Etiology Although previously attributed primarily to abnormalities of neurotransmitters, notably serotonin, norepinephrine, and dopamine, evidence now points to a multifactorial etiology of MDD, including biological, genetic, environmental, and psychosocial factors and their interaction with neurotransmitters. Recent theories and research support the interaction of complex systems that secondarily cause Differentiating Types of Depression In the DSM-5-TR, depressive disorders include eight subtypes: disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, substance/medication- induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder (American Psychiatric Association, 2022). In this course, other specified depressive disorders and unspecified depressive disorders will not be described in great detail. The DSM-5-TR diagnosis of other specified depressive disorder is appropriate to use when a client experiences sadness or depression that does not reach the severity, length, or level of impairment described by the other disorders. The clinician chooses to communicate the specific reason that the presentation does not meet such criteria (i.e., short-duration depressive episode, recurrent brief depression). In contrast, the unspecified diagnosis is appropriate when symptoms do not meet full diagnostic criteria for any of the depressive disorders, and the clinician chooses not to specify the reason the criteria are not met; this would include presentations involving insufficient information to make a specific diagnosis, such as might arise in an emergency setting (APA, 2022). Major Depressive Disorder According to the DSM-5-TR, the diagnosis of major depressive disorder requires the presence of at least one major depressive episode. Symptoms of a major depressive episode will be described in greater detail in the section that follows; however, it is essential to note that an episode involves either a depressed mood or a loss of interest in activities for at least two weeks and no prior history of mania (APA, 2022). A diagnosis of major depressive disorder is specified as either a single episode or recurrent episode, and the symptoms of major depressive disorder can be severe, last for weeks or months, and may occur with additional features (e.g., psychosis; APA, 2022). These additional specifiers are described in later sections of this course. Major Depressive Episode, Adults, Prognosis. MDD is a serious, chronic, recurrent illness. Without treatment, major depressive episodes last from 6 to 12 months. Recurrence rates range from 50% to 90%, with 50% recurrence after a first episode and 90% recurrence following a third episode. Of people with MDD, approximately two-thirds consider suicide, with 10-15% dying by suicide. The prognosis is much better for patients experiencing mild symptoms without psychotic symptoms, strong social support, strong premorbid functioning, and treatment adherence, as opposed to those with comorbid psychiatric illness, multiple psychiatric hospitalizations, personality disorder, and older age of onset (Bains & Abdijadid, 2023). According to the landmark 1999 Surgeon General’s report on mental health, a major depressive episode may last, on average, about nine months if untreated. Individuals who experience an initial depressive episode have a 40% to 60% chance of experiencing another depressive episode (Bockting et al., 2015). Studies show that individuals who experience a major depressive episode and go untreated for
disruption in neurotransmitter systems, including, for example, thyroid and growth hormone abnormalities and adverse childhood experiences (ACES). Genetic studies of families, adoption, and twins indicate that MDD results from both genetic and environmental influences. MDD concordance rates are very high for twins and monozygotic twins, indicating a strong role of genes in susceptibility to MDD (Bains & Abdijadid, 2023). six months or more are less likely to achieve remission (Bukh et al., 2013; Ghio et al., 2015). These findings emphasize the importance of early detection and treatment of the condition for better clinical outcomes (Bukh et al., 2013; Ghio et al., 2015). An adult experiencing a major depressive episode must have at least five of the following symptoms and signs over the course of at least two weeks. These symptoms must occur every day, or nearly every day, and result in impaired functioning. An episode is considered to have ended when there have been no symptoms present for a period of 2 months. The DSM-5-TR (APA, 2022) outlines the following as the symptoms of a major depressive episode: • Depressed mood: A client may be frequently tearful or may report feeling sad, hopeless, irritable, or empty. Others, such as family members, can substantiate these self-reports by offering observations about the client’s behavior. • Markedly diminished interest or pleasure in all, or almost all, activities: A client may report that they used to enjoy boating, but lately, they do not find pleasure in this activity. • Significant weight loss when not dieting or weight gain (5% of body weight per month): A client may report no longer enjoying meals like they used to. They may report that their appetite has either diminished or increased. • Difficulty sleeping (insomnia) or excessive sleeping (hypersomnia): A client experiencing hypersomnia will consistently sleep more than 9 hours; a client experiencing insomnia will consistently sleep less than 6 hours. • Psychomotor agitation or retardation: A client may report feeling restless and unable to settle down. Alternatively, they may report feeling like they are moving in slow motion, like every limb weighs a ton. • Fatigue or loss of energy: A client or their family may report that they seem to be tired all of the time and never feel like going out with the family. • Feelings of worthlessness, excessive or inappropriate guilt, or low self-esteem : A client may lament that they are an awful person, that no one likes them, and that they even disgust themself. The client’s reasons for feeling this way may be excessive or unsubstantiated. • Diminished ability to think or concentrate or indecisiveness : A client may report that they often must read the same newspaper paragraph repeatedly because they cannot focus on what they are reading. They may report that their thoughts are scattered or flighty. They may have difficulty making decisions about seemingly unimportant things, like what to have for dinner or what color shirt to wear. • Recurrent thoughts of death, a specific plan for suicide, recurrent suicidal ideation without a specific plan, or suicide attempt: A client may talk about a desire to “escape” from the problems in their life. They may imagine themself dead or how people in their life would react if they were dead. They may or may not have a specific plan to commit suicide.
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