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Major Depression
5
Major Depressive Disorder
Learning Product
By: Vanessa Powell
What is MDD?
What is (MDD)?
MDD also known as clinical depression is a multifaceted condition and includes symptoms such as feelings of worthlessness, diminished interest in one’s life, troubles concentrating, physical symptoms such as fatigue and insomnia (Baune & Christensen, 2019).
Depression is a subjective experience making disorders such as MDD difficult to define. One concept remains constant although, which is that MDD is more than a feelings of temporary sadness as symptoms are often severe and must persist at least two weeks (Harvard Health Publishing, 2018).
Figure 1
DSM-5 MDD criteria
What Diagnostic criteria does the dsm-5 list for Mdd?
1.) Depressed mood
2.) Loss of interest or pleasure
3.) Appetite or changes in weight
4.) Insomnia/hypersomnia
5.) Psychomotor retardation/agitation
6.) Lack of energy/fatigue
7.) Worthless/guilt
8.) Impaired concentration/indecisiveness
9.) Thoughts of death, suicial ideation or attempt
Individuals must have at least 5 out of 9 of these symptoms with at least one of depressed mood or lost interest/pleasure in the same two week period (Uher, Payne, Pavlova,
& Perlis, 2013)
Dr. Saraiya's description of symptoms
How Major is MDD? (Its Impact)
In terms of diagnosis, the term 'Major Depressive Disorder' was introduced in the DSM-III remained in the DSM-5 to distinguish between clinical depression and much milder, non-disabling cases (Paris, 2014). This makes MDD a hetergenous diagnosis giving physicians the impression that any individual fitting this extremely broad set of criteria should receive the same treatments which has led to over-diagnosed (Paris, 2014). Therefore, from this perspective, MDD does not seem so 'major' as it can encompass a broad range of criteria.
In terms of its impact on individuals, MDD is major as it has been estimated that the work performance lost due to MDD was $30 - $50 billion dollars per year (Wilson, Vaidyanathan, Miller, McGue & Iacono, 2014) In addition to this, it was estimated the number of cases of MDD worldwide increased from 162 million in 1990 to 241 million in 2017, which is an increase of 49.29%.
(Liu, He, Yang, Feng, Zhao & Lyu, 2019).
How 'Major' is MDD?
Treatments for MDD
How can we help people with MDD?
- 1 in 3 individuals in the US will experience clinical depression,
despite this there are a low number of standardized
treatment options for MDD
(Major, 2017 as cited by American Psychiatric Association, 2013)
Traditionally MDD treatments consist of the following (Major, 2017):
- Drug therapies: First line antidepressants include selective serotonin reuptake
inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, mirtazapine,
bupropion, agomelatine and vortioxetine (Ng, How, Ng, 2017). Others include tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) which are
second-line and third-line, respectively, due to their tolerability and safety profile
(Ng, How, Ng, 2017).
- Cognitive therapies: Psychotherapies such as Cognitive Behavioural Therapy (CBT), interpersonal psychotherapy, and problem solvng therapy
(Ng, How, Ng, 2017). CBT is the first-line and remains the most
evidence based psychological therapy for depression
(Ng, How, Ng, 2017).
*Note: It is also important there is a strong therapeutic relationship
between the patient and physician (Ng, How, Ng, 2017).
Hopefully with more time and research new
treatments will emerge!
Lets explore some other treatments! -->
How can Therapeutic Recreation help those with MDD?
Therapeutic REcreation (TR) forms of treatment for MDD
Below are some (TR) forms of treatments Recreation Therapists could implement:
- Music therapy: Involves playing music to the patients usually by singing and playing an instrument. It reduces depression and uses a psychoeducational perspective to teach patients about coping skills to help manage their symptoms (Silverman, 2013).
- Animal-Assisted Therapy: Specifically Dog-Assisted Therapy (DAT) has been proven to be beneficial for patients who experience depression and anxiety as it can decrease depressive symptoms and blood pressure of patients (Ambrosi, Ziaontz, Peragine, Sarchi & Bona, 2018).
- Art therapy: Decreases depressive symptoms while encouraging self-expression , enhancing percieved control and sense of self, promoting personal change, improving ability meet daily demands, and strengthening individual boundaries (Blomdahl, Gunnarsson, Guregard, Rusner, Wijk & Bjorklund, 2016).
- Problem Solving (PS) Therapy: Although problem solving efficacy in individuals with MDD is not well described, PS T has emerged as a promising form of psychotherapy for adults with MDD (Kirkham, Choi & Seitz). PST allows the person to clearly define a problem and resolve problems one at a time through the use of work sheets (Pierce, 2012).
- Exercise therapy: Moderate-intensity sessions for at least 150 minutes per week have also been proven to be beneficial in reducing depressive symptoms (Ng. How, Ng, 2017).
Electroconvulsive Therapy
What is an effective alternative treatment for mdd?
Electroconvulsive therapy (ECT): ECT has been met with some controversy mainly because it involves a more invasive approach to treatment. Despite this, ECT has helped many individuals who experience MDD lead more positive, fulfilling, and healthy lives. ECT involves giving the patient short-term anesthetic and the delivery of electrical inducements of seizures (Blease,2012).
Physicians must be cautious when recommending ECT as it is not a suitable treatment for everyone. For example, ECT yields a higher remission (recovery) rates in middle and old age patients than younger patients (Dong, Zhu, Zheng, Li, Ng, Ungvari, Xiang, 2018).
A short video clip on ECT!
Comorbidities of MDD
Figure 2
For many individuals a sole diagnosis of MDD is rare. In fact, there
are several comorbidities associated with MDD which often means
greater challenges. The most prevalent are listed below (Thaipisuttikul, Ittasakul, Waleeprakhon, Wisajun & Jullagate, 2014):
- Anxiety disorders: Such as Generalized Anxiety Disorder (GAD), panic disorder, agoraphobia, Obsessive Compulsive Disorder (OCD), and Post Traumatic Stress Disorder (PTSD). Anxiety disorders with MDD lead to increase suicidal risk, diminished treatment response, and greater disease severity (Thaipisuttikul, Ittasakul, Waleeprakhon, Wisajun & Jullagate, 2014).
- Substance-use disorders: Such as alcohol abuse which was also assoicated with high suicidal risk in patients (Thaipisuttikul, Ittasakul, Waleeprakhon, Wisajun & Jullagate, 2014):
- Other depressive disorders: Such as dysthamia which affects approximately 50% of patients with MDD (Thaipisuttikul, Ittasakul, Waleeprakhon, Wisajun & Jullagate, 2014):
What are the comorbidities of MDD?
Logical Fallacies, authors, and biases
In terms of logical fallacies, I was able to identify two in my research. The first called ‘begging the question’ is when the reader is asked to accept the conclusion without evidence. This was identified in the statement describing the DSM-5 as inconsistent and ambiguous, and that it will no doubt revised in the future (Uher, et al., 2013). There was no evidence to suggest revisions would be made, and therefore, the reader was asked to accept this conclusion. The second logical fallacy identified is called ‘false dichotomy’ which is when an author sets up arguments to make it seem like there are only two choices. This was identified when the author made a statement that they wanted to see whether or not antidepressants or ECT were safer options (Dong et al., 2018). It has been made clear that there are various treatment options for MDD.
I was also able to identify articles in my research authors credentials and affiliations that can pose as potential biases and strengths. The credentials and affiliations I identified in these articles ranged from Postdoc (Ph.D), Medical Doctor (MD), and professors in the Department of Psychiatry. These credentials and affiliations are present in the following articles by (Baune & Christensen, 2019), (Paris, 2014), and (Uher et al., 2013) respectively. It is definitely a strength to have authors with credentials such as these as it signifies a high likelihood that the information is legitimate and well researched. Although in addition, this may also indicate the presence of bias, for example, if they have an affiliation to the Department of Psychiatry, they may favor one approach over another, or have a limited worldview on the particular subject. The articles
also all utilized various resources to support their arguments which helped increased
the credibility and reduce the presence of any bias.
My AnalysiS & summary of my findings!
Figure 3
Strengths & Limitations
Strengths & Limitations
I was able to identify two strengths in the resources utilized. First, I want to re-emphasize the articles previously by (Baune & Christensen, 2019), (Paris, 2014), and (Uher et al., 2013) as they had a variety of credentials and affiliations which strengthened the credibility of their arguments. While conducting my research I also noticed articles utilized a variety of other references in their studies which increased not only credibility but their ability to connect and support their findings. For example, this was evident in the article by (Liu et al., 2019) who connected their findings to various other studies throughout their research.
As for limitations, I found data in the Randomized Controlled Trails (RCT) were at times limited to either specific populations, gender, and even setting. Limitations to population and gender were noticed when it was indicated that there were only Chinese patients included in the study by (Dong et al., 2018) and predominately female patients in the study by (Thaipisuttikul et al., 2014). It was also indicated in this study that results may not be representative of the community due to the tertiary care setting of the clinic used (Thaipisuttikul et al., 2014). The last limitation identified through the use of the Hamilton Depression Scale (HAM-D) (Dong et al., 2018). The Hamilton Rating Scale (HAM) is biased due to it mostly addressing physical symptoms and no other factors such as school or quality of life of participants (Wojtowicz, 2019).
In Summary...
Summary of learning
I was impressed by the wide array of research on the topic of MDD.
While searching and reading the research on MDD, I found that many of the
questions I have addressed in this presentation naturally emerged. Therefore,
one lesson I have learned is the valuable role research plays in generating these important
questions. Before diving into this topic, I was unawareof just how prevalent MDD is globally
and the consequences that can take effect from this diagnosis. With its broad range of diagnostic criteria, it also creates the concern for the possibility of individuals being over-
diagnosed. I think what this problem really comes back to is the notion that human
experience and emotion can vary significantly to the point where it is difficult to conform
individuals to one mold – we are far too complex for this. Fortunately, with this large quantity of individuals affected there has also been some excellent progress made for MDD treatment. I was unaware of the amount of available treatment options for MDD and more specifically the non-pharmaceutical treatment options such as CBT, ECT, problem solving therapy, and various other TR specific interventions. Exploring TR interventions was an important component of my research as it helped connect my current knowledge and
experience to this topic.Lastly, I explored the comorbidities of MDD which uncovered
a wide range of anxiety disorders such as GAD, OCD, and PTSD. I was unaware
that anxiety disorders often co-exist with MDD and the association with higher
suicidal risk. With this knowledge, it helped me painta new picture of
what eans to have MDD and the various challenges that can arise often
on a daily basis. After conducting this research, I feel not
only more knowledgeable on this topic, but more
confident in my ability to support patients with
MDD through their treatments.
References
References!
- Ambrosi, C., Zaiontz, C., Peragine, G., Sarchi, S., & Bona, F. (2018). Randomized controlled
study on the effectiveness of animal-assisted therapy on depression, anxiety, and illness perception in institutionalized elderly. Psychogeriatrics, 19(1), 55–64. doi: 10.1111/psyg.12367
- Blease, C.R. (2013). Electroconvulsive therapy, the placebo effect and informed consent. Journal of Medical Ethics, 39(3), p. 166-170. doi: 10.113/medethics-2012-101201
- Baune, B. T., & Christensen, M. C. (2019). Differences in Perceptions of Major Depressive Disorder Symptoms and Treatment Priorities Between Patients and Health Care Providers Across the Acute, Post-Acute, and Remission Phases of Depression. Frontiers in Psychiatry, 10. doi: 10.3389/fpsyt.2019.00335
- Blomdahl, C., Gunnarsson, B. A., Guregård, S., Rusner, M., Wijk, H., & Björklund, A. (2016). Art therapy for patients with depression: expert opinions on its main aspects for clinical practice. Journal of Mental Health, 25(6), 527–535. doi: 10.1080/09638237.2016.1207226
- Dong, M., Zhu, X. M., Zheng, W., Li, X. H., Ng, C. H., Ungvari, G. S., & Xiang, Y. T. (2018). Electroconvulsive therapy for older adult patients with major depressive disorder: a systematic review of randomized controlled trials. Psychogeriatrics, 18(6), 468–475. doi: 10.1111/psyg.12359
- Farrell, H. M. (2019, January 14). The truth about electroconvulsive therapy (ECT) . Retrieved February 8, 2020, from https://www.youtube.com/watch?v=AcmarVpo2xEFigure 1 Retrieved from https://www.pngitem.com/middle/ihmmbJb_light-bulb-idea-black-and-white-clipart-png/
- Figure 1. I Am Not Fine Cartoon. (n.d.). Retrieved from https://theglitch.home.blog/2019/02/12/i-am-not-fine/
- Figure 2. Charlie Brown: “My Anxieties Have Anxieties”. (n.d.). Retrieved from https://connectthedotblog.com/category/resolution/
- Figure 3. Argument in Everyday Life. (n.d.). Retrieved from https://commcourses.com/www/argument-everyday-life
- Health Publishing. (2018, December). Major Depression. Retrieved February 3, 2020,
from https://www.health.harvard.edu/a_to_z/major-depression-a-to-z
References continued
References (2)
- Kirkham, J. G., Choi, N., & Seitz, D. P. (2015). Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults. International Journal of Geriatric Psychiatry, 31(5), 526–535. doi: 10.1002/gps.4358
- Liu, Q., He, H., Yang, J., Feng, X., Zhao, F., & Lyu, J. (2019). Changes in the global burden of depression from
- 1990 to 2017: Findings from the Global Burden of Disease study. Journal of Psychiatric Research, 1–7.
- doi: 10.1016/j.jpsychires.2019.08.002
- Major, G. (2017). The Use of ECT as a Standard Treatment for MDD. Intuition: The BYU Undergraduate Journal in Psychology, 12(1), 32–55. Retrieved from https://scholarsarchive.byu.edu/intuition/vol12/iss1/3
- Mark, C. W., How, C. H., & Ng, Y. P. (2017). Managing depression in primary care. Singapore Medical Journal , 58(8), 459–466. doi: 10.11622/smedj.2017080
- Pierce, D. (2012). Problem solving therapy Use and effectiveness in general practice. Focus Psychological Strategies 41(9), 676–679. Retrieved from https://www.racgp.org.au/download/documents/AFP/2012/September/201209pierce.pdf
- Paris, J. (2014). The Mistreatment of Major Depressive Disorder. The Canadian Journal of Psychiatry, 59(3), 148–151. doi: 10.1177/070674371405900306
- Silverman, M. J. (2013). Effects of group songwriting on depression and quality of life in acute psychiatric inpatients: A randomized three group effectiveness study. Nordic Journal of Music Therapy, 22(2), 131–148. doi: 10.1080/08098131.2012.709268
References Continued
References (3)
- Thaipisuttikul, P., Ittasakul, P., Waleeprakhon, P., Wisajun, P., & Jullagate, S. (2014). Psychiatric comorbidities in patients with major depressive disorder. Neuropsychiatric disease and treatment, 10, 2097–2103. doi:10.2147/NDT.S72026
- Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2013). Major Depressive Disorder In Dsm-5: Implications For Clinical Practice And Research Of Changes From Dsm-Iv. Depression and Anxiety, 31(6), 459–471. doi: 10.1002/da.22217
- Wilson, S., Vaidyanathan, U., Miller, M. B., Mcgue, M., & Iacono, W. G. (2014). Premorbid risk factors for major depressive
- What Is Major Depressive Disorder? Mood Disorders. (2012, January 2). Retrieved February 16, 2020, from https://www.youtube.com/watch?v=lb-TisO17HE
MY Interest
Interest with Major Depression Disorder (MDD)
Major Depressive Disorder (MDD) was a topic that gained
my interest in the first couple weeks of this course. I wanted to learn more as MDD affects a large number of people as we will later explore. I have had the privilege of working in an Addictions and Mental Health unit where this diagnosis is seen frequently in patients who I work with on a regular basis. I wanted to research this topic to answer questions I have which will lead me to becoming a better caregiver to these individuals. These questions include: What is MDD? How major is MDD? What treatments are perscribed for it? How can therapeutic recreation and what other alternative treatments help? And lastly, what comorbidities
exist for MDD?