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Major depressive episode diagnostic criteria, lupus fatigue medication - Reviews

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Since the classic descriptions, depression has been conceived as an episodic and recurrent illness. This article provides an update on the diagnosis, causation, and treatment of chronic depressive problems, with a focus on the recently introduced diagnostic category of persistent depressive disorder (PDD). In DSM-III and DSM-IV, the protracted forms of depression have been conceptualized as dysthymia and by the chronic specifier of major depressive episodes. In DSM-III and DSM-IV, dysthymia was trumped by MDD and was only diagnosed if the threshold for a major depressive episode was not met in the initial 2 years of symptoms. While the merger of dysthymia and chronic depression into PDD is well justified by their strong sequential comorbidity and similar implications for prognosis and treatment, several aspects of the new diagnosis are not well supported by evidence and may not be useful. The assumption that most individuals with chronic depression also fulfill the dysthymia criteria may not hold consistently enough—it creates a group of individuals who suffer from chronic depression but do not receive the PDD diagnosis. The DSM-IV specifier “with atypical features” can be used to characterize the current or most recent depressive episode in patients with either unipolar or bipolar type mood disorder and in patients with dysthymic disorder.10 As described in the Table, the DSM-IV specifier requires the presence of mood reactivity (criterion A) and at least 2 of 4 criterion B features (significant weight gain or hyperphagia, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity resulting in social or occupational impairment). To avoid overdiagnosis or underdiagnosis, bear in mind definitional aspects of the clinical features that constitute the criteria for atypical depression. Interpersonal rejection sensitivity in the context of atypical depression implies a lifelong trait (during both periods of depression and periods of euthymia) that is typically exacerbated during depressive episodes. Studies have suggested that patients with atypical depression tend to have an earlier onset of symptoms and a more chronic course than their melancholic counterparts.24,26,27Atypical depression is more common in younger women. The validity of mood reactivity as a mandatory feature for diagnosing atypical depression has been challenged.
One established characteristic of atypical depression is its differential response to MAOIs.
The hypothesis that reactive mood as a mandatory criterion is not indispensable for the diagnosis of atypical depression was supported by the community study by Angst and colleagues.21 Although mood reactivity was the most common symptom reported by their sample of patients with atypical depression (89% to 90%), other symptoms (ie, rejection sensitivity, leaden paralysis, and hypersomnia) were also quite commonly present (78% to 89%). Clearly, the inclusion of mood reactivity as a mandatory or hierarchical criterion for the diagnosis of atypical depression should be reassessed.
ABSTRACT: Depression is a common complication of cancer, occurring in about 25% of all patients. Because many clinicians believe that they themselves would be depressed if they had cancer, depression is sometimes viewed as being “appropriate” in cancer patients. Given the seriousness of depression, it is important for caregivers to recognize and treat it.
The two major diagnoses for significant depressive symptoms are adjustment disorder (reactive depression) and major depression. Because these criteria may not be specific for depression in medical illnesses, a set of psychological criteria is often used in their place. Since depression is both prevalent and treatable in cancer patients, caregivers should routinely screen patients for its presence. Assessment for depression with a rapid mental status examination is feasible and should be done in the context of a regular medical visit. Some screening tools used in oncology settings include the Hospital Anxiety and Depression Scale (HADS), Primary Care Evaluation of Mental Disorders (PRIME-MD), and the Zung Self-Rating Depression Scale.[20-22].
Once depressive symptoms have been identified, the clinician should eliminate other possible diagnoses besides major depression. Within a few weeks, however, most patients have adapted to the new reality, and symptoms resolve, usually as treatment is undertaken and optimism about the future begins to return.[25] This is not a major depressive episode. Physical Illness—As noted above, it is important to try to distinguish between symptoms resulting from the medical illness and neurovegetative symptoms of depression.

Drugs Used in Cancer Treatment—Medications commonly used in cancer treatment can also cause depressive symptoms. Although a significant number of chemotherapeutic agents are known to have potentially severe side effects, relatively few of these drugs cause depression.
Dementia—When patients have difficulty with memory and concentration, it may be difficult to tell whether the symptoms are due to dementia or major depression. Neuropsychological testing may be helpful in distinguishing between dementia and the pseudodementia of depression.
Bipolar Disorder—It is important to ask the patient about any personal history of manic episodes or a family history of bipolar disorder (ie, symptoms of episodic euphoria, grandiosity, increased energy and physical activity despite sleeplessness, spending sprees, or hypersexuality), as the treatments for depression and bipolar disorder differ. Depressive episodes with clear onset and offset and sharp contrast with one’s usual mood and behaviors are perhaps the most conspicuous feature of severe mood disorders. Dysthymia was characterized by milder symptoms not fully meeting criteria for MDD, but lasting 2 years or longer and meriting clinical attention because of the cumulative burden of long-standing symptoms. Major depressive episodes could be specified as chronic if the full criteria were continuously met for 2 years or longer. This new division of depressive disorders gives more weight to duration than to severity of symptoms. Findings from 4 studies showed that mood reactivity does not significantly correlate with the presence of criterion B features, which suggests that mood reactivity should not be considered an obligatory feature for the diagnosis of atypical depression.22,28,30,31 Furthermore, regarding melancholia (which requires the loss of mood reactivity) as exclusionary of the diagnosis of atypical depression subtype makes the presence of reactive mood largely redundant.
The correlation between the presence or absence of reactive mood and a differential response to either TCAs or MAOIs has been challenged by a number of pharmacological studies.29,32-38 Findings from those studies suggest that the effectiveness of MAOIs in depression is not necessarily associated with mood reactivity, implying that the presence of this specific feature may not be essential for diagnosing this syndrome.
This suggests that atypical depression could also be effectively diagnosed when mood reactivity is not considered a mandatory criterion.21 In a more recent analysis, Angst and colleagues24 reported that diagnosis of atypical depression could be made with equal validity if 3 of 5 criteria (including mood reactivity) or 2 of 4 criteria (excluding mood reactivity) were used.
This could be done using the available literature or, ideally, through more specific studies (ie, compare subjects with 2 or more criterion B symptoms and reactive mood with subjects with 2 or more criterion B symptoms without reactive mood). Papakostas, MD is Director of Treatment-Resistant Depression Studies in the Department of Psychiatry at Massachusetts General Hospital and Associate Professor of Psychiatry at Harvard Medical School in Boston.
If left untreated, depression can contribute to poor treatment compliance, increased hospital stays, and mortality. However, it is never appropriate for cancer patients to suffer with significant depression. Past studies have shown that oncologists and primary care providers have difficulty recognizing depressive symptoms in cancer patients.[14,15] Major depression is a clinical entity with specific signs, symptoms, and treatments. Major depression is usually distinguished from an adjustment disorder by the degree, duration, or amount of symptoms.
Many of the neurovegetative symptoms of depression— especially loss of energy, loss of appetite, and sleep disturbance—overlap with common symptoms of cancer or other medical illnesses, and with side effects of medical treatments used in cancer patients. Endicott suggested substituting the psychological symptoms of self-pity, brooding, crying spells, and pessimism for the neurovegetative symptoms.[17] Some clinicians highlight the importance of the cognitive symptoms of depression, such as depressed thoughts, hopelessness about appreciating any degree of quality in their lives, guilt or worthlessness, or persistent suicidal ideation. Several predisposing factors have been correlated with the development of depression in cancer patients.

Symptoms typically associated with depression can be seen with other situations related to cancer. If the diagnosis is still in question after applying the Endicott substitution criteria, it may be beneficial to institute a trial of antidepressant therapy to see whether symptoms improve. Because the depression is the direct result of medical illness, psychiatrists technically call it a mood disorder secondary to a medical condition. Endocrinologic abnormalities that should be looked for include hyperthyroidism or hypothyroidism, Cushing’s syndrome, hyperparathyroidism, and adrenal insufficiency.[26] Depression occurs with greater frequency and severity in patients with pancreatic cancer, although the mechanism is not fully understood. Depressive symptoms can be seen with primary central nervous system lesions or brain metastases, particularly right-sided or frontal lesions. The glucocorticosteroids, prednisone and dexamethasone frequently cause alterations in mood, which range from euphoria to irritability to severe depression, as well as delirium and psychosis. Patients with personality disorders, particularly borderline personality disorder, describe lifelong histories of depression and long-standing patterns of intense, conflictual relationships, self-destructive behaviors, and chronic feelings of emptiness.
The symptomatic criteria for dysthymia differed in part from those for major depressive episode, with an emphasis on low self-esteem and hopelessness (Table 1).
DSM-5 defines PDD on the basis of the set of symptoms for dysthymia, with the assumption that most individuals who meet the full symptoms for MDD also meet criteria for dysthymia. The inclusion of mood reactivity as an essential feature also neglects the fact that some depressive episodes, when quite severe, manifest with a nonreactive mood, even in the presence of reversed neurovegetative symptoms. Medical issues, as well as psychosocial stressors, can complicate the diagnosis of depression in people with cancer. Referred to as the “neurovegetative symptoms” of depression, some of these symptoms are related to bodily functions. This section reviews common medical problems and psychiatric disorders that must be considered and ruled out before diagnosing major depressive disorder in a cancer patient. Relief of the pain, or even acknowledgment of its existence and an attempt to relieve it, often leads to an improvement in depressive symptoms. Neurologic problems unrelated to cancer, such as cerebral vascular disease, Parkinson’s disease, and Huntington’s disease, have also been known to produce depression. Interferon-alfa (Intron A, Roferon-A) and interleukin-2 (aldesleukin [Proleukin]), which are also frequently given to cancer patients, may cause depressive symptoms, as well as cognitive deficits. Depression can sometimes have psychotic features, but hallucinations are not typically visual. The history, including the onset, time course of depressive and cognitive symptoms, course of illness, and responses to treatment, is often helpful in making this determination.[16] In patients with dementia, there is usually a history of slowly declining cognitive function, whereas in those with major depressive episode, there is usually an abrupt onset of cognitive difficulties associated with the depression. They may, however, also experience a comorbid episode of depression and require psychotropic medication.
The term “anergic depression” is sometimes used to describe depressive episodes that take this form. This article describes the clinical presentation of depression in cancer patients, reviews the differential diagnosis, and discusses various treatment options, including antidepressants. Just as one would not immediately diagnose pneumonia in a patient who has a cough, a patient who is crying may not necessarily have a major depressive episode.

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