Major Depressive Disorder

Diagnosis

There are two diagnosis criteria in the DSM-IV-TR that clinicians refer to when assessing an individual for MDD.  The first set is for MDD single episode and the second is MDD recurrent.  This paper will be focusing on MDD, Recurrent.  To be considered for MDD a client must have had two or more separate Major Depressive Episodes (American Psychology Association, 2000).  To be considered separate episodes, there must be an interval of at least two consecutive months in which criteria are not met for a Major Depressive Episode (MDE) (American Psychology Association, 2000).  To meet criteria for MDE, a clinician would ensure that the client expresses symptoms of; depressed mood for most of the day, and every day, reduced interest in activities, increased or decreased appetite, insomnia or hypomania, feelings of restlessness, fatigue, and loss of energy, feelings of inappropriate guilt or worthlessness, recurrent thoughts of death or dying or suicidal thoughts and an inability to concentrate on a daily basis (American Psychology Association, 2000).  HIV is transferred from human to human through contact with blood, semen, vaginal fluids and breast milk.  Since HIV is a chronic infection that has a great deal of stigma attached to being positive an infected individual can fall into a depressive episode  soon after being informed of their status.  The need to deal with the connection between mental health issues and HIV is emphasized in a study of Tanzanian women, which found depression was associated with disease progression and death (Avert).  A similar relationship was found in the US, where a third of HIV-positive women were assessed as chronically depressed. Further, the AIDS-related mortality rate of those women with chronic HIV was around double that of women who had only little or no signs of depression (Avert). Although a cause-and-effect relationship between depression and mortality was not established it was believed that finding ways to reduce symptoms of depression could potentially prolong and improve the lives of women with HIV (Avert).  HIV-seropositive women without current substance abuse exhibited a significantly higher rate of major depressive disorder and more symptoms of depression and anxiety than did a group of HIV-seronegative women with similar demographic characteristics (Morrison M. F., 2002).

Prevalence

Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44 affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year (National Institute of Mental Health, 2010).  While MDD can develop at any age, the median age at onset is 32 (National Institute of Mental Health, 2010).  Data shows that lifetime risk for MDD in community samples has varied from 10 to 25 percent for women and 5 to 12 percent for men (American Psychology Association, 2000).  There is no data that shows prevalence as it relates to ethnicity, income, marital status, or education (American Psychology Association, 2000).   The prevalence of MDD in HIV infection is significantly higher than that in the general population, with estimates of current MDD in the range of 10% and recent at approximately 36% compared with population prevalence’s of 5% and 7.6% (Patterson K., 2006).    

Causes

Depression is believed to be caused by events that occur in our lives, such as losing a loved one, chronic diseases, substance abuse, or experiencing a trauma (Wrong Diagnosis, 2010).  Current research, reviewed here, suggests that the gender difference in depression may result because women exhibit higher levels of depression associated with anxiety and somatic symptoms including fatigue and sleep and appetite disturbance (Silverstein, 1999). Depression not greatly associated with anxiety and a somatic symptom appears to occur with equal frequency among female and male subjects (Silverstein, 1999).  Evidence from neuroscience, genetics, and clinical investigation demonstrate that depression is a disorder of the brain (National Institute of Mental Health, 2001). Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters – chemicals used by nerve cells to communicate – are out of balance (National Institute of Mental Health, 2001).  The mental health facility’s clinician stated that the individuals that they see with MDD and HIV infection have such a long list of concerns other than HIV that they can’t even take the time out to deal with their infection.  A self-reported 70% of their clients have substance use issues, and little to no income.  Infected individuals face the prospect of social stigma, long-term physical discomfort and illness, and eventual death (Cielsa J. A., 2001).  Given this state of chronic stress for infected individuals, researchers have been naturally concerned about their psychological adjustment to living with this disease (Cielsa J. A., 2001).  Antiretroviral drugs used by infected individuals can also cause or exasperate depression.  Sustiva, Emtriva, Viread, and Atripla (which is a combination of the previous two) have documented cases of severe depression, strange thoughts, or angry behavior, some patients have thoughts of suicide and a few have actually committed suicide (Test positive aware network, 2010).         

Prognosis

HIV is presently incurable and once infected an individual will spend the rest of their life treating their infection.  If HIV goes untreated it can weaken the immune system to a point that it can no longer fight off infection and an opportunistic infection will often occur.  When this happens an infectious disease doctor will usually diagnose the individual with AIDS, the final stage of HIV infection.  While approximately 80 percent of people with depression respond very positively to treatment, a significant number of individuals remain treatment refractory (National Institute of Mental Health, 2001).  Even among treatment responders, many do not have complete or lasting improvement, and adverse side effects are common (National Institute of Mental Health, 2001).

Common Co-occurring Disorders

MDD occurs with many other disorders, as well as medical conditions.  Medical disorders may contribute biologically to depression (Mental Health America, 2010).  Medically ill people may become clinically depressed as a psychological reaction to the prognosis, the pain and/or incapacity caused by the illness or its treatment (Mental Health America, 2010).  There are also various medications and drug interactions that can lead to depression syndromes. Several alternative diagnoses, such as bipolar disorder (especially bipolar II disorder), delirium, dementia, thyroid disorders, fibromyalgia, CFS, PTSD, and others are also possible causes of depressive symptoms (Wrong Diagnosis, 2010). PTSD sufferers have some of the highest rates of depression with over 40 percent of diagnoses showing signs of MDD (National Institute of Mental Health, 2001). 

Differential Diagnosis Issues

Major Depressive Disorder is the most widely studied depressive disorder (Hersen, 2007).  To qualify for a MDD episode, wither depressed mood or lack of interest or pleasure in usual activities must be present, most of the day, nearly every day, and episode must last at least 2 weeks (Hersen, 2007).  With Dysthymia, because of its chronicity and its lack of responsiveness to existing treatments, some feel that dysthymia may more accurately be considered a personality disorder rather than an acute illness like MDD.  This opinion is widely contested however.  Helen’s symptoms in my opinion back up this theory and I think more research on the subject will make it clearer if this is true.  A history of manic, mixed, or hypomanic precludes the diagnosis of MDD (American Psychology Association, 2000).  These episodes indicate a diagnosis of Bipolar I or II disorders. 

Cultural Issues related to diagnosis or course of disorder

Women tend to have more depressive episodes when compared to men.  The differences in rates have been found repeatedly throughout many cultures and thus appear to be an accurate reflection of true differences in the prevalence of the disorder between men and women (Hersen, 2007).  Asian Americans have the lowest rates of depressive episodes.  Interestingly enough Hispanic who has migrated to the U.S has lower rates of depression, but Hispanics that were born here have the same prevalence rates as white Americans (Hersen, 2007).

Treatment Comparison

Interpersonal psychotherapy treatment approach is a short term that usually lasts about 20 hour long sessions (University of Michigan Depression Center, 2006).  Although depression may not be caused by interpersonal events, it usually has an interpersonal component, that is, it affects relationships and roles in those relationships (University of Michigan Depression Center, 2006). IPT was developed to address these interpersonal issues. The precise focus of the therapy targets interpersonal events (such as interpersonal disputes / conflicts, interpersonal role transitions, complicated grief that goes beyond the normal bereavement period) that seems to be most important in the onset and / or maintenance of the depression (University of Michigan Depression Center, 2006).  The typical course of Cognitive Behavioral Therapy for depression consists of three phases, the first phase of treatment focuses on symptom relief (Mor, 2009). The aim of this phase is to re-engage clients in their daily activity and to promote resumed functioning (Mor, 2009). The middle phase of treatment addresses cognitive change, in this phase clients learn to identify automatic thoughts, critically evaluate these thoughts and examine alternative modes of thinking (Mor, 2009). The final phase focuses on maintenance of treatment effects and on relapse prevention. In this phase, clients are encouraged to challenge their underlying negative schemas by engaging in behavioral experiments that test the veracity of the schemas as well as their adaptiveness (Mor, 2009). 

Observed Approach

Oasis Counseling Center utilizes the cognitive behavioral approach when treating someone with MDD.  Cognitive behavioral therapy (also considered to include cognitive psychotherapy) maintains that irrational beliefs and distorted attitudes toward the self, the environment, and the future perpetuate depressive affects (Karasu, 2000). The goal of cognitive behavioral therapy is to reduce depressive symptoms by challenging and reversing these beliefs and attitudes (Karasu, 2000).  The clinician meets with MDD clients on a weekly basis an hour at a time.  She assesses their current situation, the way they are dressed, their personal hygiene etc. are all noted.  The treatment plan developed on a person to person basis lasts for 6 months and is re-evaluated at that time. 

Chosen Treatment Plan

The chosen treatment approach is Interpersonal Psychotherapy.  Interpersonal therapy focuses on losses, role disputes and transitions, social isolation, deficits in social skills, and other interpersonal factors that may impact the development of depression (Karasu, 2000).  Interpersonal therapy attempts to intervene by facilitating mourning and promoting recognition of related affects, resolving role disputes and transitions, and overcoming deficits in social skills to permit the acquisition of social supports (Karasu, 2000).  During studies it was found that interpersonal therapy was reported to be more effective than placebo plus clinical management and comparable to cognitive behavioral therapy or imipramine plus clinical management (Karasu, 2000).  In one trial conducted among HIV-positive patients with major depressive disorder, significantly greater improvement was observed following interpersonal therapy than supportive therapy (Karasu, 2000). In a subsequent study among depressed HIV-positive 56 APA Practice Guidelines patients, greater improvements were observed after interpersonal therapy or interpersonal therapy plus imipramine than supportive psychotherapy or cognitive behavioral therapy (Karasu, 2000). 

Reference Page

American Psychology Association. (2000). Diagnostic and statistical manual of mental disorders (4th edition). Washington: American Psychiatric Association.

Avert. (n.d.). Living with HIV/AIDS: emotional needs and support. Retrieved October 17, 2010, from Averting HIV & AIDS: http://www.avert.org/emotional-needs-support.htm

Avert. (n.d.). The different stages of HIV infection. Retrieved October 18, 2010, from AVERTing HIV & AIDS: http://www.avert.org/stages-hiv-aids.htm

Cielsa J. A., r. J. (2001). Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry, 725-730.

Karasu, B. G. (2000). Practive guideline for the treatment of patients with Major Depressive Disorder, 2nd edition. Phoenix: APA.

Mental Health America. (2010). Co-Occurring disorders and depression. Retrieved October 18, 2010, from Mental health America: http://www.nmha.org/index.cfm?objectid=C7DF94C1-1372-4D20-C8FE4E509C20471B

Mor, N. H. (2009). Cognitive behavioral therapy. Psychiatry Relations, 269-273.

Morrison M. F., P. J.-S. (2002). Depressive and anxiety disorders in women with HIV. Am J Psychiatry, 798-796.

National Institute of Mental Health. (2001, March 14). Depression research. Retrieved October 18, 2010, from Wrong Diagnosis: http://www.wrongdiagnosis.com/artic/depression_research_nimh.htm

National Institute of Mental Health. (2010, October 5). The Numbers Count: Mental Disorders in America. Retrieved October 15, 2010, from National Institute of Mental Health: http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml

Patterson K., C. Y. (2006). Screening for major depression in persons with HIV infection: the concurrent predictive validity of the profile of mood states depression-dejection scale. Methods in Psychiatric Research, 75-82.

Silverstein, B. (1999). Gender difference in the prevalence of clinical depression: the role played by depression associated with somatic symptoms. Psychiatry, 480-482.

Test positive aware network. (2010, March/April). The 14th annual HIV drug guide. Positively aware, pp. 3-67.

University of Michigan Depression Center. (2006, February 6). interpersonal psychotherapy for depression. Retrieved October 18, 2010, from About Depression: http://med.umich.edu/depression/ipt.htm

Wrong Diagnosis. (2010). Misdiagnosis of depression. Retrieved October 18, 2010, from Wrong Daignosis: http://www.wrongdiagnosis.com/d/depression/misdiag.htm

Wrong Diagnosis. (2010). Wrong diagnosis. Retrieved October 15, 2010, from Causes of depression: http://www.wrongdiagnosis.com/d/depression/causes.htm