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Depression can present in many different fashions. There can be mood changes, somatic symptoms, issues with concentration, fatigue, substance use disorders, and medical complications. Many patients may not even recognize the degree of depression they are suffering with and complain of other symptoms, such as anxiety. In this article, we will discuss the basic diagnosis of depression.
What is the incidence of depression?
According to the National Health and Nutrition Examination Survey 2009–2012, it was found that nearly 8% of persons 12 years of age and older had current (past two-week) diagnosable depression.
Women suffer from depression more than men by almost 2:1 and the highest rate of depression is in the 40–59-year-old group in which 12% of women and 7% of men suffer from depression.
Depression in adults over 65 is 1-5%, but increases in those who require healthcare, in which case 13.5% suffer from depression. The recurrence rate in the elderly is over 40% for depressive episodes, and chronic medical comorbidities increase the rates of depression.
Persistent Depressive Disorder (PDD): This is a consolidation of dysthymia and chronic major depressive disorder (MDD) in the new guidelines. The average age for PDD is 31 years old, and the 2-month prevalence in the United States is approximately 0.5% for persistent depressive disorder and 1.5% for chronic MDD.
Between 14% and 23% of women will experience a depressive disorder while pregnant, and 10% to 15% of women will experience a depressive disorder postpartum. Pregnancy may be the most common time for depression to occur.
What are the risk factors for depression?
Early life events such as physical abuse, emotional abuse, sexual abuse, abandonment, death of family members increase depression risk.
In adults, recent loss such as death or divorce, domestic abuse, trauma such as assault, military trauma such as battlefield injury or witnessing death, and major life changes such as financial hardship or job changes can increase risk.
Risk for recurrence in depression
Adult Depression in Primary Care Guideline
There is a sex difference in depression prevalence with women having twice the risk as men, and obesity is also associated with increased depression risk.
Family history also plays a role with MDD being two to four times more common in persons with afflicted first-degree biological relatives. Likewise, affective disorders in the family increase the risk of depression.
Lower socioeconomic status and being single are also risk factors for depression in men and women.
Medical conditions can increase the risk of depression, especially neurological disorders such as Parkinson’s Disease, stroke, multiple sclerosis, and seizures. Cancer, cardiac conditions, and stroke result in a 25% chance of depression.
Chronic pain also increases the risk of depression.
In geriatric populations, being widowed, impaired functional status, heavy alcohol consumption, and low educational status increases risk.
Peripartum depression risks include:
- Depression or anxiety during pregnancy
- Substance abuse
- Poor social support
- Difficulty breastfeeding in the first two months postpartum
- Stressful life events
- Pre-pregnancy and gestational diabetes
- Fragmented sleep
- Current or past abuse experiences
- Previous history of a mood disorder
In summary the risks include:
- Previous personal or family history of depression
- Psychosocial adversity (divorce, domestic violence)
- Excessive utilization of the healthcare system
- Chronic medical conditions (especially cardiovascular disease, diabetes, neurologic disorders)
- Other psychiatric conditions
- Times of hormonal challenge (e.g., peripartum)
If you suffer with one episode of MDD, there is a 50% chance of a subsequent episode, whereas two episodes have a 70% chance of depression recurrence. Three episodes have a 90% chance of recurrence of depression.
What are the signs and symptoms of depression?
Symptoms one might see in depression may include the following:
- Unexplained physical symptoms
- Chronic pain
- Fatigue – a very common presenting problem
- Complaints about memory, concentrating, making decisions
- Substance abuse
- Weight gain or loss
- Sleep disturbance
- Dampened affect
- Sexual dysfunction
We may see patients with multiple medical visits, work dysfunction, changes in interpersonal relationships, poor behavioral follow-through with activities of daily living or prior treatment recommendations, irritable bowel syndrome symptoms, weight gain or loss, and memory and cognitive issues such as poor concentration.
A summary of symptoms of depression is:
- Sleep disorder (increased or decreased)
- Interest deficit (anhedonia)
- Guilt (worthlessness, hopelessness, regret)
- Energy deficit
- Concentration deficit
- Appetite disorder (increased or decreased)
- Psychomotor retardation or agitation
Several domains are altered in depression: Appearance, mood and thought, thought content, cognition, and speech.
Appearance in Depression:
Many people suffering with depression can appear normal initially, however, some may have poor grooming and hygiene-related issues or weight changes due to ongoing depression. Some may move slowly, if at all, a condition called psychomotor retardation, in which they move very little. There may be decreased emotional expression, with minimal range of emotional responses such as laughter or smiling, which may not be displayed due to their blunted affect. They may effectively have a ‘poker face.’ There may be low reactivity in their emotional expressions or there may be agitation, with hand wringing or hair pulling as examples.
Mood and Though Processes:
A depressed person may appear to be tearful, sad, or not even make eye contact. They may have dysphoria, described as sadness, numbness, moody, loss of interest in recreational or leisure activities.
Some patients will describe:
- Feelings of worthlessness
- Negative thoughts and self-doubt
- Loss of energy
- No motivation
For some with depression, it is hard to get out of bed, take a shower, brush their teeth, or even do basic grooming due to the lack of energy and motivation that accompanies the disorder. Some may have delusions and physical decline that may be the result of other conditions such as medical illness, substance abuse, or schizophrenia, which must be distinguished from this disorder of depression.
Poor memory, concentration, and disorganized thinking may also be a part of depression.
Thought content and suicidality:
A dysphoric mood may be associated with suicidal or homicidal ideations, and prior suicide attempts may predict future behavior. These individuals are at higher risk of self-harm.
When a person gets very depressed, their speech may be slow and monotonic. If it is pressured or filled with racing thoughts, consider mania.
Measurement of Depression:
There are several medically validated scoring systems for depression. Resources are below:
U.S. Department of Veterans Affairs, Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder. Washington, DC: U.S. Department of Veterans Affairs; 2016.
Gursky TM, Haight R, Hardwig J, et al. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. 17th ed.
Michigan Quality Improvement Consortium. Primary Care Diagnosis and Management of Adults with Depression. Southfield, MI: Michigan Quality Improvement Consortium; 2020.
Practice Guidelines for the Psychiatric Evaluation of Adults
Tennessee Department of Mental Health
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
Many patients have been depressed for so long, they complain only of having anxiety or somatic symptoms such that only with validated measures can depression be recognized.
The first option for screening is the PHQ-2, a 2 questions screening test:
- ”In the last month, have you been bothered by little interest or pleasure in doing things?’
- ”In the last month, have you been feeling down, depressed, or hopeless?’
Any yes to the questions requires further screening usually with the PHQ-9 (patient health questionnaire) which is nine questions covering two weeks of symptoms. The last question of the survey, “Thoughts that you would be better off dead or of hurting yourself in some way,” if answered yes, reflect a higher risk of suicide.
Other screening tests are below:
- Zung Self-Rating Depression Scale: A widely used depression measure.
- Beck Depression Inventory II (BDI-II): Widely used as a depression outcome measure in research and practice.
- Geriatric Depression Scale (GDS): Developed to assess depression in older adults.
- Hamilton Rating Scale for Depression (HAM-D or HDRS): Extensively used in clinical research.
- Montgomery-Åsberg Depression Rating Scale (MADRS): Greater sensitivity to medication or other treatment response than the HAM-D.
- Edinburgh Postnatal Depression Scale (EPDS): The most widely used assessment tool for postpartum depression, administered to patients six weeks after delivery.
The official criteria for depression are below:
The DSM-5 has specific criteria to diagnose depression as follows:
DSM-5 Criteria: Major Depressive Episode To qualify for a diagnosis of major depressive episode, the patient must meet criteria A through E:
A. Five or more of the following symptoms have been present and documented during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation)
3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down
) 6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a mixed episode.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
And severity is described as follows based on functional disability:
• Mild, single episode ICD-10 F32.0, recurrent episode ICD-10 F33.0: Few, if any symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
• Moderate, single episode ICD-10 F32.1, recurrent episode ICD-10 F33.1: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”
• Severe, single episode ICD-10 F32.2, recurrent episode ICD-10 F33.2: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.
DSM-5 Criteria: Persistent Depressive Disorder
This disorder represents a consolidation of the DSM-IV-defined chronic major depressive disorder and dysthymic disorder, ICD-10 F34.1. To qualify for a diagnosis of persistent depressive disorder, the patient must meet criteria A through H:
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account of observation by others, for at least two years.
B. Presence while depressed of two or more of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
C. During the two-year period of the disturbance, the individual has never been without the symptoms in criteria A and B for more than two months at a time
For many patients, anxiety plays a large role in their symptoms. An anxious distress specifier can be attached to a MDD diagnosis if two of the following are seen:
- Feeling keyed-up or tense
- Feeling unusually restless
- Having difficulty concentrating due to worry
- Fearing that something awful may happen
- Worrying about losing control
MDD with mixed features of Bipolar 1 or II can be diagnosed if three of the following are found:
- Elevated, expansive mood
- Inflated self-esteem, grandiosity
- More talkative than usual or feeling pressure to continue talking
- Ideas, thoughts are racing
- Increase in energy or goal-directed activity
- Increased or excessive involvement in activities with high potential for painful consequences
- Decreased need for sleep
Atypical features with mood hyperreactivity with MDD include:
- Significant weight gain or increase in appetite
- Leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
- Long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
- Atypical MDD is characterized by vegetative symptoms of reversed polarity (e.g., increased rather than decreased sleep, appetite, weight), marked mood reactivity, hypersensitivity to rejection, phobic symptoms, or a sense of severe fatigue that creates a sensation of leaden paralysis or extreme heaviness of the extremities
Both metabolic complications occur in depression as well as other mental health comorbid disorders. The following are associated with depression as well.
- Generalized anxiety disorder (62%)
- Social phobia (52%)
- Post-traumatic stress disorder (PTSD) (50%)
- Panic disorder (48%)
- Specific phobia (43%)
- Obsessive-compulsive disorder (42%)
- Any personality disorder (30%)
- Impulse control disorders (30%)
- Substance use disorders (24%)
- Borderline personality disorder (10% to 15%)
The DSM criteria give the ‘firm’ diagnosis of depression, but evaluation needs to exclude medical conditions that can cause depression, medication effects, substance use disorders, and other mental health diagnosis. Laboratory and a medical examination are critical to ruling out another possibility. The various depression rating scales serve as handy guides to quantifying depression and the risks associated with it as well.
So, depression can present with multiple expressions which also underlies the possibility of multiple etiologies for its cause. We will look into possible causes, treatments, and alternative therapies for depression shortly.
NOVA Health Recovery is a Ketamine Treatment Center in Fairfax, Virginia (Northern Virginia Ketamine) that specializes in the treatment of depression, anxiety, bipolar disorder, OCD, and chronic pain such as CRPS, cluster headaches, and fibromyalgia using Ketamine therapies. We offer ketamine infusions and home-based ketamine nasal spray and oral tablets. For CRPS, we offer multi-day, high-dose infusions and prescriptions for maintenance ketamine therapies for home. We utilize integrative psychiatric therapies for mood disorders as well and offer IV Vitamin support as well as IV NAD+ for mental health, pain, opioid detox, and mood disorders. We also offer addiction treatment services with Suboxone, Vivitrol, and Sublocade therapies for opiate addiction as well as alcohol treatment regimens. Contact us at 703-844-0184 for more information or to schedule. No referral is needed.