Major depression is a significant global health concern, ranking second leading cause of disability worldwide. The international community has acknowledged its growing prevalence and impact.
Types of major depression:
Major depressive disorder (MDD): MDD is characterized by a loss of interest for over two weeks. It was accompanied by manifestations like alterations in appetite or body weight, sleep disturbances (either insomnia or hypersomnia), psychomotor restlessness or slowed movements, persistent fatigue, overwhelming guilt, impaired concentration, and contemplating death or suicide.
Persistent depressive disorder: Another form of depressive disorder recognized is persistent depressive disorder, formerly known as dysthymia. This condition involves a consistently low mood for at least two years and several other symptoms, such as hopelessness, changes in sleep and appetite, fatigue, low self-esteem, and difficulty making decisions.
The mood may manifest as irritability in children and adolescents, lasting at least one year.
Other Specified Depressive Disorder: Patients who don't fully meet the criteria for MDD or persistent depressive disorder, termed Other Specified Depressive Disorder. This category includes patients with insufficient symptoms but experiencing recurrent episodes of depression for 2–13 days (recurrent brief depression) or having a depressive episode lasting 4–13 days (short-duration depressive episode).
How common is depression?
Depression is a highly prevalent psychiatric condition, particularly among adolescents. Based on the reported studies, the prevalence is around 11.7% for major depressive disorder or dysthymic disorder in adolescents. Moreover, there has been a noticeable 2.6% increase in adolescents experiencing major depressive episodes from 2005 to 2014. Rates of depression are even higher among adolescents from low socioeconomic backgrounds or marginalized populations. Adolescence represents a critical period with a significant rise in the risk of depression, and the impairments associated with adolescent depression can persist into adulthood, resulting in substantial morbidity and lifelong challenges.
Despite widespread depressive symptoms, less than 1% of children and adolescents in the United States receive outpatient treatment for depression each year.
Sex differences in children and adolescents: Rates of depression show variations between genders throughout childhood and adolescence. Before puberty, the rates of depressive disorders were similar for both sexes.
However, after puberty, there is a noticeable shift toward a 2:1 ratio of females to males, a pattern that continues into adulthood.
Prevalence among adults: Major depression remains a prevalent mood disorder among young and middle-aged adults. The Substance Abuse and Mental Health Services Administration (SAMHSA) has published a report in 2014 reporting that, approximately 15.7 million adults in the US experienced at least one major depressive episode in the previous year, representing 6.7% of the total adult population. Additionally, 4.3% of adults (equivalent to 10.2 million individuals) reported having a major depressive episode with severe impairment.
Sex differences in adults: On a global scale, women are more prevalent to depression than men. For instance, women have a lifetime prevalence rate for major depression of approximately 21%, compared to 12% among men. This disparity between genders becomes evident early in adolescence, and several factors, including developmental, biological, cultural, and social aspects, contribute to this difference.
Adult depression and suicide: Depression plays a significant role in suicide risk. An estimated two-thirds of individuals who die by suicide in the United States have depression at the time of the act. F
Prevalence of depression in older adults: The overall prevalence rate of depression in the more ageing adult population is estimated to be 2.6%.
Symptoms | Characteristics of depression
Depressive disorders share common symptoms across age groups, including sadness, crying, loss of interest in previously enjoyed activities, decreased energy, and changes in sleep and eating patterns.
In adolescents, however, depression may manifest in slightly different ways. For instance, more than 60% of depressed teenagers experience significant impairments in school or work performance, family life, daily chores, and social relationships. Recent research has also highlighted atypical presentations of depression in youth, including fatigue, irritability, and anger. These emotional symptoms often manifest in poor school performance, negative acting out, and strained interpersonal relationships. These behavioural changes must persist for at least two weeks to be considered impaired and represent a noticeable deviation from the individual's previous normal functioning levels. It's important to note that while episodes of major depressive disorder occur less frequently in children compared to adolescents, they tend to be longer in duration in the former group, with children experiencing a median episode length of 16 weeks compared to 8 weeks in adolescents. Therefore, clinicians are encouraged to intervene rather than adopt a watchful waiting approach to alleviate suffering, particularly considering the sensitive developmental stages of childhood and adolescence.
Worldwide, women are approximately twice as likely as men to experience depression. Lifetime prevalence rates for major depression in women are around 21%, compared to 12% in men.
This gender difference emerges early in adolescence and is attributed to developmental, biological, cultural, and social factors. As per the World Health Organization (WHO), depression imposes an approximately 50% higher burden on women than men. It is the primary cause of functional impairment in women across various socioeconomic contexts. Another concerning aspect is that maternal depression, especially in developing countries, may pose a risk factor for impaired growth in young children, underscoring the intergenerational impact of depression.
Additionally, there are gender-based differences in the presentation of depression in adults. For instance, women commonly report sadness, worthlessness, and guilt symptoms. In contrast, men are more likely to describe feelings of fatigue, irritability, sleep disturbances, and a loss of interest in previously enjoyable activities.
Treatment
Treatment guidelines for children and adolescents with depressive disorders are cautious due to insufficient evidence.
Psychotherapies such as behavioural therapy, cognitive therapy, and cognitive-behavioral therapy, among others, haven't shown clear advantages over one another.
Similarly, recommendations regarding pharmacotherapy are limited, emphasizing the importance of shared decision-making between clinicians, patients, and their families.
For adults with depression, treatment options expand.
Initial treatment options include psychotherapy or second-generation antidepressants. The effectiveness of various psychotherapies appears comparable, including behavioural therapy, cognitive-behavioral therapy, mindfulness-based cognitive therapy, interpersonal psychotherapy, and psychodynamic therapies.
'For those considering combined treatment, cognitive-behavioural therapy or interpersonal psychotherapy, in addition to a second-generation antidepressant, is recommended.
Complementary and alternative treatments are suggested for cases where psychotherapy or pharmacotherapy proves ineffective or unacceptable. These may include exercise, St. John's Wort, bright light therapy, yoga, and acupuncture. However, evidence for some treatments still needs to be provided.
In cases of subclinical depression, psychotherapy, including cognitive-behavioral and non-cognitive-behavioral therapy, is recommended.
For patients who do not respond adequately to initial antidepressant treatment, the guidelines propose switching to cognitive therapy alone or another antidepressant. Combination therapy, such as adding psychotherapy to antidepressant medication, is also an option.
Relapse prevention strategies focus on psychotherapy, including cognitive-behavioural therapy, mindfulness-based cognitive therapy, or interpersonal psychotherapy. The choice between these therapies depends on patient preference and clinical context.
Older adults with depression may require tailored approaches. Initial treatment options include group life review, cognitive-behavioural therapy, combined pharmacotherapy, and interpersonal psychotherapy. Individual cognitive-behavioural therapy or interpersonal psychotherapy may be offered when these are not acceptable or available.
Subthreshold or minor depression in older adults can be treated with various approaches, including cognitive-behavioural therapy, life review course, problem-solving therapy, or selective serotonin reuptake inhibitors, with consideration of their side-effect profile.
Depression in older adults with cognitive impairment or dementia may benefit from problem-solving therapy, behavioural therapy, or pleasant events behavioural therapy, depending on the individual's condition.
Patients with MDD and comorbid medical or other complications have specific treatment options, including cognitive-behavioural therapy, multicomponent interventions, or coping improvement therapy, designed to address their unique needs.
For older adults with a history of depression, a combination of interpersonal psychotherapy and pharmacotherapy is recommended to prevent recurrence. When this isn't suitable, interpersonal psychotherapy alone may be considered.
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