Depression and Suicide _ ______________________________________________________________________
PERSONAL AND SOCIETAL COSTS OF DEPRESSION Major depressive disorder exacts an enormous toll on afflicted persons and is recurrent or chronic in approximately 35% of patients. It is associated with numerous chronic medical comor- bidities and complications from acute medical illness, such as myocardial infarction [22]. Interpersonal connections and role functioning as spouse, parent, or worker are impaired. MDD is the leading cause of disability in the United States for persons 15 to 44 years of age and is second only to chronic back and neck pain in disability days per year among all Americans [22]. MDD is among the most costly illnesses in the world. The cost of depression in the United States was estimated at $210.5 bil- lion in 2010, a 21.5% increase from 2005 [23]. Approximately 50% of this figure was attributed to workplace costs, 45% to direct costs, and 5% to suicide-related costs [23; 24]. The economic burden of MDD was an estimated $236 billion in 2018, an increase of more than 35% since 2005 [25]. From 2010 to 2018, the largest increase was in workplace costs, which rose from 48% of depression-related costs in 2010 to 61% of costs in 2018. The direct cost of treating depression accounted for only 11.2% of the overall economic burden. For every dollar of direct costs, an additional $2.30 was spent on depression-related indirect costs [25]. Even low-grade depression is associated with decreased work productivity [26]. Patients who do not achieve full treatment response use twice as many healthcare services, and cost employers almost four times as much as patients achieving remission [27]. Women with early-onset depression (before 22 years of age) often fail to graduate from college and earn substantially less income than women with later-onset depression or no depression [28]. In the United States, the annual cost of suicidal behaviors (attempts and deaths) was estimated to be $93.5 billion in 2016 [29]. Depression causes an estimated 200 million lost workdays each year at a cost to employers of $17 to $44 billion [30]. However, attempts to quantify such costs on a national scale are hampered by incomplete data, such as the under-reporting of suicides [31].
Women have greater risk of depression, with a lifetime preva- lence almost twice that of men [33]. Among women, severe obesity (body mass index greater than 40) is strongly associated with depression [34]. Lower socioeconomic status and being single are also risk factors for both genders [32]. Family history of psychopathology, affective disorders in gen- eral, and major depression are particularly robust risk factors. MDD is two to four times more common among persons with an afflicted first-degree biologic relative (a parent or sibling) than among the general population [10]. Relative risks appear to be higher for early-onset and recurrent forms [10]. However, family studies indicate that major depression is not caused by any single gene but is a disease with complex genetic features. No specific genetic risk factor has been reliably identified and associated with the development of depression [35]. Certain neurologic disorders are risk factors, such as Parkin- son disease, stroke, multiple sclerosis, and seizure disorders. Among persons with certain general medical conditions, such as cancer, diabetes, myocardial infarction, or stroke, 20% to 25% will go on to experience a major depressive episode (MDE) [22]. Chronic pain, medical illness, and persistent or severe psychosocial stress elevate the risk of MDD [32]. Risk factors for late-onset depression include widowhood, physical illness, educational attainment less than high school, impaired functional status, and heavy alcohol consumption [21; 36]. As noted, peripartum women are particularly vulnerable to depression. Risk factors for peripartum depression include [21]: • Depression or anxiety during pregnancy • Previous history of a mood disorder • Poor social support • Stressful life events • Pre-pregnancy and gestational diabetes • Fragmented or poor sleep • Substance abuse • Current or past abuse experiences • Difficulty breastfeeding in the first two months postpar- tum NATURAL HISTORY OF DEPRESSION Onset of a first major depressive episode (MDE) can be trig- gered by a serious psychosocial stressor and is associated with a history of panic attacks and alcohol or substance use disorder [21; 37]. A prodromal syndrome of anxiety or low-grade depres- sion symptoms may persist for several months before onset of an initial MDE. Major depression has a variable age of onset, but the mid- to late-20s is typical [10; 22].
BACKGROUND
RISK FACTORS Several demographic/socioeconomic, psychosocial, familial, medical, and psychologic factors are associated with higher risk for depression. Adverse early life events such as early childhood parental abandonment or death, or emotional trauma from physical, sexual or emotional abuse are major risk factors for depression and other psychiatric disorders in adulthood. In adulthood, recent loss (e.g., death, divorce), domestic abuse/ violence, traumatic civilian (assault, serious car accident) or military (battlefield injury, witnessing death and dismember- ment) events, and major life changes (e.g., job change, financial hardships) are all potential red flags for depression [21; 32].
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