Major Depression

Aka: Major Depression, Major Depressive Disorder, Depressive Disorder

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II. Epidemiology

  1. Lifetime Major Depression Incidence: 21 to 25%
  2. Major Depression Prevalence: 6 to 8% (16 Million/year adults in U.S.)
  3. Age of Peak Incidence: 55 to 65 years old
  4. Women have higher risk of Major Depression
  5. Men have higher completed Suicide rate (esp. over age 75 years)
  6. Leading Disability cause worldwide (Prevalence 300 Million)
  7. Accounted for 10% of physician office visits in 2014
  8. Family History: Twin concordance
    1. Monozygotic twins: 75%
    2. Dizygotic twins: 38%
  9. Under-diagnosed
    1. Depression is missed in elderly and Nursing Homes
      1. Up to 50% of Nursing Home population may have Major Depression
      2. Brown (2002) J Am Geriatr Soc 50:69-76 [PubMed]
    2. Only 5% of the clinic population is screened for Major Depression
      1. Akincigil (2017) Psychaitry Serv 68(7): 660-6 [PubMed]

III. Pathophysiology

  1. Since the 1960s chemical imbalance theory, and esp. Serotonin deficiency has been theorized to cause depression
    1. Has lead to a focus on serotonergic agents to treat depression
    2. However, evidence is variable for Serotonin imbalance and mechanism of activity is not clear
  2. Chemical imbalances (e.g. Serotonin) may be a consequence of depressive symptoms, rather than a cause
  3. References
    1. Moncrieff (2023) Mol Psychiatry 28(8):3243-56. doi +PMID: 35854107 [PubMed]

IV. Risk Factors: General

  1. Prior episodes of Major Depression
  2. Prior Suicide attempts
  3. Age under 40 years old
  4. Comorbid medical condition (see associated neurologic and other medical causes below)
  5. Stressful life events
  6. Increased stress reaction with associated negativity (neuroticism)
  7. Family History of depression
  8. Female gender
  9. Recent childbirth
  10. Lack of social support (divorce, widowed, parental loss, disturbed family environment)
  11. Anxiety Disorder history
  12. Low self esteem
  13. Conduct Disorder
  14. Childhood sexual abuse or other lifetime Trauma
  15. Current Chemical Dependency or Substance Abuse

V. Risk Factors: Neurologic Conditions Predisposing to Major Depression

  1. Cerebrovascular Accident
  2. Traumatic Brain Injury
  3. Multiple Sclerosis
  4. Dementia
  5. Parkinsonism

VI. Risk Factors: Medical Conditions Predisposing to Major Depression

  1. See Medications Predisposing to Depression
  2. Alzheimer's Disease or other Dementia
  3. Cancer
  4. Chronic Fatigue Syndrome
  5. Chronic Pain Syndrome
  6. Chornic Liver Disease
  7. Collagen vascular disease
  8. Coronary Artery Disease
  9. Congestive Heart Failure
  10. Crohn's Disease
  11. Diabetes Mellitus
  12. Fibromyalgia
  13. Human Immunodeficiency Virus (HIV)
  14. Hypothyroidism
  15. Insomnia

VII. Differential Diagnosis

  1. See Major Depression Differential Diagnosis

VIII. Symptoms

  1. Core symptoms
    1. Depressed mood
    2. Anhedonia (decreased interest)
    3. Suicidality
    4. Appetite change (decreased or increased)
    5. Psychomotor Agitation retardation or Agitation
    6. Decreased energy
    7. Excessive Guilt (e.g. worthlessness, hopelessness or regret)
    8. Sleep disorder (increased or decreased)
  2. Atypical presentations in women
    1. Headaches
    2. Myalgias
    3. Gastrointestinal symptoms
  3. Atypical presentations in men
    1. Anger and aggression
    2. Substance Use Disorder
    3. Risky behavior

IX. Evaluation

  1. Evaluate for Suicide Risk
  2. Screening Mnemonics
    1. See Depression Screening with SALSA
    2. See Depression Screening with SIG E CAPS
  3. Screening Tools
    1. Patient Health Questionaire 2 (PHQ-2)
      1. Most common initial screening tool
      2. Positive result should prompt other screening tools and clinical interview
    2. Patient Health Questionaire 9 (PHQ-9)
    3. Beck Depression Inventory
    4. Zung Self-Rating Depression Scale
    5. Hamilton Depression Scale
    6. Mazmanian Mania-Depression Mood Scale
  4. Screening Tools for Adolescents (ages 12 to 18 years old)
    1. Beck Depression Inventory
    2. Patient Health Questionaire 2 (PHQ-2)
    3. Patient Health Questionaire for Adolescents (PHQ-A)
      1. Nearly identical to PHQ-9 except wording includes concentration on school work
  5. Screening Tools in pregnancy and Postpartum Period
    1. See Postpartum Major Depression
    2. Edinburgh Postnatal Depression Scale (most commonly used Postpartum Depression screening tool)
    3. Patient Health Questionaire 2 (PHQ-2)
    4. Patient Health Questionaire 9 (PHQ-9)
    5. Postpartum Depression Screening Scale (PDSS)
  6. Screening Tools for the Elderly
    1. Patient Health Questionaire 2 (PHQ-2)
    2. Five-Item Geriatric Depression Scale
    3. Fifteen-Item Geriatric Depression Scale
    4. Cornell Scale for Depression in Dementia

X. Diagnosis

  1. See Major Depression Diagnosis

XI. Labs

  1. Thyroid Stimulating Hormone (TSH)
  2. Hemoglobin (or Complete Blood Count)
    1. Consider Vitamin B12 Deficiency screening
  3. Consider additional lab studies
    1. Serum Electrolytes
    2. Liver Function Tests
    3. Urinalysis

XII. Comorbid Conditions (Differentiate or Integrate)

  1. Major Depression
  2. Anxiety Disorder
  3. Panic Disorder

XIII. Criteria: Indications for Psychiatric Consultation

  1. Serious Suicidal Ideation
  2. Psychotic symptoms with poor judgment
  3. Acute manic symptoms
  4. Bipolar Depression
  5. Refractory to Antidepressant medications
  6. Refuses medications despite severe depression
  7. Inpatient psychiatric care
  8. Electroconvulsive Therapy

XIV. Management

  1. See Suicide
  2. See Depression Management
  3. See Depression Medical Management
  4. See Refractory Depression Management
  5. See Depression Management Special Circumstances

XV. References

  1. (1994) DSM-IV, APA, p. 320-7
  2. Bhatia (1997) Am Fam Physician 55(5):1683-94 [PubMed]
  3. Kuzel (1996) Postgrad Med 99(5):179-95 [PubMed]
  4. Maurer (2018) Am Fam Physician 98(8): 508-15 [PubMed]

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