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Major Depressive Disorder . A clinical review Barry J. Fenton, M.D. Depression—an Overview. Prevalence Comorbidity Impact on society Diagnosis Treatment options Treatment guidelines Treatment compliance. 17.1%. Major depressive disorder. Alcohol dependence. 14.1%. 13.3%.

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major depressive disorder

Major Depressive Disorder

A clinical review

Barry J. Fenton, M.D.

depression an overview
Depression—an Overview
  • Prevalence
  • Comorbidity
  • Impact on society
  • Diagnosis
  • Treatment options
  • Treatment guidelines
  • Treatment compliance
lifetime prevalence of common psychiatric disorders


Major depressive disorder

Alcohol dependence



Social anxiety disorder

Posttraumatic stress

disorder (PTSD)


Generalized anxiety

disorder (GAD)


Premenstrual dysphoricdisorder (PMDD)



Panic disorder


disorder (OCD)












Lifetime prevalence (%)

Lifetime Prevalence of Common Psychiatric Disorders

*In menstruating women.

Kessler 1994; Kessler 1995; DSM-IV-TR™2000.

depression prevalence
  • In any given year, about 21 million American adults suffer a major depressive episode
  • Nearly 1 out of 6 American adults experience depression at some time in their lives
    • 21% of women
    • 13% of men

Kessler 1994; US Bureau of the Census 2000; Depression in Primary Care, 1 (AHCPR) 1993; DSM-IV-TR 2000.

depression medical comorbidities
Depression—Medical Comorbidities

Kessler 1999; Carney 1987; Frasure-Smith 1993; AHCPR Guidelines 1993; Anderson 2001; Bing 2001; Reifler 1986; Rovner 1989; Breslau 1991; Minden 1987; Joffe 1987.

medical conditions implications of comorbid depression
Medical Conditions—Implications of Comorbid Depression
  • Increased somatic symptoms, eg, multiple pain complaints
  • Excess functional disability
  • Increased morbidity/mortality
  • Increased healthcare utilization and costs
  • Poor self-care
  • Decreased adherence to treatment regimens
  • Higher drug interaction potential due to polypharmacy

Katon 1990; Gregor 1997.

depression anxiety comorbidities

48% of patients with PTSD

Up to 65% of patients with panic disorder*


stress disorder

Panic disorder

42% of patients with generalized anxiety disorder



Social anxiety disorder


34% to 70% of patients with social anxiety disorder

67% of patients with obsessive-compulsive disorder

Depression—Anxiety Comorbidities

Many patients with anxiety disorders have depression at some time during their lives

*Figures for panic disorder and depression not specified as lifetime in DSM-IV-TR™.

Kessler 1995; DSM-IV-TR™ 2000; Brawman-Mintzer 1993; Rasmussen 1992; Stein 2000; Van Ameringen 1991; Wittchen 1999.

anxiety is a common symptom of depression


Depression With

Anxiety Symptoms


Anxiety Is a Common Symptom of Depression

Sadock and Sadock 2003.

depression implications of anxiety comorbidities
Depression—Implications of Anxiety Comorbidities
  • Increased severity of symptoms
  • Increased impairment of mental and physical functioning
  • Delayed recovery

In patients with comorbid panic disorder and depression,

  • Increased prevalence of suicide attempts
  • Decreased work productivity and attendance
  • Increased service use (medical, mental health, social services)

Brown 1996; Coryell 1988; Roy-Byrne 2000.

depression economic impact

Direct Costs = $12.4 billion per year

Indirect Costs = $31.3 billion per year






Direct Costs

(inpatient, outpatient, and partial care)



Reduced Productivity


Depression—Economic Impact

Cost of depression in the US estimated at $43.7 billion (1990 dollars)

Prevalence-based analysis of direct and indirect costs of depression, including direct costs of medical, psychiatric, and pharmacologic care; mortality costs from depression-related suicides; and morbidity costs (reduced productivity and absenteeism) associated with depression in the workplace.

Greenberg 1993.

depression impact on the healthcare system
Depression—Impact on the Healthcare System
  • Compared with those without depression, depressed individuals may
    • Utilize all types of healthcare services more often
    • Incur 1½ to 2 times greater healthcare costs
    • Have an increased length of hospital stay
    • Report significant worsening of physical, social, and role functioning

Simon 1995; Luber 2000; Verbosky 1993; Wells 1989.

major depressive disorder diagnostic criteria
Major Depressive Disorder—Diagnostic Criteria

Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks

At least 1

of these2 symptoms

  • Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

DSM-IV-TR™ 2000.

depression underdiagnosis
  • Prevalence
    • About 1/3 of people experiencing depression do not seek treatment
    • Approximately 1/3 to 1/2 of patients with depression who present in primary care do not receive a diagnosis of depression
  • Implications
    • Increased time spent on history taking and physical examination
    • Unnecessary diagnostic procedures, particularly in response to patients’ vague somatic complaints

Hirschfeld 1997; US Dept of Health and Human Services 1999; Simon 1999; Simon and VonKorff 1995; Callahan 1996.

depression somatic presentation
Depression—Somatic Presentation
  • Overall, 69% of depressed patients (range 45%-95%; P=.002) present with somatic complaints that can complicate diagnosis, such as
    • Headaches
    • Weakness
    • Constipation
  • Back pain
  • Joint pain
  • Abdominal pain

Simon 1999; Depression in Primary Care 1 (AHCPR), 1993.

patient health questionnaire 9 phq 9 diagnostic tool for primary care
Patient Health Questionnaire-9 (PHQ-9)— Diagnostic Tool for Primary Care
  • Validated self-administered questionnaire
  • Scores interpreted by clinician
  • Quick and easy to administer
  • Yields accurate, validated depression diagnoses
  • Patient rates each of the 9 DSM-IV-TR™ criteria for depression on a scale of 0 (not at all) to 3 (nearly every day)
  • Brevity and ease of use make it a valuable resource
  • Tear-off sheets may be used as a diagnostic screener or to monitor disease severity over time

Kroenke 2001.

depression common treatment options
Depression—Common Treatment Options

IMS America February 2003; Sadock and Sadock 2003; Depression in Primary Care 2 (AHCPR), 1993.

depression ahcpr treatment guidelines


Acute Phase of Treatment


Continuation Phase of Treatment


Maintenance Phase of Treatment














Progression to Disorder


Treatment phases

Acute(6-12 weeks)

Continuation(4-9 months)


(1 or more years)

Depression—AHCPR* Treatment Guidelines

*Agency for Health Care Policy and Research currently known as the Agency for Healthcare Research and Quality (AHRQ), an agency within the US Department of Health and Human Services.

Kupfer 1991; Depression in Primary Care, 2 (AHCPR) 1993.

depression undertreatment

Patients (%)

Any antidepressantuse

Appropriate antidepressantuse


Appropriate counselinguse

Appropriate treatment

Inappropriate or no treatment


In a 12-month period, one study showed,

A majority of patients with depressive disorder did not receive adequate treatment

Young 2001.

depression predictors of appropriate care

Patients who received appropriate care (%)













Age (yr)

Depression—Predictors of Appropriate Care

In a 12-month period, one study showed,

Receipt of minimally adequate treatment varied by gender, ethnicity, and age

Young 2001.

depression adherence to treatment

Patients adherence totreatment (%)

Treatment month

Depression—Adherence to Treatment

In a study examining adherence,

28% of patients discontinued antidepressant treatment within the first month

  • According to AHCPR, patients who discontinue medication early have a relapse rate of about 25% within 2 months

Lin 1995; Depression in Primary Care, 2 (AHCPR) 1993.

depression a highly recurrent disorder

Risk of recurrence (%)

After 1 depressive episode

After 2 depressive episodes

After 3 depressive episodes

Depression—a Highly Recurrent Disorder

DSM-IV-TR™ 2000; Kupfer; 1991.

depression summary
  • Depression will affect nearly 1 in 6 American adults at some time in their lives
  • Depression has been associated with both chronic medical and psychiatric conditions
  • Depression is often underdiagnosed and undertreated
  • Depression can
    • Be costly to society
    • Decrease patient quality of life
  • Effective treatments are available
  • Treatment guidelines recommend that antidepressant treatment be continued for a minimum of 4 to 9 months after remission

Kessler 1994; Bureau of the Census 2000; Depression in Primary Care, 1 (AHCPR), 1993; Kessler 1999; Carney 1987; Frasure-Smith 1993; Anderson 2001; Bing 2001; Reifler 1986; Rovner 1989; Breslau 1991; Minden 1987; Joffe 1987; Kessler 1995; Brawman-Mintzer 1993; Rasmussen 1992; Stein 2000; Van Ameringen 1991; Hirschfeld 1997; US Department of Health and Human Services 1999; Simon 1999; Simon and VonKorff 1995; Callahan 1996; Greenberg 1993; Simon 1995; Luber 2000; Verbosky 1993; Wells 1989; Hirschfeld 2000; Kroenke 2001; Kupfer 1991. Depression in Primary Care, 2 (AHCPR) 1993.

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