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Major Depression

Also known as unipolar disorder, major depression is a syndrome of persistently sad, dysphoric mood accompanied by disturbances in sleep and appetite, lethargy, and an inability to experience pleasure (anhedonia). Major depression occurs in up to 17% of adults, affecting all racial, ethnic, and socioeconomic groups. It affects both sexes but is more common in women.

About half of all depressed patients experience a single episode and recover completely; the rest have at least one recurrence. Major depression can profoundly alter social, family, and occupational functioning.

However, suicide is the most serious complication of major depression, resulting when the patient's feelings of worthlessness, guilt, and hopelessness are so overwhelming that he no longer considers life worth living. Nearly twice as many women as men attempt suicide, but men are far more likely to succeed.


The multiple causes of depression are not completely understood. Current research suggests possible genetic, familial, biochemical, physical, psychological, and social causes. Major depression is caused by imbalance of certain neurotransmitters (chemical messengers) in the brain. The following are the most common causes for major depression:

  • unemployment
  • family history of depression
  • death of loved one
  • financial difficulties
  • poor self-esteem,
  • a pessimistic view of oneself and the world.
  • other chronic illnesses
  • loss of relationship

Signs and symptoms

The primary features of major depression are a predominantly sad mood and a loss of interest or pleasure in daily activities. Symptoms tend to be more severe than those caused by dysthymic disorder, which is a milder, chronic form of depression.

The depressive patient may complain of feeling "down in the dumps," express doubts about his self worth or ability to cope, or simply appear unhappy and apathetic. He also may report feeling angry or anxious.

Other common signs include difficulty concentrating or thinking clearly, distractibility, and indecisiveness. Take special note if the patient reveals suicidal thoughts, a preoccupation with death, or previous suicide attempts.

The psychosocial history may reveal life problems or losses that can account for the depression. Alternatively, the patient's medical history may implicate a physical disorder or the use of prescription, nonprescription, or illegal drugs that can cause depression.

The patient may report an increase or a decrease in appetite, sleep disturbances (for example, insomnia or early awakening), a lack of interest in sexual activity, constipation, or diarrhea. Other signs that you may note during a physical examination include agitation (such as hand wringing or restlessness) and reduced psychomotor activity (for example, slowed speech).


The diagnosis of major depression is supported by psychological tests, such as the Beck Depression Inventory, which may help determine the onset, severity, duration, and progression of depressive symptoms A toxicology screening may suggest drug induced depression.


Depression is difficult to treat, especially in children, adolescents, elderly patients, and those with a history of chronic disease. The primary treatment methods are drug therapy, electroconvulsive therapy (BCT), and psychotherapy.

Drug therapy

In depression, drug therapy includes tricyclic antidepressants (TCAs) such as amitriptyline, serotonin reuptake inhibitors such as fluoxetine, and monoamine oxidase (MAO) inhibitors, such as isocarboxazid, maprotiline, and trazodone.

  • The most widely used class of antidepressant drugs, TCAs prevent the reuptake of norepinephrine or serotonin (or both) into the presynaptic nerve endings, resulting in increased synaptic concentrations of these neurotransmitters. They also cause a gradual loss in the number of betaadrenergic receptors.
  • After resolution of the acute episode, patients with a history of recurrent depression may be maintained on low doses of antidepressants as a preventive measure.
  • Selective serotonin reuptake inhibitors, including fluoxetine, paroxetine, and sertraline, are increasingly becoming the drugs of choice. They are effective and produce fewer adverse effects than the TCAs; however, they're associated with sleep and GI problems and alterations in sexual desire and function.
  • MAO inhibitors block the enzymatic degradation of norepinephrine and serotonin. These agents often are prescribed for patients with atypical depression (for example, depression marked by an increased appetite and need for sleep, rather than anorexia and insomnia) and for some patients who fail to respond to TCAs.

MAO inhibitors are associated with a high risk of toxicity; patients treated with one of these drugs must be able to comply with the necessary dietary restrictions. Conservative doses of an MAO inhibitor may be combined with a TCA for patients refractory to either drug alone.

Maprotiline is a potent blocker of norepinephrine uptake, whereas trazodone is a selective serotonin uptake blocker. The mechanism of action of bupropion is unknown.


When a depressed patient is incapacitated, suicidal, or psychotically depressed, or when antidepressants are contraindicated or ineffective, ECT often is the treatment of choice. Six to 12 treatments usually are needed, although improvement often is evident after only a few treatments. Researchers hypothesize that ECT affects the same receptor sites as antidepressants.


Short-term psychotherapy also is effective in treating major depression. Many psychiatrists believe that the best results are achieved with a combination of individual, family, or group psychotherapy and medication. Therapeutic interventions focus on identifying the patient's negative thoughts and interpretations and substituting adaptive responses.

Some episodes of depression can be avoided by:

  • Learning how to relax and manage stress
  • Avoiding alcohol, drugs, and caffeine
  • Exercising regularly
  • Maintaining good sleep habits

Counseling may help you through times of grief, stress, or low mood. Family therapy may be particularly important for teens who feel blue.

For elderly or others who feel socially isolated or lonely, try volunteering or getting involved in group activities.

Medications and psychiatric counseling may prevent recurrences. Some episodes of depression are not preventable.

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