1. DSM-III-R criteria for major depressive disorder 2. Prevalence of major depressive and other mood disorders 3. Major depressive disorder subgroups 6. Confounds in the diagnosis and treatment of depression in 1. Guideline development process 2. Conditions associated with mood symptoms 3. Differential diagnosis of primary mood disorders . . Executive Summary Up to one in eight individuals may require treatment for depression during their lifetimes. The direct costs of treatment for major depressive disorder combined with the indirect costs from lost productivity are significant, accounting for approximately $16 billion per year in 1980 dollars. Regrettably, only one-third to one-half of those with major depressive disorder are properly recognized by practitioners. Fewer than one-third of patients with bipolar disorder are in treatment. Despite the high prevalence of depressive symptoms and major depressive episodes in patients of all ages, depression is underdiagnosed and undertreated by primary care and other nonpsychiatric practitioners, who are, paradoxically, the providers most likely to see these patients initially. Depression may occur concurrently with other nonpsychiatric general medical disorders or with other psychiatric disorders; it may also be brought on by the use of certain medications. Major risk factors for depression include a personal or family history of depressive disorder, prior suicide attempts, female gender, lack of social supports, stressful life events, and current substance abuse. The social stigma surrounding depression is substantial and often prevents the optimal use of current knowledge and treatments. The cost of the illness in pain, suffering, disability, and death is high. Once identified, depression can almost always be treated successfully, either with medication, psychotherapy, or a combination of both. Not all patients respond to the same therapy, but a patient who fails to respond to the first treatment attempted is highly likely to respond to a different treatment. This Clinical Practice Guideline focuses on the diagnosis of depressive disorders, particularly in outpatients. Depression is defined according to the current U.S. standard diagnostic system in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), published by the American Psychiatric Association. A clinical depression or a mood disorder is a syndrome (i.e., a constellation of signs and symptoms) that is not a normal reaction to life's difficulties. Depressive and other mood disorders involve disturbances in emotional, cognitive, behavioral, and somatic regulation. Depressive disorders should not be confused with the depressed or sad mood that is a normal response to specific life experiences-particularly losses or disappointments. These responses are transient and are not associated with significant functional impairment. A sad or depressed mood is only one of the many signs and symptoms of clinical depression. In fact, the mood disturbance may include apathy, anxiety, or irritability rather than or in addition to sadness; further, the patient's interest or capacity for pleasure or enjoyment may be markedly reduced. Primary mood disorders include both depressive (unipolar) and manicdepressive (bipolar) conditions. Major depressive disorder (sometimes called unipolar depression) is characterized by one or more episodes of mild, moderate, or severe clinical depression without episodes of mania or hypomania (i.e., low-level mania). By definition, major depressive episodes last at least 2 weeks (typically much longer) in both major depressive and bipolar disorders. A sad mood or a significant loss of interest is required, along with several associated signs and symptoms, to warrant a diagnosis of a major depressive episode. A major depressive episode can occur as part of a primary mood disorder (e.g., major depressive or bipolar disorder), as part of other nonmood psychiatric conditions (e.g., eating, panic, or obsessive-compulsive disorders), in association with drug or alcohol intoxication or withdrawal, as a biologic consequence of various general medical conditions (secondary mood disorders), or as a consequence of selected prescribed medications. Unipolar forms of primary mood disorders are divided into three groups: ■ Major depressive disorder consists of one or more episodes of major depression with or without full recovery between episodes. ■ Dysthymic disorder features a low-grade, more persistent depressed mood and associated symptoms for at least 2 years, during which a major depressive episode has not occurred. Over extended followup, many patients with this disorder develop episodes of major depression. ■ Depression not otherwise specified (DNOS) is a residual category for patients with symptoms and signs of depression that do not meet the formal diagnostic criteria for either major depressive or dysthymic disorder. Bipolar disorders are recurrent, episodic conditions characterized by a history of at least one manic or hypomanic episode. Bipolar disorders have been grouped into three types: Bipolar I disorder features at least one manic episode along with (nearly always) major depressive episodes. ■ Bipolar disorder not otherwise specified is a residual category that includes bipolar II disorder, a condition characterized by recurrent episodes of major depression along with hypomanic (but not full-blown manic) episodes, as well as other forms that do not meet formal criteria for bipolar I or cyclothymic disorder. ■ Cyclothymic disorder is characterized by numerous periods of mild depressive symptoms insufficient in duration or severity to meet the criteria for major depressive episodes interspersed with hypomanic episodes; it lasts at least 2 years by definition. Patients with this condition are rarely free of mood symptoms. Major depressive disorder may begin at any age, but it most commonly begins in the 20s to 30s. Symptoms develop over days to weeks. Some persons have only a single episode, with a full return to premorbid functioning. However, more than 50 percent of those who initially suffer a single major depressive episode eventually develop another. In these cases, the diagnosis is revised to recurrent major depressive disorder. The course of recurrent major depressive disorder is variable. In some patients, the episodes are separated by many years of normal functioning without symptoms. For others, the episodes become increasingly frequent with greater age. Major depressive episodes nearly always reduce social, occupational, and interpersonal functioning to some degree, but functioning usually returns to the premorbid level between episodes if they remit completely. Major depressive episodes may end completely or only partially. If the latter occurs: ■ The likelihood of a subsequent episode is higher. ■ The need for longer term treatment is increased. The prognosis following subsequent episodes is for continuing poor or partial interepisode recovery. ■The need for treatment with both medication and psychotherapy may be greater. The point prevalence for major depressive disorder in the Western industrialized nations is 2.3 to 3.2 percent for men and 4.5 to 9.3 percent for women. The lifetime risk for major depressive disorder is 7 to 12 percent for men and 20 to 25 percent for women. Prevalence rates are unrelated to race, education, income, or civil status. Risk factors for major depressive disorder include female gender, a history of depressive illness in first-degree relatives, and prior episodes of major depression. The point prevalence of major depressive disorder seen in primary care outpatient settings ranges from 4.8 to 8.6 percent. Three subgroups of major depressive disorder based on cross-sectional symptom features-psychotic (with delusions or hallucinations), melancholic, and atypical-may have implications for treatment selection. Two subgroups based on course features—seasonal pattern and postpartum onset-have prognostic utility; the seasonal type may also suggest the specific therapeutic option of light therapy. The essential feature of dysthymic disorder is a chronic mood disturbance (sadness in adults; sadness and, possibly, irritability in children and adolescents) present most of the time for at least 2 consecutive years (1 year for children and adolescents). The differentiation between dysthymic disorder and major depressive disorder can be difficult. Their symptoms are similar, differing only in duration and severity. Data from the large, multisite Epidemiologic Catchment Area (ECA) Study indicate a lifetime rate of dysthymic disorder of 4.1 percent for women and 2.2 percent for men. Depression not otherwise specified identifies mood conditions with depressive symptoms that do not meet either the severity or the duration criteria for dysthymic, major depressive, or bipolar disorders. An analysis of the ECA Study data showed that 11.0 percent of subjects met the |