Major depressive disorder with anxious distress symptoms

History

Patients with major depressive disorder may not initially present with a complaint of low mood, anhedonia, or other typical symptoms. In the primary care setting, where many of these patients first seek treatment, the presenting complaints often can be somatic (e.g., fatigue, headache, abdominal distress, or change in weight). Patients may complain more of irritability or difficulty concentrating than of sadness or low mood.

Children with major depressive disorder may also present with initially misleading symptoms such as irritability, decline in school performance, or social withdrawal. Elderly persons may present with confusion or a general decline in functioning; they also experience more somatic complaints, cognitive symptoms, and fewer complaints of sad or dysphoric mood.

Familial, social, and environmental factors

Depression can be familial. Thus, a thorough family history is quite important. Familial, social, and environmental factors appear to play significant roles in the course of depressive illness in children and youths, even in preschool children. [73] René Spitz described anaclitic depression (marasmus) in infants being raised in an orphanage and in hospitalized children whose parents were not allowed to visit. [74]

Dysphoric mood

A dysphoric mood state may be expressed by patients as sadness, heaviness, numbness, or sometimes irritability and mood swings. They often report a loss of interest or pleasure in their usual activities, difficulty concentrating, or loss of energy and motivation. Their thinking is often negative, frequently with feelings of worthlessness, hopelessness, or helplessness.

Psychosis

Patients with major depressive disorder commonly show ruminative thinking. Nevertheless, it is important to evaluate each patient for evidence of psychotic symptoms, because this affects initial management.

Psychosis, when it occurs in the context of unipolar depression, is usually congruent in its content with the patient's mood state; for example, the patient may experience delusions of worthlessness or some progressive physical decline.

Symptoms of psychosis should prompt a careful history evaluation to rule out any of the following:

• Substance abuse

• Organic brain syndrome

Physical Examination

No physical findings are specific to major depressive disorder; instead, the diagnosis is based on the history and the mental status examination. Nevertheless, a complete mental health evaluation should always include a medical evaluation to rule out organic conditions that might imitate a depressive disorder. Most of these fall into the following major general categories:

• Infection

• Medication

• Endocrine disorder

• Tumor

• Neurologic disorder

Appearance and affect

Most patients with major depressive disorder present with a normal appearance. In patients with more severe symptoms, a decline in grooming and hygiene can be observed, as well as a change in weight. Patients may show psychomotor retardation, which manifests as a slowing or loss of spontaneous movement and reactivity, as well as demonstrate a flattening or loss of reactivity in the patient's affect (i.e., emotional expression). Psychomotor agitation or restlessness can also be observed in some patients with major depressive disorder.

Speech

Speech may be normal, slow, monotonic, or lacking in spontaneity and content. Pressured speech should suggest anxiety or mania, whereas disorganized speech should prompt an evaluation for psychosis. Racing thoughts could also be an indication of anxiety, mania, or hypomania.

Major Depressive Disorder

The specific DSM-5 criteria for major depressive disorder are outlined below.

At least 5 of the following symptoms have to have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood) [2] :

• Depressed mood: For children and adolescents, this can also be an irritable mood

• Diminished interest or loss of pleasure in almost all activities (anhedonia)

• Significant weight change or appetite disturbance: For children, this can be failure to achieve expected weight gain

• Sleep disturbance (insomnia or hypersomnia)

• Psychomotor agitation or retardation

• Fatigue or loss of energy

• Feelings of worthlessness

• Diminished ability to think or concentrate; indecisiveness

• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide

The symptoms cause significant distress or impairment in social, occupational or other important areas of functioning.

The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders

There has never been a manic episode or a hypomanic episode

Depressive disorders can be rated as mild, moderate, or severe. The disorder can also occur with psychotic symptoms, which can be mood congruent or incongruent. Depressive disorders can be determined to be in full or partial remission.

DSM-5 further notes the importance of distinguishing between normal sadness and grief from a major depressive disorder. While bereavement can induce great suffering, it does not typically induce a major depressive disorder. When the two exist concurrently, the symptoms and functional impairment is more severe and the prognosis is worse compared to bereavement alone. When major depressive disorder is most likely to be induced by bereavement in persons with other vulnerabilities to depressive disorders. A diagnosis of major depressive disorder following a significant loss requires clinical judgement based on the individuals history and the cultural context for expression of grief.

Depression with Anxious Distress

Anxious distress is defined as the presence of at least 2 of the following symptoms [2] :

• Feeling keyed up or tense

• Feeling unusually restless

• Difficulty concentrating because of worry

• Fear that something awful may happen

• Feeling of potential loss of control

Severity is further specified as:

• Mild: Two symptoms

• Moderate: Three symptoms

• Moderate-severe: Four or five symptoms

• Severe: Four or five symptoms with motor agitation

High levels of anxiety are associated with higher suicide risk, longer duration of illness and greater likelihood of nonresponse to treatment.

Depression With Melancholic Features

In depression with melancholic features, either a loss of pleasure in almost all activities or a lack of reactivity to usually pleasurable stimuli is present. Additionally, at least 3 of the following are required:

• A depressed mood that is distinctly different from the kind that is felt when a loved one is deceased

• Depression that is worse in the morning

• Waking up 2 hours earlier than usual

• Observable psychomotor retardation or agitation

• Significant weight loss or anorexia

• Excessive or inappropriate guilt

According to DSM-5, this subtype is applied only when there is a near-complete absence of the capacity for pleasure, not merely a diminution. A depressed mood that is described as merely more severe, longer lasting or present without a reason is not considered a distinct quality. Melancholic features are more frequent in inpatients and are less likely to occur in milder major depressive episodes. They are also more likely to be comorbid with psychotic features.

Depression With Catatonia

The DSM-5 criteria for diagnosis of depressive episodes with catatonia requires the presence of 3 or more of 12 psychomotor features during most of the episode: [2]

• Stupor

• Catalepsy

• Waxy flexibility

• Mutism

• Negativism

• Posturing

• Mannerism

• Stereotypy

• Agitation, not influenced by external stimuli

• Grimacing

• Echolalia

• Echopraxia

Atypical Depression

An episode of depression may be identified as having atypical features. Characteristics of this subtype are mood reactivity and exclusion of melancholic and catatonic subtypes in addition to 2 or more of the following for a period of at least 2 weeks:

• Increased appetite or significant weight gain

• Increased sleep

• Feelings of heaviness in arms or sensitivities of the legs that extend far beyond the mood disturbance episodes and result in significant impairment in social or occupational functioning

• A pattern of longstanding interpersonal rejection sensitivity that extends far beyond the mood disturbance episodes and results in significant impairment in social or occupational functioning

Postpartum Depression

Depression in the postpartum period is a common and potentially very serious problem; up to 85% of women can develop mood disturbances during this period. For most women, symptoms are transient and relatively mild (ie, “postpartum blues”); however, 10-15% of women experience a more disabling and persistent form ofdepression, with an onsetlaterthan the postpartum blues, and 0.1-0.2% of women experience postpartum psychosis. [33, 75, 76, 77]

Postpartum psychiatric illness was initially conceptualized as a group of disorders specifically linked to pregnancy and childbirth and thus was considered diagnostically distinct from other types of psychiatric illness. However, evidence within the past decade suggests that postpartum psychiatric illness is virtually indistinguishable from psychiatric disorders that occur at other times during a woman's life. [78, 79, 80] However, the likelihood of a bipolar outcome is substantially higher in postpartum psychosis.

Postpartum mood disorder (major depressive or manic) episodes with psychotic features appear to occur in from 1 in 500 to 1 in 1000 deliveries. The risk is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder or a family history of bipolar disorder. Women who have had a postpartum episode with psychotic features have a risk of recurrence between 30-50% for subsequent deliveries. [2]

Rapidly fluctuating mood, tearfulness, irritability, and anxiety are common symptoms of postpartum blues. [81, 82, 83, 84] Symptoms peak on the fourth or fifth day after delivery and last for several days, but they are generally time-limited and spontaneously remit within the first 2 postpartum weeks. [81] Symptoms do not interfere with a mother's ability to function and to care for her child.

Women with more severe symptoms or symptoms persisting longer than 2 weeks should be screened for postpartum depression. [79, 80] According to DSM-5, 50% of “postpartum” major depressive episodes actually begin prior to delivery, and the specifier used collectively for these episodes is “with peripartum onset.” [2]

Signs and symptoms of postpartum depression are clinically indistinguishable from major depression that occurs in women at other times. These symptoms interfere with the mother’s ability to function, with risk of self-harm or harm to the infant. [85]

The American Academy of Pediatrics (AAP) states that more than 400,000 infants are born each year to mothers who are depressed. The AAP encourages pediatric practices to create a system to better identify postpartum depression to ensure a healthier parent-child relationship. [86]

Although effective nonpharmacologic and pharmacologic treatments are available, both patients and their caregivers frequently overlook postpartum depression. [79] Untreated postpartum affective illness places both the mother and infant at risk and is associated with significant long-term effects on child development and behavior [78, 80, 85] ; therefore, appropriate screening, prompt recognition, and treatment of depression are essential for both maternal and infant well-being and can improve outcomes. [87]

Seasonal Affective Disorder

About 70% of depressed people feel worse during the winter and better during the summer. To meet the DSM-5 diagnostic criteria [2] for major depressive disorder with seasonal pattern, depression should be present only at a specific time of year (e.g., in the fall or winter) and full remission occurs at a characteristic time of year (e.g., spring). An individual should demonstrate at least 2 episodes of depressive disturbance in the previous 2 years, and seasonal episodes should substantially outnumber nonseasonal episodes. Patients with seasonal affective disorder are more likely to report atypical symptoms, such as hypersomnia, increased appetite, and a craving for carbohydrates.

Cases where there is an obvious effect of seasonally related psychosocial stressors, (e.g., seasonal unemployment) do not meet the diagnostic criteria.

Diagnosing seasonal affective disorder in children is difficult because they experience the recurrent universal stressor of beginning school every autumn. Also, a young child might present with apparent seasonal affective disorder but not yet have had previous episodes.

Major Depressive Disorder with Psychotic Features

The presentation of severe major depressive disorder may include psychotic features. Psychotic features include delusions and hallucination and may be mood congruent or mood incongruent. Mood-congruent psychoses are often consistent with classic depressive themes, such as personal inadequacy, guilt, disease, or deserved punishment. Mood-incongruent psychoses are not consistent with these typical themes but may also occur in depression.

Major depressive disorder with psychotic features is considered a psychiatric emergency. Patients may require psychiatric hospitalization.

Other Specificed Depressive Disorders

The DSM-5 includes a category of disorders with features of depression that do not meet criteria for a specific depressive disorder. Examples include the following: [2]

• Recurrent brief depression

• Short duration depressive episode

• Depressive episode with insufficient symptoms

Consult the DSM-5 for further details regarding the diagnostic criteria for other specified depressive disorders

Metabolic Depression

Several studies report an association between metabolic syndrome and depression. Vogelzangs et al suggest that later in life, waist circumference and not metabolic syndrome can predict onset of depression. Specifically, the larger the waistline, the higher the incidence of depression. [88] However, longitudinal studies have also shown that depression predicts subsequent obesity and centripetal obesity, likely because of poor diet, lack of exercise, and psychobiologic changes such as increased cortisol levels.

On the other hand, individuals with depression who have metabolic syndrome may simply be more likely to have persistent or recurrent depression. Thus, depression with metabolic abnormalities could be labeled metabolic depression, a possible chronic subtype of depression. [88]

Cultural Influences on Expression of Depression

Cultural influences on the presentation of depression can be significant. The practitioner should be aware of differences in the expression of psychological distress in patients from other countries or cultures.

Culturally distinctive experiences (e.g., fear of being hexed or bewitched; experience of visitations from the dead) should be distinguished from actual hallucinations or delusions that may be part of a major depressive episode with psychotic features.

Suicidal Ideation

Patients with depression should be assessed for suicidal ideation, especially if agitation is present. When a patient has contemplated or attempted suicide, the burden is on the health care provider to directly explore the situation with the patient in as much detail as possible to determine the current presence of suicidal ideation as well as accessible means and plans. Discussing these is the most important step clinicians can take in an attempt to prevent suicide in an at-risk patient. For more information, see the Medscape Reference article Suicide.

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Author

Jerry L Halverson, MD Medical Director of Rogers Memorial Hospital at Oconomowoc; Voluntary Clinical Assistant Professor, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health; Clinical Assistant Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, Medical College of Wisconsin

Jerry L Halverson, MD is a member of the following medical societies: American College of Psychiatrists, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Coauthor(s)

Ravinder N Bhalla, MD Assistant Clinical Professor of Child Psychiatry, Rutgers New Jersey Medical School; Medical Director, Mental Health Clinic of Passaic; Consulting Staff, Christian Health Care Center

Ravinder N Bhalla, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Received income in an amount equal to or greater than $250 from: Allergen.

Pascale Moraille-Bhalla, MD Medical Director, Outpatient Clinic of Hoboken University Medical Center; Staff Psychiatrist, Mental Health Clinic of Passaic

Pascale Moraille-Bhalla, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Rachel C Leonard, PhD Clinical Director, Rogers Behavioral Health

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Acknowledgements

Iqbal Ahmed, MBBS, FRCPsych (UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Sarah C Aronson, MD Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland

Disclosure: Nothing to disclose.

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Residency Program, University of Kansas School of Medicine; Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Art Walaszek, MD Associate Professor of Psychiatry, Residency Training Director, Department of Psychiatry, University of Wisconsin School of Medicine and Public Health; Consulting Staff, University of Wisconsin Hospital and Clinics, Meriter Hospital

Art Walaszek, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Terra Nova Learning Systems, Inc. Consulting fee Consulting; Wisconsin Psychiatric Association Honoraria Speaking and teaching; Care Wisconsin, Inc. Honoraria Speaking and teaching

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