Major Depressive Disorder

Major depressive disorder is major depressive episodes without a history of manic, mixed, or hypomanic episodes. This disorder is 2 times more likely in adolescent and adult females than in males. In the preadolescent period, this disorder affects boys and girls equally. Major depressive disorder causes the person to feel unmotivated, sad, listless, and emotionally drained. Behavioral manifestations may vary from profound psychomotor retardation and withdrawal to agitation and irritability. These symptoms have a profound impact on activities of daily living. A person suffering from this disorder may find it difficult to work, sleep, eat, and function from day to day. Approximately 25% of the cases include a “presumed” precipitating factor. It appears that there is a precipitant in 50% of the elderly population. A thought disorder is sometime present (major Depression with psychotic features. Delusions are often mood congruent and hallucinations are rare and when present usually paranoid or self-deprecating in nature. In the elderly, depression is often called Pseudodemetia because it often “looks like” dementia (e.g., psychomotor retardation, confusion, memory impairment).

Classical psychoanalytic theory postulates that depressed patients have suffered a real or imagined loss of an ambivalently loved object. The person reacts with rage that is turned inward. Cognitive theory postulates a cognitive triad of distorted perceptions. This theory holds that a person’s negative interpretation of his own life causes self-deprecating thought that lead to depression. Biological theories focus on several neurotransmitters, particularly norpinenphrine (NE) and serotonin (5 HT). It is suggested that lower levels of one or more of these neurotransmitters causes depression. Some of the evidence for these theories comes from the action of antidepressants (They increase levels of neurotransmitters and thereby reduce depressive symptoms, hence it must be lower levels of these chemicals that “creates” the depression.) While some tests that measure neurotransmitter levels show lowered presence in depressed patients, the results are inconsistent.

Assessment should include both psychosocial and medical. You will need to conduct an assessment and address any safety issues with your patient. Establishing a good therapeutic rapport and relieving immediate symptoms is imperative. Supportive psychotherapy is imperative. Warm and empathic understanding can go a long way to improving functioning quickly.

During the clinical interview or assessment, you might use the BDI-II to measure the severity of the patient’s depression. The assessment should include suicide and homicide risks. If suicidality is present, you should discuss the plan or means of suicide and take necessary action. A referral to a physician is a good idea to rule out any possible general medical condition that may pre-exist (obtain a release).

A referral to a physician will be necessary also to obtain an antidepressant medication evaluation. Finally, explain the diagnosis and treatment suggestions to the patient. Make sure you are supportive and nonjudgmental to relieve some of the patient’s immediate symptoms. Find out what type of support the patient has and elicit community resources.

Individuals suffering from depression apparently have a greater number of stressful life events than healthy individuals. Psychosocial stressors appear to have more significant impact early in the course of the depression and during the first episode. Psychosocial stressors appear to have less impact on later episodes and later during the course of the initial onset. Further, loss early in ones life has been linked to depression. This includes loss of a parent other than death. However, the link is considered weak and less impactful than recent events.

There are a number of approached that have been found effective in the treatment of depression. Some theoretical approaches that seem to be helpful are cognitive-behavioral (CT) and interpersonal psychotherapy (IPT). When patients exhibit mild or moderate symptoms psychotherapy is the number one treatment. More severe depressions appear to be most effectively treated with medication and psychotherapy. The primary reason for using a cognitive behavioral approach is to help patients change their thinking and behavior. In the cognitive behavioral school, it is believed that distorted cognitions and beliefs cause depression. The therapist helps identify negative thoughts and assumptions and replace them with more positive beliefs.

The interpersonal therapy helps to refine social functioning. Social support is considered important in the development of depression. The goal of Interpersonal therapy is to improve disturbed relationships, thereby improving adaptation to stress. The focus is on current relationships. However, earlier relationships are not ignored. Several problem areas are generally addressed in IPT. These areas are 1) unresolved grief, 2) difficulties with role transitions, 3) interpersonal disputes, and 4) inadequate social skills. The first stage of treatment involves diagnosing, educating, and assessing interpersonal relationships. Treatment involves identifying problems and using specific here and now interventions. Depression is considered a “medical condition” and is thereby legitimized. It should be noted that IPT is neither psychodynamic, nor cognitive behavioral therapy but it shares qualities of both.

Several forms of brief psychodynamic therapy are considered useful in the treatment of depression. These include “brief focal therapy”, “short-term anxiety-provoking therapy”, and “broad focus psychodynamic therapy”. While these approaches are considered valuable, none have been significantly researched.

Both IPT and CT have been researched and found effective in the treatment of depression. However, they have been research largely by the creators of the therapies. Since they are concrete and can be “replicated” with some consistency, they lend themselves to research. Further, the creators are empirically oriented and they designed approaches that lend themselves to research. Researchers have created manuals that are used by clinicians. They follow specific protocols and procedures. Psychodynamic approaches are less replicable and have generally not been studies with any consistency. Hence, they do not have the empirical backing of IPT and CT. However, more research is being conducted by psychodynamic clinicians and researchers. In the future, other forms of therapy may be proven as effective as CT and IPT.