in both the initiation and maintenance of major depressive
disorder. The psychological component of these risk factors is
discussed below. However, neurochemical hypotheses point to the
deleterious effects of cortisol and other stress-related substances on the
neuronal substrate of mood in the CNS.
 Psychosocial contributors: While major depressive disorder can arise
without any precipitating stressors, stress and interpersonal losses certainly
increase risk. Psychodynamic formulations find that significant losses in
early life predispose to major depressive disorder over the lifespan of the
individual, as does trauma, either transient or chronic.