Major Depressive Disorder

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I. DSM-IV Diagnostic Criteria for Major Depressive Disorders

A. History of one or more Major Depressive Episodes

B. No history of manic, hypomanic or mixed episodes

II. Clinical Features of Major Depressive Disorder

A. High mortality; 15% suicide rate. Common coexisting diagnoses include panic disorder, eating disorders, substance-related disorders. These disorders should be excluded by the clinical history.

B. Major depressive disorder often complicates the presentation and treatment of patients with medical conditions such as MI, CVA, and diabetes.

C. The disorder often follows an episode of severe stress, such as loss of a loved one.

D. All patients should be asked about suicidal ideation as well as intent. Hospitalization may be necessary for acutely suicidal patients.

E. Suicide risk may increase as the patient begins to respond to treatment. Lack of initiative and poor energy can improve prior to improvement in mood, allowing patients to follow through on suicidal ideas.

F. Suicide risk is most closely related to the degree of hopelessness a patient is experiencing and not to the severity of depression.

III. Epidemiology of Major Depressive Disorder

A. Prevalence is approximately 3-6%, with a 2:1 female-to-male ratio.

B. Approximately 50% of patients who have a single episode of major depressive disorder will have a recurrence. This rises to 70% after two episodes and 90% after three episodes.

C. Functioning returns to the premorbid level between episodes in approximately two-thirds of patients.

D. The disorder is two times more common in first-degree relatives of patients with major depressive disorder compared to the general population.

IV.Classification of Major Depressive Disorder

A. Major Depressive Disorder with Psychotic Features. Depression is accompanied by hallucinations or delusions, which may be mood-congruent (content is consistent with typical depressive themes) or mood incongruent (content does not involve typical depressive themes).

B. Major Depressive Disorder, Chronic. Full diagnostic criteria for major depressive disorder have been met continuously for at least 2 years.

C. Major Depressive Disorder with Catatonic Features Accompanied by at least 2 of the following:

1. Motor immobility or stupor.

2. Excessive purposeless motor activity.

3. Extreme negativism or mutism.

4. Bizarre or inappropriate posturing, stereotyped movement, or facial grimacing.

5. Echolalia or echopraxia.

D. Major Depressive Disorder with Melancholic Features. Depression is accompanied by severe anhedonia or lack of reactivity to usually pleasurable stimuli and at least 3 of the following:

1. Quality of mood is distinctly depressed.

2. Mood is worse in the morning.

3. Early morning awakening.

4. Marked psychomotor slowing.

5. Significant weight loss.

6. Excessive guilt.

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