Depression and Suicide _ ______________________________________________________________________
- Increase in goal-directed activity or psychomotor agitation - Excessive involvement in pleasurable or hedonistic activities with a high potential for painful conse- quences • The mood disturbance sufficiently severe to cause marked impairment in social or occupational function- ing or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features • The episode is not attributable to the physiologic effects of a substance (e.g., an illicit drug, a medication, other treatment) or to another medical condition These criteria constitute a manic episode. At least one life- time manic episode is required for the diagnosis of bipolar I disorder. Other psychiatric conditions with similar presentation to MDD include seasonal affective disorder, persistent depres- sive disorder, anxiety disorders, eating disorders, and per- sonality disorders, especially borderline personality disorder. Many patients with MDD who appear labile, demanding, or pathologically dependent look dramatically different after the depressive episode has been treated adequately. COMORBID CONDITIONS Additional psychiatric disorders are present in many patients with MDD. Comorbidity rates differ between studies con- ducted with community compared with clinical populations. However, the most commonly occurring psychiatric comorbidi- ties and their rates of occurrence in persons with MDD are [22; 105; 106; 107; 108]: • Generalized anxiety disorder (62%) • Social phobia (52%) • Post-traumatic stress disorder (PTSD) (50%)
CNS Conditions A broad range of CNS processes and conditions can produce changes in mood, cognition, and behavior that resemble MDD. These include Alzheimer disease, Parkinson disease, Huntington disease, multiple sclerosis, stroke, and seizure disorders; neoplastic lesions of the CNS; inflammatory condi- tions such as systemic lupus erythematosus; sleep disorders, particularly obstructive sleep apnea; and infectious diseases such as syphilis, Lyme disease, and human immunodeficiency virus (HIV) encephalopathy. Pharmacologic Agents Medications that can induce mood changes include antihy- pertensive medications, steroids, medications that affect sex hormones, H2 histamine blockers, sedatives, muscle relaxants, appetite suppressants, and cytotoxic chemotherapy agents. Patients taking several medications are at increased risk. Endocrine Disorders Several endocrine disorders, including Addison disease, Cushing disease, hyper- and hypothyroidism, prolactinomas, and hyperparathyroidism, have been linked to symptoms of depression. Treatment of the underlying disease should allevi- ate depressive symptoms. Other Psychiatric Conditions Depressive symptoms or mood disturbance can be due to psychiatric conditions other than MDD. Intoxication or acute withdrawal associated with alcohol and almost all rec- reational drugs can disrupt mood, cognition, and behavior. Furthermore, depressive symptoms may be a phase of bipolar disorder. It is important to distinguish bipolar from unipolar depression, as treatment decisions are based on this distinc- tion. Assessment should always involve inquiry about manic or hypomanic episodes, using the following DSM-5-TR criteria for bipolar disorder [10]: • A distinct period of abnormally and persistently ele- vated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary) • During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irri- table) and have been present to a significant degree and represent a noticeable change from usual behavior: - Inflated self-esteem or grandiosity - Decreased need for sleep - More talkative than usual or pressure to keep talk- ing (pressured speech) - Flight of ideas or subjective experience that thoughts are racing
• 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%) In addition, depression and certain medical conditions co- occur at very high rates. One large clinical trial found that depressed study participants had an average of 3.3 general medical conditions, including chronic pain, diabetes, cancer, HIV, Parkinson disease, and cardiovascular disease [109]. Medical comorbidity is highest among the elderly, with very high rates of depression found in patients with stroke (30% to 60%), coronary artery disease (up to 44%), cancer (up to 40%), Parkinson disease (40%), and Alzheimer disease (20% to 40%). The recurrence rate of MDD in the elderly is also extremely high, at roughly 40% [18].
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