Major depressive disorder

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Major depressive disorder
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Major depressive disorder, also known as major depression, unipolar depression, clinical depression, or simply depression, is a mental disorder characterized by a pervasive low mood, loss of interest in a person's usual activities and diminished ability to experience pleasure. The diagnosis is made if a person has suffered one or more major depressive episodes. The onset is usually in early- to mid-adulthood. Diagnosis is based on the patient's self-reported experiences and observed behavior. There is no laboratory test for major depression, although physicians often test for physical conditions that may cause similar symptoms before arriving at a diagnosis. The course varies widely: it can be a once-in-a-lifetime event or have multiple recurrences; it can appear either gradually or suddenly; and can either last for a few months or be a life-long disorder.

The term "depression" is commonly used in the vernacular to describe a temporary depressed mood, when a person may feel sad or "down." Ideas about what causes and constitutes depression have evolved over the centuries. Today, many mental health professionals regard "major depression" as a serious and often disabling condition that can significantly affect a person's work, family and school life, sleeping and eating habits, general health and ability to enjoy life.[1] Depression is a major risk factor for suicide; in addition, people with depression suffer from higher mortality from other causes.[2] Clinical depression may be isolated or be a secondary result of a primary condition such as bipolar disorder or chronic pain. When specific treatment is indicated, it usually consists of psychotherapy and antidepressants.

Signs and symptoms

A major depressive episode can manifest with a variety of symptoms, but almost all patients display a marked change in mood, a deep feeling of sadness, and a noticeable loss of interest or pleasure in favorite activities. The psychological or mood change symptoms may include persistent sad, anxious or "empty" moods, and feelings of worthlessness, inappropriate guilt, helplessness, hopelessness, and/or pessimism, a sense of restlessness or irritability, and difficulty thinking, concentrating, remembering, or making decisions. Physical symptoms associated with depression include increased or decreased appetite and/or weight; insomnia, early morning awakening, or oversleeping; decreased energy, fatigue, feeling "slowed down" or sluggish; psychomotor agitation or psychomotor retardation; and persistent physical symptoms that do not respond to treatment, such as headaches, digestive problems, and chronic pain.

Other symptoms include:

  • A loss of interest or pleasure in hobbies and activities that were once enjoyed
  • Withdrawal from social situations, family gatherings and activities with friends
  • Thoughts of death or suicide or attempts at suicide

Not all patients will suffer from every symptom. The severity of symptoms will vary widely among individuals. According to one diagnostic standard, symptoms, with the exception of suicidal thoughts or attempts, must persist for at least two weeks before being considered a potential sign of depression.[3][1]

Diagnosis of an episode in children is more difficult than in adults. Depression in children is often undiagnosed, and thus untreated, because the symptoms in children are often written off as normal childhood moodiness. Diagnosis is also made difficult because children are more likely than adults to show different symptoms depending on the situation.[4]

While some children still function reasonably well, most who are suffering from depression will exhibit a noticeable change in their social activities and life, a loss of interest in school and poor academic performance, and possibly drastic changes in appearance. They may also begin abusing drugs and/or alcohol, particularly past the age of 12. Although much more rarely than adults, children with major depression may attempt suicide or have suicidal thoughts even before the age of 12.[4]

Comorbidity

Depression and anxiety frequently co-occur; the National Comorbidity Survey (US) reports that 58 percent of those with major depression also suffer from lifetime anxiety. Even mild anxiety symptoms can have a major impact on the course of a depressive illness, and the commingling of any anxiety symptoms with the primary depression is important to consider. A pilot study by Ellen Frank et al., at the University of Pittsburgh, found that depressed or bipolar patients with lifetime panic symptoms experienced significant delays in their remission.[5] These patients also had higher levels of residual impairment. On a similar note, Robert Sapolsky of Stanford University argues that the relationship between stress, anxiety, and depression could be measured and demonstrated biologically.[6]

About one-third of individuals diagnosed with attention-deficit hyperactivity disorder (ADHD) may develop comorbid depression.[7] Dysthymia, a form of chronic, low-level depression, is particularly common in adults with undiagnosed ADHD who have encountered years of frustrating ADHD-related problems with education, employment, and interpersonal relationships.[8]

Diagnosis

Before a diagnosis of major depressive disorder is made, a physician may perform a medical examination to rule out a physical cause for the suspected depression. Although there are no biological tests which confirm major depression, tests are carried out to exclude medical illnesses. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection. Two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions. Early dementia may present with depressive symptoms in older patients.

If no such cause is found, a psychological evaluation should be done by the physician or by referral to a psychiatrist or psychologist.[1] The evaluation will include a complete history of symptoms, a discussion of alcohol and drug use, and a determination of whether the patient has had or is having suicidal thoughts or thinking about death. The evaluation will also include a family medical history to see if other family members suffer from any form of depression or similar mood disorder.[1]

Investigations are not generally repeated for a recurrent episode unless there is a specific medical indication. These may include measuring serum sodium if the person presents with polyuria and is on a selective serotonin reuptake inhibitor (SSRI). Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.

Rating scales

There are several criteria lists and diagnostic tools that can also aid in the diagnosis of depression. Most are based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a book published by the American Psychiatric Association that defines the criteria used to diagnose various mental disorders, including depression. Many are used in research or as screening tools. No screening tool should be used to confirm diagnosis in the absence of review by a medical practitioner or psychologist.

The Beck Depression Inventory, originally designed by psychiatrist Aaron T. Beck in 1961, is a 21-question patient-completed survey that covers items related to the basic symptoms of depression, such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex.[9] The Beck Inventory is one of the most widely used diagnostic tools for self-diagnosis of depression, although its main purpose is not the diagnosis of depression, but determining the severity and presence of symptoms.[10]

There are also two Patient Health Questionnaires available that are also self-administered questionnaires. The PHQ-2 has only two questions that asks about the frequency of depressed mood and a loss of interest in doing things, with a positive to either question indicating the need for further testing.[11] The PHQ-9 is a slightly more detailed nine question survey covering some of the major symptoms of depression and the frequency a person has experienced them. It is based directly on the diagnostic criteria listed in the DSM-IV and often used as a follow up to a positive PHQ-2 test.[12]

Other scales commonly used include the Geriatric Depression Scale, in older populations, the widely-used Hamilton Depression Rating Scale designed by psychiatrist Max Hamilton in 1960,[13] and the Montgomery-Åsberg Depression Rating Scale (MADRS).

DSM IV-TR Criteria

The most widely used criteria for diagnosing depressive conditions are found in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter system is typically used in European countries, while the DSM criteria are used in the USA and many other non-European nations, and are frequently referenced in research studies.

The DSM IV-TR diagnosis hinges on the presence of a major depressive episode, which may be either single or recurrent. Further qualifiers are used to classify both the episode itself and the course of the disorder. The ICD-10 system does not use the term major depressive disorder, but the diagnosis of depressive episode is very similar. Minor depression is a less-used term for a subclinical depression that does not meet criteria for major depression but in which at least two symptoms are present for two weeks. It is not mentioned in DSM IV-TR.

Major depressive episode

Main article: major depressive episode

A major depressive episode has been defined as a severely depressed mood that persists for at least two weeks. Episodes may be isolated or recurrent and categorized as mild, major or severe. If the patient has already had an episode of mania or markedly elevated mood, a diagnosis of bipolar disorder is made instead. Depression without periods of elation or mania is sometimes referred to as unipolar depression because the mood remains at one emotional state or "pole". The diagnosis usually excludes cases in which the symptoms are a normal result of bereavement (though it is possible for normal bereavement to turn into a depressive episode).

Diagnosticians recognize several possible subtypes:

  • - with melancholic features – melancholia is characterized by a loss of pleasure (anhedonia) in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early morning waking, psychomotor retardation, excessive weight loss (not to be confused with Anorexia Nervosa), or excessive guilt.
  • - with atypical features – atypical depression is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite ("comfort eating"),[14] excessive sleep or somnolence (hypersomnia), leaden paralysis, or significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection. Contrary to its name, atypical depression is the most common form of depression.[15]
  • - with Psychotic Features – Some people with a major depressive episode, particularly of melancholic nature, may experience psychotic features. They may be presented with hallucinations or delusions that are either mood-congruent (content coincident with depressive themes) or non-mood-congruent (content not coincident with depressive themes). It is clinically more common to encounter a delusional system as an adjunct to depression than to encounter hallucinations, whether visual or auditory.
  • Postpartum depression refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth. Postpartum depression, which has incidence rate of 10-15%, typically sets in within three months of labor, and can last for as long as three months.[16]

Differential diagnoses

  • Dysthymia is a chronic, mild depression in which a person suffers from a depressive mood almost daily over a span of at least two years without episodes of major depression. The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to co-occurring episodes of major depression (sometimes referred to as "double depression").[17]
  • Bipolar disorder is an episodic condition characterized by alternating states of mania, hypomania and depression. In the United States, bipolar disorder has also been called "manic depression", but this term is no longer favored by the medical community.
  • Adjustment disorder with depressed mood, which overlaps with what was previously known as Reactive depression.
  • Recurrent brief depression (RBD) is distinguished from clinical depression primarily by differences in duration. Patients with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 2–3 days. Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of the menstrual cycle. People with clinical depression can develop RBD, and vice versa, with both illnesses having similar risks.[18]

Epidemiology

Major depressive disorder affects about 8–17 percent of the population on at least one occasion in their lives, before the age of 40. In some countries, such as Australia, one in four women and one in six men will suffer from depression. In Canada, major depression affects approximately 1.35 million people[citation needed], and in the United States approximately 14 million adults per year.[19] An estimated 121 million people worldwide currently suffer from depression.[20]

People who have had one episode of depression may be more than normally likely to have more episodes in the future, so the first time a young person becomes depressed is important as both a personal and public health concern.[21]

About twice as many females as males report or receive treatment for clinical depression, though this imbalance has recently shrunk, and the difference seems to disappear completely for those over the age of 50–55. Clinical depression is currently the leading cause of disability in North America, and is expected to become the second leading cause of disability worldwide (after heart disease) by the year 2020, according to the World Health Organization.[22]

The diagnostic criteria for depression may be too broad, resulting in diagnosis of major depression in people who are not truly suffering from the disorder, but who have shown normal responses to negative events.[23]

Causes

Current theories regarding the risk factors and causes of clinical depression can be broadly classified into three categories: psychological, physiological, and environmental:

Psychological

Low self-esteem and self-defeating or distorted thinking are connected with depression. The question of whether this is the result of depression or a cause of it is a matter of debate. In either case, it is known that depressed persons who are able to make corrections in their thinking patterns can show improved mood and self-esteem.[24] Psychological factors related to depression include the complex development of one's personality and how one has learned to cope with external environmental factors, such as stress.[25]

Existential psychologists argue that "depression is the inability to construct a future."[26] In order to construct a future, people must become acutely aware of both their mortality and their freedom, and they must exercise the latter within the explicit framework of the former. This awareness and responsibility produce "normal anxiety,"[27] whereas the lack of these things leads to "neurotic anxiety,"[27] "self-alienation,"[28] "inauthentic" living,[29] and depression. Humanistic psychologists agree with many facets of existentialism, but argue that depression results from a specific incongruity between society on the one hand, and the individual's innate drive to self-actualize on the other.[30]

Physiological

Genetic predisposition

The tendency to develop depression may be inherited: according to the National Institute of Mental Health[31] there is some evidence that depression may run in families. Most experts believe that both biological and psychological factors play a role.

Brain chemicals called neurotransmitters allow electrical signals to move from the axon of one nerve cell to the soma of another. A shortage of neurotransmitters impairs brain communication.

Neurological

Many modern antidepressant drugs change synaptic levels of certain neurotransmitters, especially serotonin and norepinephrine. However, the precise relationships among serotonin, SSRIs, and depression are largely unknown and, typically, are greatly oversimplified when presented to the public.[32]

There may be a link between depression and neurogenesis of the hippocampus,[33] a center for both mood and memory. Loss of neurons in the hippocampus is found in some depressed individuals and correlates with impaired memory and dysthymic mood. Drugs may increase serotonin levels in the brain, stimulating neurogenesis and thereby increasing the total mass of the hippocampus. This increase in mass may help to restore mood and memory.[citation needed]

Depression may also be caused in part by an overactive hypothalamic-pituitary-adrenal axis (HPA axis) that resembles the neuro-endocrine response to stress. These HPA axis abnormalities participate in the development of depressive symptoms, and antidepressants serve to regulate HPA axis function.[34]

Many individuals with clinical depression exhibit markedly higher levels of monoamine oxidase A (MAO-A) in the brain compared to people without depression.[35] MAO-A is an enzyme which reacts with and decreases the concentration of monoamines such as serotonin, norepinephrine and dopamine.

Medical conditions

Certain illnesses, including cardiovascular disease,[36] hepatitis, mononucleosis, hypothyroidism, fructose malabsorption,[37] sleep apnea, and organic brain damage caused by degenerative conditions such as Parkinson's disease, multiple sclerosis or by traumatic blunt force injury may contribute to depression, as may certain prescription drugs such as hormonal contraception methods and steroids. Depression also occurs in patients with chronic pain, such as chronic back pain, much more frequently than in the general population. Fibromyalgia sufferers also experience depression and anxiety.

Environmental

Early experiences

Events such as the death of a parent, issues with biological development, school related problems, abandonment or rejection, neglect, chronic illness, and physical, psychological, or sexual abuse can increase the likelihood of depression later in life. Post-traumatic stress disorder (PTSD) and depression often co-occur, and both can result from childhood trauma.[38]

Life experiences

Stressful or traumatic life experiences or circumstances may trigger a depressive episode. These experiences include rape, assault, and grief over the death of a relative or friend. A depressive episode may also be triggered by other major changes such as unemployment, divorce, or a loss of religious faith.[39] Ongoing issues, such as financial difficulties or poverty, ongoing major health problems (e.g., eating disorders), addictions (e.g., gambling addiction or drug addiction), sexual difficulties, or work-related stress can also contribute to depression.

Treatment

The three most often used conventional treatments are medication, psychotherapy, and electroconvulsive therapy.

Medication

Main article: Antidepressant

A patient's doctor may change the antidepressant taken, adjust the dosages of medications, or try different combinations of antidepressants before finding the most effective option; response rates to the first agent administered may be as low as 50 percent.[40] It may take anywhere from three to eight weeks after the start of medication before its therapeutic effects can be fully discovered. Patients are generally advised not to stop taking an antidepressant suddenly and to continue its use for at least four months to prevent the chance of recurrence. For patients who have chronic depression, medication may be continued for the remainder of their life.[1]

A wide range of antidepressant drugs can be prescribed to treat depression. These drugs have historically been divided into four major groups: selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and other antidepressants.

Selective serotonin reuptake inhibitors, such as sertraline (Zoloft), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil) and citalopram (Celexa) are the primary medications considered for patients, due to their relatively mild side effects and their potentially broad effect on the symptoms of depression and anxiety. Those who do not respond to the first SSRI tried, can be switched to another SSRI antidepressant. Such a switch results in improvement in almost 50% of cases.[41] Another popular option is to switch the patient to the atypical antidepressant bupropion (Wellbutrin, Zyban) or to add bupropion to the existing therapy[42] with the latter strategy possibly more effective.[43][44] Venlafaxine (Effexor) may be moderately more effective than SSRIs;[45] however, it is not recommended as a first line treatment because of the high rate of the side effects.[46] Tricyclic antidepressants are less well tolerated than SSRIs and are usually reserved for the treatment of inpatients, where tricyclic antidepressant amitriptyline, in particular, appears to be more effective.[47][48] The causing or worsening of insomnia is not uncommon with SSRIs; a sedating antidepressant mirtazapine (Zispin, Remeron) can be used in such cases.[49][50][51] Monoamine oxidase inhibitors have historically been plagued by the issues of efficacy and life-threatening adverse effects. They are still used only rarely, and newer agents of this class, with a better side effect profile, have been developed.[52]

A meta-analysis combined 35 clinical trials submitted to the FDA before licensing of four newer antidepressants. The authors found that although the antidepressants were statistically superior to placebo they often did not exceed the NICE criteria for a 'clinically significant' effect. In particular they found that the effect size was very small for moderate depression but increased with severity reaching 'clinical significance' for very severe depression.[53] This result is consistent with the earlier clinical studies in which only patients with severe depression benefited from the treatment with a tricyclic antidepressant imipramine or from psychotherapy more than from the placebo treatment.[54][55][56]

Psychotherapy

See also: Psychotherapy

There are a number of different psychotherapies for depression, which may be provided to individuals or groups. Psychotherapy can be delivered by a variety of mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, and psychiatric nurses. The most studied form of psychotherapy for depression is Cognitive behavioral therapy. Several clinical trials have shown that CBT is as effective as antidepressant medications, even among more severely depressed clients. CBT is thought to work by teaching clients to learn a set of cognitive and behavioral skills, which they can employ on their own. This type of therapy attempts to teach people to learn healthier behaviors. Earlier research suggested that psychotherapy, specifically cognitive-behavioral therapy, was not as effective as medication in the treatment of depression; however, recent research suggests that CBT can perform as well as anti-depressant medication in the treatment of moderate to severe depression treated on an outpatient basis.[57] With more complex and chronic forms of depression the most effective treatment is often considered to be a combination of medication and psychotherapy.[58]

Two randomized, controlled trials of mindfulness-based cognitive therapy (MBCT), which includes elements of meditation, have been reviewed. MBCT was significantly more effective than "usual care" for the prevention of recurrent depression in patients who had had three or more depressive episodes. According to the review, the "usual care" did not include antidepressant treatment or any psychotherapy, and the improvement observed may have reflected the non-specific or placebo effects.[59]

Interpersonal psychotherapy focuses on the social and interpersonal triggers that may cause depression. There is evidence that it is an effective treatment for depression. Here, the therapy takes a structured course with a set number of weekly sessions (often 12) as in the case of CBT, however the focus is on relationships with others. Therapy can be used to help a person develop or improve interpersonal skills in order to allow him or her to communicate more effectively and reduce stress.[60]

Psychoanalysis, a school of thought founded by Sigmund Freud that emphasizes the resolution of unconscious mental conflicts,[61] is used by its practitioners to treat clients presenting with major depression.[62] A more widely practiced, eclectic technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has an additional social and interpersonal focus.[63] In a meta-analysis of three controlled trials, psychodynamic psychotherapy was found to be as effective as medication for mild to moderate depression.[64]

Electroconvulsive therapy

Electroconvulsive therapy (ECT), also known as electroshock, is a treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is a last resort, and is most often used as a treatment for severe major depression which has not responded to other treatment. An estimated 1 million people worldwide receive ECT every year[65] usually in a course of 6-12 treatments administered 2 or 3 times a week. In a study, ECT was shown clinically to be the most effective treatment for severe depression, and to result in improved quality of life in both short- and long-term.[66] After treatment, drug therapy can be continued, and some patients receive continuation/maintenance ECT. Short-term memory loss, disorientation, and headache are very common side effects. Detailed neuropsychological testing in clinical studies has not been able to prove permanent effects on memory.

ECT produces a very fast response in the client; however, this response has been shown not always to last unless maintenance electroshock or maintenance medication is used. Whereas antidepressants usually take around a month to take effect, the results of ECT have been shown to be much faster. For this reason, it is the treatment of choice in emergencies (e.g., in catatonic depression in which the patient has ceased oral intake of fluid or nutrients). The American Psychiatric Association and the National Institute for Health and Clinical Excellence have concluded that the procedure does not cause brain damage.[67][68] Like all forms of psychiatric treatment, ECT can be given without a patient's consent,[citation needed] but this is subject to legal conditions dependent on the jurisdiction. In Oregon, patient consent is necessary by statute.[69]

Other conventional methods of treatment

  • St John's wort extract is used extensively in Europe to treat mild and moderate depression. It is a prescription antidepressant in several European countries but is classified as herbal supplement and sold over the counter in the U.S. The opinions on its efficacy for major depression differ. The systematic meta-analysis of 37 trials conducted by Cochrane Collaboration indicated statistically significant weak-to-moderate effect as compared to placebo. The same meta-analysis found that St John's wort efficacy for major depression is not different from prescription antidepressants.[70] NCCAM and other NIH-affiliated organizations hold that St John's wort has minimal or no effects beyond placebo in the treatment of major depression, based primarily on one study with negative outcome conducted by NCCAM.[71][72]
  • S-Adenosyl methionine (SAM-e) is available as a prescription antidepressant in Europe and an over-the-counter dietary supplement in the United States. A fairly strong evidence, based on 16 clinical trials, suggests it to be more effective than placebo and as effective as standard antidepressant medication for the treatment of major depression.[73][74]
  • Repetitive transcranial magnetic stimulation (rTMS) use in treatment-resistant depression is supported by multiple controlled studies, and it has been approved for this indication in Europe, Canada and Australia, but not in the U.S.[75] A 2008 meta-analysis based on 32 trials found a robust effect of this method on depression, and it appeared similarly effective for both uncomplicated depression and depression resistant to medication.[76] However, in a side-by-side randomized trial rTMS was inferior to electroconvulsive therapy.[77]
  • Vagus nerve stimulation (VNS) is an approved therapy for treatment-resistant depression and is used as an adjunctive to existing antidepressant treatment. The support for this method comes primarily from open-label trials, which indicate that a several month period may be necessary for the therapy to become effective.[75] The only large double-blind trial conducted lasted only 10 weeks and yielded inconclusive results. VNS failed to show superiority over a sham treatment on the primary efficacy outcome but the result were more favorable for the secondary outcome.[78]

Alternative treatment methods

  • A meta-analysis of bright light therapy commissioned by the American Psychiatric Association found it to be more effective than placebo—usually, dim light—for both seasonal affective disorder and for nonseasonal depression, with effect sizes similar to those for conventional antidepressants. For non-seasonal depression, adding light therapy to the standard antidepressant treatment was not effective.[79] A meta-analysis of light therapy for non-seasonal depression conducted by Cochrane Collaboration, studied a different set of trials, where light was used mostly as an addition to medication or sleep deprivation. A moderate statistically significant effect of light therapy was found; however, it disappeared if a different statistical technique was used.[80] Both analyses noted poor quality of most studies and their small size, and urged caution in the interpretation of their results. The short 1-2 weeks duration of most trials makes it unclear whether the effect of light therapy could be sustained in the longer term.
  • A 2004 Cochrane Review concluded that there was insufficient evidence to judge the efficacy of acupuncture in the management of depression. Although acupuncture showed no difference in the improvement of depression compared with conventional medication, the methodological quality of the evidence base was found to be poor.[81]
  • Exercise, when used in conjunction with medication with non-suicidal patients can have beneficial effects in preventing the return of depression. Patients that completed 30 minutes of brisk exercise at least three times a week were found to have a significantly lower incidence of relapse.[82]
  • Tryptophan and 5-hydroxytryptophan may be more effective than placebo in alleviating depression according to the Cochrane Collaboration meta-analysis. However, only two out of 108 trials were of sufficient quality to be included in this analysis.[83]
  • Omega-3 fatty acids have been studied in clinical trials for major depression primarily as an adjunctive to antidepressant therapy. A meta-analysis of eight such trials indicated a statistically significant superiority of combinations with omega-3 fatty acids over single antidepressants; however, the authors warned that, due to multiple problems with these trials, a reliable conclusion is difficult to achieve.[84]
  • Dehydroepiandrosterone (DHEA), available as a supplement in the U.S., has been shown to be more effective than placebo for major depression in two small double-blind trials: in one—as an adjunctive to antidepressant treatment[85], in another—as monotherapy.[86]
  • Zinc supplementation was found in a single small study to augment the effect of antidepressants.[88]
  • Cranial electrotherapy stimulation (CES, electrosleep) devices currently on the market have been granted marketing authorization by the FDA based on the legacy waver, that is because a sufficiently similar device had been marketed before 1976, when the new regulations requiring controlled testing were introduced.[89] The FDA considers them to be the class III devices—"devices for which insufficient information exists to ... provide reasonable assurance of safety and effectiveness"[90] The effects of CES on depression were inconclusive or negative in multiple double-blind studies of psychiatric patients.[91][92][93][94][92][95] In one of them, four out of six clinically depressed patients dropped out of the study because of the massive worsening of depressive symptoms, with two of them becoming actively suicidal.[95] One of the authors of the latter study cautioned that CES “should not be used as a treatment of choice” for the patients with the primary diagnosis of depression, “and should be used with caution if this diagnosis is suspected.”[96] Nevertheless, the CES practitioners continue to employ it as a treatment of choice for depression.[97][98]

Prognosis

Recurrence is more likely if treatment has not resulted in full remission of symptoms.4 Current guidelines for antidepressant use recommend 4 to 6 months of continuing treatment after symptom resolution to prevent relapse. Combined evidence from many randomized controlled trials indicates that continuing antidepressant medications after recovery can reduce the odds of relapse by 70% (41% on placebo vs. 18% on antidepressant). The preventive effect probably lasts for at least the first 36 months of use. Thus, in a significant minority of patients depression recurs despite the prolonged treatment with antidepressants.[99] The reason for recurrence in these cases is as poorly understood and could be a "true pharmacologic failure or a worsening of the disease, a relapse that overrides medication." Because of the difficulties of carrying out controlled clinical trials of longer duration, the approval of most antidepressants for the prevention of recurrence is based on up to a year-long trials.[100]

History

In prehistory, humans probably "saw mental illness as possession by supernatural forces." Supporting this theory, "human skulls have been found with large holes in them." This may have resulted from an attempt to "let evil spirits out."[101] The Greek scholar Empedocles (490-430 BC) proposed that humans experienced disease when their four humours were imbalanced. The four humours were Fire (Blood); Earth (Phlegm); water (Yellow bile); and Air (Black bile). Empedocles' theories were further developed by Hippocrates (460-377 BC), who argued that "mental disorder must be explained on the basis of natural causes" such as the "sudden flow of bile to the brain". Hippocrates believed that the appropriate treatment for a mental disorder depended on which humor had caused the problem.[102]

Plato (427-347 BC) argued that there were two types of mental illness: "divinely inspired" mental illness that gave the person prophetic powers, and a second type that was caused by a physical disease.[103] Aristotle (384-322 BC), who studied under Plato, abandoned the divinely-caused mental illness theory, and proposed instead that all mental illness was caused by physical problems. The Roman physician Asclepiades claimed that emotional disturbances were “passions of sensations”. Arateus (ca AD 30-90) suggested that it is hard to pinpoint where a mental illness comes from. His contemporary Galen (AD 30-90) rehashed the Greek theories, proposing that there are "animal spirits" which cause melancholy. The modern idea of depression appears similar to the much older concept of melancholia. The name melancholia derives from "black bile", one of the four humours postulated by Galen. In the Old Testament, the description of King Saul includes symptoms that resemble some elements in the modern diagnosis of depression; eventually the King commits suicide.

In the 16th century, the physician Johann Weyer (1515-1588) argued against the witchcraft theories. Juan Luis Vives (1492-1540) founded hospitals for the mentally ill. With the turn of the 17th century, science gained increasing prestige, and emotions and anatomy were studied more closely. The philosopher Spinoza (1632-1677) argued that the mind and body are closely connected. Literary figures such as William Shakespeare (1564-1616) and Miguel de Cervantes (1547-1616) described mental illness in an insightful way in their works. Phillipe Pinel in France argued that insanity was caused by factors in the environment or in a person's background. Franz Joseph Gall proposed the theory of phrenology, which claimed that locations of the brain are connected to body parts.[104]

In the 19th century, Johann Christian Heinroth revived the notion that mental illness was caused by moral sins of the patient. But by the mid-19th century, scholars began to believe that mental illness was caused by physical, organic conditions. The German psychiatrist Wilhelm Griesinger (1817-1868) argued that mental illnesses were caused by the brain. Emil Kraepelin (1855-1926) argued that metabolic factors caused mental illness. Freud argued that each patient's unique life history and experiences caused their mental problems. Freud's psychoanalysis was one of the main theories of mental illness until the 1970s.

In the mid 20th century, many considered clinical depression to be a chemical imbalance in transmitters in the brain, a theory based on observations made in the 1950s of the effects of reserpine and isoniazid in altering monoamine neurotransmitter levels and affecting depressive symptoms.[105] Subsequently, many other causes for clinical depression have been proposed.[106]

Psychiatrist David Healy wrote about the growth of the diagnosis, along with perspectives on the development and promotion of antidepressants and the biological model since the late 1950s.[107] After the 1970s, scholars proposed a range of "genetic, biochemical and neuropathological causes of mental disorder."[108]

Sociological and cultural aspects

Evolutionary approaches

Main article: Evolutionary approaches to depression

Some medical professionals and anthropologists have formed several theories as to how depression may have evolutionary advantages, i.e., how it might have increased genetic fitness in ancestral populations. For example, psychic pain may have evolved in an analogous way to physical pain so that organisms avoid behaviour which hinders reproduction. This insight may be helpful in counselling therapy.[109][110] Proponents of the psychic pain theory tend to view clinical depression as a dysfunctional extreme of low mood or mild depression.

Cultural references

See also: List of people with depression

Samuel Johnson first coined the term "the black dog" when describing his own battles with depression [111]. The phrase was subsequently popularised by another famous sufferer, the former British Prime Minister Sir Winston Churchill. Journeys with the Black Dog is an anthology of essays of sufferers writing on their experiences. The critically acclaimed 1980 film Ordinary People depicts a young man's torrid course of a severe depressive episode,[112] while the 1956 Alfred Hitchcock film The Wrong Man has the protagonist's wife Rose suffering.[113]

References

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