MAJOR DEPRESSION: SYMPTOMS, CAUSES, AND TREATMENTS - ECONOMÍA - 2025

The major depressive disorder, also called major depressive disorder or clinical depression, is a mental illness characterized by a depressed mood in the extreme and decreased interest in experiencing any pleasure in life.

In addition, it includes cognitive symptoms (indecision, feelings of little worth) and altered physical functions (changes in appetite, weight changes, disturbed sleep, loss of energy). Although all the symptoms are important, the physical changes are remarkable in this disorder and signal its appearance.

People with this disorder are also said to have "unipolar depression," because the mood stays at one pole. It is now known that a single episode of Major Depressive Disorder (MDD) is rare.

If there are two or more episodes separated by a period of at least two months without depression, it is called "recurrent major depressive disorder." The diagnosis of MDD is based on the experiences reported by the person, on the behavior reported by friends or family, and on the evaluation of the mental state.

There is no laboratory test for major depression, although tests are usually done to rule out the possibility that symptoms are caused by physical illness.

The most common time of appearance is between 20 and 40 years, with a peak between 30 and 40 years. Patients are usually treated with antidepressants, supplemented with cognitive-behavioral therapy.

The more severe the depression, the greater the effect of antidepressants. On the other hand, hospitalization may be necessary in the most serious cases or at risk of suicide or harm to others.

The proposed causes are psychological, psychosocial, hereditary, evolutionary, and biological.

Symptoms

Although depression may occur only once in a lifetime, several depressive episodes usually occur.

During these episodes, symptoms occur most of the day and can be:

• Feelings of sadness, emptiness, or unhappiness.
• Outbursts of anger, irritability, or frustration.
• Loss of pleasure in normal activities.
• Sleep problems, including insomnia or hypersomnia.
• Tiredness or lack of energy, to the point that any task requires effort.
• Changes in appetite: decreased appetite (leading to weight loss) or increased appetite (weight gain).
• Anxiety, agitation, or restlessness.
• Slow thinking, speaking, or movements.
• Feelings of little worth or guilt.
• Focus on past failures or events.
• Trouble concentrating, making decisions, or remembering things.
• Frequent thoughts of death, suicidal thoughts, or suicide attempts.
• Unexplained physical problems, such as headaches or back pain.

Depressive symptoms in children and adolescents

Symptoms of MDD in children and teens are common to those in adults, although there may be some differences:

• In young children, symptoms can include sadness, irritability, worry, pain, refusing to go to school, or being underweight.
• Symptoms in adolescents may include sadness, irritability, negative feelings, low self-esteem, hatred, absence from school, alcohol or drug use, self-harm, loss of interest in normal activities, avoidance of social interactions.

Depressive symptoms in older people

MDD is not a normal part of older people and must be treated. Depression in older people is often poorly diagnosed and treated, and they may refuse to seek help.

Symptoms of depression in older people may be different or less obvious and may include:

• Difficulty remembering or personality changes.
• Fatigue, loss of appetite, sleep problems, pain not caused by medical or physical conditions.
• Not wanting to leave home.
• Suicidal thoughts.

Causes

The biopsychosocial model proposes that the factors involved in depression are biological, psychological and social.

-Biological causes

Monoaminergic hypothesis

Most antidepressants influence the balance of three neurotransmitters: dopamine, noreprinephrine, and serotonin.

Most antidepressant medications increase the levels of one or more monoamines (neurotransmitters serotonin, noreprinephrine, and dopamine) in the synaptic space between brain neurons. Some medications directly affect monoaminergic receptors.

It is hypothesized that serotonin regulates other neurotransmitter systems; the reduction in serotonergic activity could allow these systems to err.

According to this hypothesis, depression arises when low levels of serotonin promote low levels of noreprinephrine (a monoaminergic neurotransmitter). Some antidepressants directly improve noreprinephrine levels, while others increase levels of dopamine, another monoaminergic neurotransmitter.

Currently, the monomaminergic hypothesis states that the deficiency of certain neurotransmitters is responsible for the symptoms of depression.

• Noreprinephrine is related to energy, alertness, attention and interest in life.
• The lack of serotonin is related to anxiety, compulsions and obsessions.
• Dopamine is related to attention, motivation, pleasure, interest in life and reward.

Other biological hypotheses

1-Magnetic resonance images of patients with depression have shown certain differences in brain structure.

People with depression have a larger volume of the lateral ventricles and adrenal gland, and a smaller volume of the basal ganglia, thalamus, hypothalamus, and frontal lobe.

On the other hand, there could be a relationship between depression and hippocampal neurogenesis.

2-The loss of neurons in the hippocampus (involved in memory and humor) occurs in some people with depression and correlates with less memory and dysthymic mood. Certain drugs can stimulate the level of serotonin in the brain, stimulating neurogenesis and increasing the mass of the hippocampus. 3-A similar relationship has been observed between depression and the anterior cingulate cortex (involved in the modulation of emotional behavior).

4-There is some evidence that major depression could be caused in part by overactivation of the hypothalamic-pituitary-adrenal axis, which results in an effect similar to the stress response.

5-Estrogen has been related to depressive disorders due to their increase after puberty, prenatal and postmenopausal periods.

6-The responsibility of a molecules called cytokines has also been studied.

-Psychological causes

There are several aspects of personality and its development that appear to be integral to the occurrence and persistence of MDD, with the tendency to negative emotions being the primary precursor.

Depressive episodes are correlated with negative life events, although their coping characteristics influence indirectly. On the other hand, low self-esteem or the tendency to have irrational thoughts are also related to depression.

Aaron T. Beck

The psychologist Aaron T. Beck developed a known model of depression in the early 1960s. This model proposes that there are three concepts that create depression:

• The triad of negative thoughts: irrational or negative thoughts about yourself, irrational or negative thoughts about the world, and irrational or negative thoughts about the future.
• Recurring patterns of depressive thoughts (schemata).
• Distorted information.

From these principles, Beck developed cognitive behavioral therapy.

Martin Seligman

Another psychologist, Martin Seligman, proposed that depression is similar to learned helplessness; learn that you have no control over situations.

In the 1960s, John Bowlby developed another theory; attachment theory, which proposes a relationship between depression in adulthood and the type of relationship between the child and the parent or caregiver in childhood.

It is believed that experiences of loss of family, rejection or separation can cause the person to be considered of little value and is insecure.

There is another personality trait that depressed people often have; They often blame themselves for the occurrence of negative events and accept that they are the ones that create the positive results. This is the so-called pessimistic explanatory style.

Albert bandura

Albert Bandura proposes that depression is associated with a negative self-concept and lack of self-efficacy (they believe that they cannot achieve personal goals or influence what they do).

In women there are a number of factors that make depression more likely: loss of the mother, being responsible for several children, lack of trustworthy relationships, unemployment.

Older people also have some risk factors: going from "giving care" to "needing care", death of someone close, change in personal relationships with wife or other relatives, changes in health.

Finally, existential therapists relate depression to a lack of meaning in the present and a lack of vision for the future.

-Social causes

Poverty and social isolation are related to an increased risk of developing mental disorders. Sexual, physical or emotional abuse in childhood is also related to developing depressive disorders in adulthood.

Other risk factors in family functioning are: depression in parents, conflicts between parents, deaths or divorces. In adulthood, stressful events and events related to social rejection are related to depression.

Lack of social support and adverse conditions at work - poor decision-making capacity, bad work climate, poor general conditions - are also related to depression.

Finally, prejudice can lead to depression. For example, if in childhood the belief develops that working in a certain profession is immoral and in adulthood one works in that profession, the adult may blame and direct the prejudice to himself.

-Evolutionary causes

Evolutionary psychology proposes that depression may have been incorporated into human genes, due to its high heritability and prevalence. The current behaviors would be adaptations to regulate personal relationships or resources, although in the modern environment they are maladaptations.

From another point of view, depression could be seen as an emotional program of its kind activated by the perception of personal worthlessness, which may be related to guilt, perceived rejection and shame.

This trend could have appeared in hunters thousands of years ago who were marginalized by declining skills, something that could continue to appear today.

-Drug and alcohol abuse

In the psychiatric population there is a high level of substance use, especially sedatives, alcohol and cannabis. According to DSM-IV, a diagnosis of mood disorder cannot be made if the direct cause is the effect produced by substance use.

Excessive alcohol consumption significantly increases the risk of developing depression, as do benzodiazepines (central nervous system depressants).

Diagnosis

Diagnostic criteria for major depressive disorder, single episode (DSM-IV)

A) Presence of a single major depressive episode.

B) Major depressive episode is not better explained by the presence of a schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or unspecified psychotic disorder.

C) There has never been a manic episode, a mixed episode or a hypomanic episode.

Specify:

• Chronic.
• With catatonic symptoms.
• With melancholic symptoms.
• With atypical symptoms.
• Onset postpartum.

Diagnostic Criteria for Major Depressive Episode (DSM-IV)

A) Presence of five or more of the following symptoms during a period of 2 weeks, representing a change from previous activity; one of the symptoms must be 1. depressed mood, or 2. loss of interest or capacity for pleasure:

1. Depressed mood most of the day, almost every day as indicated by the subject himself (sad or empty) or the observation made by others (crying). In children or adolescents the mood can be irritable.
2. Marked decrease in interest or in the capacity for pleasure in all or almost all activities, most of the day.
3. Significant weight loss without dieting, or weight gain, or loss or increase in appetite almost every day. In children, the failure to achieve the expected weight gains must be assessed.
4. Insomnia or hypersomnia every day.
5. Feelings of worthlessness or excessive or inappropriate guilt almost every day.
6. Decreased ability to think or concentrate, or indecision, almost every day.
7. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan to commit suicide.

B) Symptoms do not meet criteria for a mixed episode.

C) Symptoms cause clinically significant discomfort or impairment of the individual's social, occupational, or other important areas of activity.

D) The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

E) Symptoms are not better explained by the presence of grief, symptoms persist for more than two months or are characterized by marked functional disability, morbid worries of worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Types

DSM IV recognizes 5 subtypes of TDM:

• Melancholic depression: loss of pleasure in most activities. A depressed mood, rather than grief or loss. Worsening of symptoms in the morning, psychomotor retardation, excessive weight loss or excessive guilt.
• Atypical depression: characterized by excessive weight gain, excessive sleep, a feeling of heaviness in the limbs, hypersensitivity to social rejection and deterioration of social relationships.
• Catatonic depression: disturbances in motor behavior and other symptoms. The person is speechless and almost stupor, or is immobile and shows strange movements.
• Postpartum depression: it has an incidence of 10-15% in new mothers and can last up to three months.
• Seasonal affective disorder: depressive episodes that arrive in the fall or winter and that stop in the spring. At least two episodes have had to occur in cold months without occurring in other months, over a period of 2 years or more.

Comorbidity

Major depressive disorder often co-occurs with other mental disorders and physical illnesses:

• About 50% also suffer from anxiety.
• Alcohol or drug dependence.
• Post-traumatic stress disorder.
• Attention deficit and hyperactivity.
• Cardiovascular diseases.
• Depression.
• Obesity.
• Pain.

Differential diagnosis

When diagnosing MDD, other mental disorders that share some characteristics should be considered:

• Dysthymic Disorder: This is a persistently depressed mood. The symptoms are not as severe as in depression, although a person with dysthymia is vulnerable to developing a major depressive episode.
• Bipolar disorder: it is a mental disorder in which you alternate between a depressive state and a manic one.
• Adjustment disorder with depressed mood: it is a psychological response given to a stressful event.
• Depressions due to physical illness, substance abuse, or use of medication.

Treatments

The three main treatments for depression are cognitive behavioral therapy, medication, and electroconvulsive therapy.

The American Psychiatric Association recommends that initial treatment be tailored based on the severity of symptoms, co-occurring disorders, patient preferences, and response to previous treatments. Antidepressants are recommended as initial treatment in people with moderate or severe symptoms.

Cognitive behavioral therapy

It is currently the therapy that has the most evidence of its effectiveness in children, adolescents, adults and the elderly.

In people with moderate or severe depression, they may work as well or better than antidepressants. It is about teaching people to challenge irrational thoughts and change negative behaviors.

Variants that have been used in depression are rational emotional behavioral therapy and mindulness. Specifically minfulness appears to be a promising technique for adults and teens.

Antidepressants

Sertraline (SSRI) has been the most prescribed compound in the world, with more than 29 million prescriptions in 2007. Although more results are needed in people with moderate or acute depression, there is evidence of its usefulness in people with dysthymia.

Research conducted by the National Institute for Health and Care Excellence found that there is strong evidence that selective serotonin reuptake inhibitors (SSRIs) are more effective than placebo in reducing moderate and severe depression by 50%.

To find the right drug treatment, you can readjust the doses and even combine different classes of antidepressants.

Typically, it takes 6-8 weeks to start seeing results and is typically continued for 16-20 weeks after remission to minimize the chance of recurrence. In some cases it is recommended to keep the medication for a year and people with recurrent depression may need to take it indefinitely.

SSRIs are the most effective compound or drug today. They are less toxic than other antidepressants and have fewer side effects.

Monoamine oxidase inhibitors (MAOIs) are another class of antidepressants, although they have been found to have interactions with drugs and foods. They are rarely used today.

Other medications

There is some evidence that selective COX-2 inhibitors have positive effects for major depression.

Lithium appears effective in reducing the risk of suicide in people with bipolar disorder and depression.

Electroconvulsive therapy

Electroconvulsive therapy is a treatment that induces electrical seizures in patients to reduce psychiatric illness. It is used as a last option and always with the consent of the patient.

One session is effective for about 50% of people resistant to other treatments, and half of those who respond relapse at 12 months.

The most common adverse effects are confusion and memory loss. It is administered under anesthesia with a muscle relaxant and is usually given two or three times per week.

Others

Bright light or light therapy reduces the symptoms of depression and seasonal affective disorder, with effects similar to those of conventional antidepressants.

For non-seasonal depressions, adding light therapy to normal antidepressants is not effective. Physical exercise is recommended for mild and moderate depression. According to some research it is equivalent to the use of antidepressants or psychological therapies.

Forecast

The average duration of a depressive episode is 23 weeks, being the third month in which there are more recoveries.

Research has found that 80% of people who experience their first episode of major depression will experience at least one more in their lifetime, with an average of 4 episodes in their lifetime.

Recurrence is more likely if symptoms have not completely resolved with treatment. To avoid it, current guidelines recommend continuing the medication for 4-6 months after remission.

People suffering from recurrent depression require continuous treatment to prevent long-term depression and in some cases it is required to continue the medication indefinitely.

People with depression are more susceptible to heart attacks and suicide. Up to 60% of people who commit suicide suffer from mood disorders.

Prevention

Once an episode of major depression arises, you are at risk for another. The best way to prevent is to be aware of what triggers the episode and the causes of major depression.

It is important to know what the symptoms of major depression are so that you can act quickly or get treatment. These are some tips for its prevention:

• Avoid alcohol or drug use.
• Do sports or physical activities for at least 30 minutes 3-5 times a week.
• Maintain good sleep habits.
• Do social activities.
• Do activities that are fun or that cause pleasure.
• Do volunteering or group activities.
• Try to find social supports that are positive.
• If a medical treatment is followed: keep the medication as prescribed and continue with the therapy sessions.

Risk factor's

More women are diagnosed than men, although this trend may be due to the fact that women are more willing to seek treatment.

There are several risk factors that seem to increase your chances of developing major depression:

• Depression has started in childhood or adolescence.
• History of anxiety disorders, borderline personality disorder, or post-traumatic stress disorder.
• Personality traits such as being pessimistic, emotionally dependent, or having low self-esteem.
• Alcohol or drug abuse.
• Having had serious illnesses such as cancer, diabetes, or heart disease.
• Having suffered traumatic events, such as sexual or physical abuse, relationship difficulties, financial problems or loss of family members.
• Family members with depression, bipolar disorder, suicidal behaviors, or alcoholism.

epidemiology

According to the World Health Organization, depression affects more than 350 million people worldwide, being the main cause of disability and contributing significantly to morbidity.

The first depressive episode is most likely to develop between the ages of 30 and 40, and there is a second peak in incidence between the ages of 50 and 60.

It is more common after cardiovascular diseases, parkinson's, stroke, multiple sclerosis and after the first child.

Complications

Untreated depression can lead to health, emotional, and behavioral problems that affect all areas of life. Complications can be:

• Alcohol and drug abuse.
• Being overweight or obese
• Anxiety, social phobia, or panic disorder.
• Family problems, relationship conflicts or problems at school.
• Social isolation.
• Suicide or suicide attempts.
• Self-harm.

How to help if you are a family member or friend?

If you have a family member or friend who is affected by depression, the most important thing is to help diagnose the disease and start treatment.

You could make an appointment and accompany your family member, encourage them to continue the treatment later or to seek a different treatment if there is no improvement after 6-8 weeks.

You can follow the following tips:

• Talk to your family member and listen carefully.
• Offer emotional support, patience, encouragement, and understanding.
• Don't dismiss feelings but offer hope.
• Do not ignore comments about suicide and communicate them to the therapist.
• Invite to participate in recreational activities.
• Accompany therapeutic appointments if the family member requests it.

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Help yourself if you have depression

If you have depression you can feel hopeless, without energy and without wanting to do anything. It can be very difficult for you to act to help yourself, although you need to recognize the need for help and treatment.

Some advices:

• Try to visit a professional as soon as possible. The longer you wait, the more complicated the recovery can be.
• Exercise frequently, 30 minutes at least 3-5 days a week.
• Participate in recreational activities such as sports, going to the cinema, taking a walk, attending events…
• Divide large tasks into small ones and set priorities.
• Set realistic and motivating goals. Divide big goals into small goals.
• Don't isolate yourself socially; spend time with friends, family, and new friends.
• Expect the depression to overcome little by little, not suddenly.
• If you have important decisions to make, wait until you are in a stable frame of mind.
• Keep learning about depression (without obsessing over it) and taking action to overcome it.

References

1. Depression (PDF). National Institute of Mental Health (NIMH). Retrieved 7 September 2008.
2. Schulman J and Shapiro BA (2008). "Depression and Cardiovascular Disease: What Is the Correlation?". Psychiatric Times 25 (9).
3. Boden JM, Fergusson DM (May 2011). "Alcohol and depression". Addiction 106 (5): 906–14. doi: 10.1111 / j.1360-0443.2010.03351.x. PMID 21382111.
4. "PsychiatryOnline - APA Practice Guidelines - Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition".
5. "The treatment and management of depression in adults" (PDF). NICE. October 2009. Retrieved 12 November 2014.
6. "Depression, Major: Prognosis". MDGuidlines. Guardian Life Insurance Company of America. Retrieved July 16, 2010.