Scope of the Diagnosis
Hedden et al. (2015) found that 6.6 percent of American adults had at least one major depressive episode (MDE) over the past year and that more than two-thirds of these individuals had an MDE “with severe impairment,” meaning it “caused severe problems with their ability to manage at home, manage well at work, have relationships with others, or have a social life” (p. 30). Kessler et al. (2003) and Hasin, Goodwin, Stinson, and Grant (2005) found that 6.6 percent and 5.3 percent of adults had MDD over the past year, respectively, and that 16 percent and 13 percent of adults have had MDD sometime in their lives, respectively (p. 3099, p. 1099).
Kessler et al. (2003) concluded that risk for MDD is “fairly low until the early teens” (p. 3099). Hasin et al. (2005) found that the risk for depression increases “sharply between ages 12 and 16 years” and continues to increase, “albeit more gradually, up to the early 40s, when it [begins] to decline” (p. 1101). Hedden et al. (2015) found that 11.4 percent of adolescents had an MDE in the past year and that more than 70 percent of these episodes caused a severe impairment (p. 31).
Women have significantly higher rates of MDD than men, making up 59 percent of MDD cases (Pratt & Brody, 2014, p. 1). Women aged 40-59 have the highest rates of MDD (12.3 percent), while men aged 12-17 and 60 and older have the lowest rates (4 percent and 3.4 percent, respectively) (Pratt & Brody, 2014, p. 2).
González, Tarraf, Whitfield, and Vega (2010) “found both excess recurrence and greater severity of major depression among the largest and most socioeconomically disadvantaged US ethnic minorities, namely Mexican and African Americans” (p. 1051). Pratt and Brody (2014) write that those living below the poverty line are more than twice as likely to have MDD as those living above it (p. 3). Kessler et al. (2003) found that MDD is “largely unrelated to geography (region of the country or urbanicity)” (p. 3099).
The Course of MDD
The National Institute of Mental Health (n.d.) writes that depression is most likely “caused by a combination of genetic, biological, environmental, and psychological factors.” Wilde et al. (2014) confirm in their meta-analysis that “family loading remains the best predictive risk factor for MDD” (p. 45). Hammen (2005) writes that extensive research has “established a robust and causal association between stressful life events and major depressive episodes” (p. 293).
Stegenga, Kamphuis, King, Nazareth, and Geerlings (2012) studied adult “primary care patients” diagnosed with MDD and found that after 39 months, 43 percent had gone into remission, 17 percent were still depressed, and 40 percent vacillated between depression and remission (pp. 90-91). The Centers for Disease Control and Prevention (CDC) (n.d.) reports that experiencing just “one episode of depression places the individual at a 50% risk for experiencing another, with subsequent episodes raising the likelihood of experiencing more episodes in the future.” If left untreated, depression can “lead to longer episodes” (Orenstein, 2012). More than one-fourth of those with MDD have persistent depressive disorder (Rubio et al., 2011, p. 626).
Symptoms as Coping Techniques
MDD manifests itself in different ways, and it is common for individuals to focus on these symptoms instead of addressing the disorder itself. For example, MDD causes some to gain weight, causing many to respond by changing their diets or exercising more, actions which might be healthy but do not address the causes of depression. MDD reduces sexual interest and/or ability in others, leading many of these individuals to seek prescriptions for Viagra. MDD causes insomnia in still others, causing them to take sleeping pills or consume alcohol before bed.
Treatment
The CDC (n.d.) notes that the use of “medications and/or specific psychotherapeutic techniques has proven very effective in the treatment of major depression.” Hasin, Goodwin, Stinson, and Grant (2005) found that nearly 60 percent of those with MDD receive treatment, with women more likely to receive treatment than men (p. 1101). Kessler et al. (2003) found that 52 percent of those with MDD receive treatment but that just 42 percent of these individuals receive adequate treatment (p. 3095). Mojtabai (2009) hypothesized that so many people with MDD receive inadequate treatment because “a large majority” of these individuals make “fewer than four outpatient visits in the past year” (p. 301). Mojtabai also noted that most seek treatment from primary care physicians, and “research has generally found that compared with psychiatrists, general medical providers are less accurate in diagnosing mental disorders and tend to provide treatments with lower intensity than required by evidence-based standards” (p. 301).
Mohr et al. (2010) list nine common barriers that prevent individuals with MDD from seeking treatment: stigma (“the perceived negative meaning that psychological treatment would carry, as well as fear of judgment from others and from oneself”); lack of motivation; emotional concerns (“undesirable emotion expected to emerge in or from therapy”); negative evaluations of therapy (“the belief that interaction with a therapist would be unhelpful or deleterious”); misfit of therapy to needs (“concerns that therapy [is] an unjustifiable luxury or that one’s problems [are] poorly suited for therapeutic intervention”); time constraints; participation restriction (“physical and transportation problems associated with attending therapy”); availability of services; and cost (p. 399). Mojtabai (2009) found “[c]oncern about treatment costs” to be “the largest single barrier” for those seeking treatment for MDD (p. 304)
Costs of MDD
Kessler (2012) summarizes considerable research showing the many deleterious effects of depression. MDD is “significantly associated with a wide variety of chronic physical disorders, including arthritis, asthma, cancer, cardiovascular disease, diabetes, hypertension, chronic respiratory disorders, and a variety of chronic pain conditions.” MDD also impedes one’s ability to perform various roles: for instance, marital functioning (MDD increases “marital dissatisfaction and discord,” as well as marital violence and the likelihood that a couple will divorce), parenting (MDD in parents often causes “maladaptive interactions that impede infant affect regulation and later child development”), and job performance (MDD is associated with higher unemployment rates, and the “personal earnings and household income of people with MDD are substantially lower than those of people without depression”).
MDD also negatively affects adolescents. Kessler (2012) reports that MDD reduces an adolescent’s chances of graduating from high school. Glied and Pine (2002) write that children and adolescents with MDD “miss an extra day of school each month and are more likely to smoke, binge, and engage in suicidal ideation” (p. 714). For all ages, depression significantly increases one’s chances of committing suicide (Nemeroff, 2008).
Given all this, it should come as no surprise that MDD places an enormous economic burden on society. Greenberg et al. (2015) note that depression “is a leading cause of disability for people aged 15–44 years, resulting in almost 400 million disability days per year, substantially more than most other physical and mental conditions.” They estimate “the incremental cost of people with MDD” to be $173.2 billion in 2005 and $210.5 billion in 2010, approximately 5 percent of this money lost to suicide-related costs, 45 percent to medical costs, and 50 percent to workplace costs (i.e., “absenteeism from work and presenteeism”).
Case Study
Kate Gompert is a character in David Foster Wallace’s (1996) novel Infinite Jest. Kate is 21 years old, an administrative assistant in a real estate office in Newton, Massachusetts. She has been hospitalized four times in the past three years for depression. Twice during this timeframe, she attempted suicide; her last attempt “had been serious, a real attempt” and had landed her on suicide-watch at the Ennet House Drug and Alcohol Recovery House in suburban Boston (p. 70).
Diagnosis
Kate meets the criteria of MDD, recurrent episode, severe, 296.33 (F33.2). First, she has had at least five of the symptoms in Criterion A for at least two consecutive weeks: (1) “Depressed mood most of the day, nearly every day” (e.g., both times readers are given an extended glimpse into her mind, she continually thinks about her unbearable emotional pain and her willingness to do “anything” to make “the feeling go away,” p. 78); (2) “Markedly diminished interest or pleasure in all, or almost all, activities” (“I don’t want to smoke any [marijuana], and I don’t want to work, or go out, or read, or watch TP, or go out, or stay in, or either do anything or not do anything, I don’t want to anything except for the feeling to go away,” pp. 77-78); (3) “Fatigue or loss of energy nearly every day (when readers first meet her, she is lying “fetal, dead-eyed, w/o facial affect,” p. 70); (4) “Diminished ability to think or concentrate” (it is “always a titanic struggle to get [her] to do anything to help [her] focus,” p. 72); and (5) “Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide” (American Psychiatric Association, 2013, pp. 160-161).
Second, Kate meets Criterion B, as her emotional pain impairs her ability to function properly and do anything other than think about it (“OK,” she tells the doctor, “but imagine if you felt that way all over, inside. All through you. Like every cell and every atom or brain-cell or whatever was so nauseous it wanted to throw up, but it couldn’t, and you felt that way all the time, and you’re sure, you’re positive the feeling will never go away, you’re going to spend the rest of your natural life feeling like this,” p. 74) (American Psychiatric Association, 2013, p. 161). Third, Kate meets Criterion C, as her depression “is not attributable to the physiological effects of a substance or to another medical condition” (It is true that her doctor suggests that there might be a connection between her depression and her marijuana consumption, but this is never corroborated and seems to be contradicted by Kate’s narrative, pp. 76-78) (American Psychiatric Association, 2013, p. 161). Fourth, Kate meets Criterion D, as the occurrence of her MDE “is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders” (American Psychiatric Association, 2013, p. 161). And fifth, Kate meets Criterion E, as there “has never been a manic episode or a hypomanic episode” (p. 161).
Cultural Formulation
Kate is a middle-class white American of English descent. White Americans tend to be more likely than members from multicultural groups to trust healthcare professionals, more likely to prefer medical, as opposed to spiritual, explanations for mental health problems, less likely to turn to family for help, and less likely to attach stigma to mental health diagnoses (Alvidrez, 1999, p. 517). The novel does not say much about Kate’s “key stressors and supports” (American Psychiatric Association, 2013, p. 750), although she does appear to have a somewhat close relationship with her mother (p. 76), and she evidently made friends with fellow Ennet House residents Geoffrey Day and Bruce Green (pp. 648-651).
Clinical Bias
I have struggled with depression in the past, and therefore I believe I am likely to be especially sympathetic with those currently suffering from it. In other words, since, like Kate Gompert, I understand what it is like to be desperate to do “anything” to make that feeling “go away,” I might be well positioned to empathize with such clients. Nonetheless, when treating individuals with MDD, I need to remember that depression tends to manifest itself differently among different groups. Ayalon and Young (2003) found that African Americans tend to have more somatic symptoms (e.g., “sleep disturbance, loss of appetite, and loss of libido”) while Caucasian Americans had more cognitive-affective symptoms (e.g., “pessimism, self-blame, suicidal ideation, and dissatisfaction”) (pp. 111, 119). Similarly, Myers et al. (2002) found that African American and Latina women have more somatic symptoms than their white counterparts (p. 149). Depressed men and women also tend to have different symptoms, with women being more likely to report “increased appetite,” being “often in tears,” “loss of interest,” and “thoughts of death” (Romans, Tyas, Cohen, & Silverstone, 2007, p. 905). Since it might not be realistic to become fully aware of these differences, the best culturally competent skill I can have is that of being curious and asking my clients ample questions before reaching any conclusions.
Evidence Based Treatment
Montgomery (2006) writes that selective serotonin reuptake inhibitors (SSRIs) “remain the first-line therapy” for treating MMD (p. 7). He cites a randomized controlled trial (RCT) in which one group of individuals took citalopram for 12 months for their depression, while another group took a placebo. Those who took citalopram went significantly longer before having a relapse (p. 5). Montgomery also cites a study disproving the belief that taking SSRIs increases one’s risk of suicide, and he cites other studies showing that “treatment of depression with effective antidepressants reduces the rate of completed suicides in a statistically significant manner” (p. 5). Although SSRIs tend to be very effective, patients can experience a range of side effects from them, including insomnia, headaches, nausea, diminished sexual interest or ability, dyskinesiam parkinsonism, akathisia, and diminished fine motor skills (“What are the real risks of antidepressants?” 2009).
Hofmann, Asnaani, Vonk, Sawyer, and Fang (2012) conducted a meta-analysis and found that cognitive-behavioral therapy (CBT) for depression proved to be “more effective than control conditions such as waiting list or no treatment” (p. 430). They found some studies showing CBT to be superior to other psychotherapies (e.g., psychodynamic therapy) while other studies showed that it was equally effective (p. 430).These authors also found that a “combination therapy of CBT with pharmacotherapy was more effective in comparison to CBT alone” (p. 430).
Husain et al. (2004) found ECT to be more effective than pharmacotherapy, noting that usually around 50 to 60 percent of clients who received pharmacotherapy “receive results” and 35 to 45 percent “achieve remission,” while 79 percent of those who received ECT three times a week showed results and 75 percent went into remission (p. 485). Equally impressive is how quickly the treatment works; 34 percent of patients went into remission during the first two weeks and 65 percent during the third and fourth weeks (p. 485). Although generally safe, ECT can have such side effects as retrograde amnesia, temporary confusion, nausea, muscle pain, and medical complications (“Electroconvulsive therapy,” n.d.).
Fitzgerald and Daskalakis (2011) report that TMS is generally safer than ECT, as “few adverse events of major concern have been reported despite the proliferation of clinical trials over the last 10 years.” They cite two meta-analyses showing that TMS is significantly more effective at treating depression than placebos and note that TMS works on many patients who do not respond to medication.
Resources
The Colorado Depression Center is a local organization that provides treatment for individuals with depression and bipolar disorder (“About us,” n.d.). One can make an appointment by calling 303-724-3300. The National Alliance of Mental Illness is a national organization that educates individuals about mental illness, advocates for public policy that better serves individuals with mental illness, and provides appropriate referrals (“Depression,” n.d.). The Alliance can be contacted at 1-800-950-NAMI or info@nami.org. The World Health Organization recently established the Mental Health Gap Action Programme (mhGAP) with the goal of “scaling up care for mental, neurological and substance use disorders” in low and middle-income countries (World Health Organization, 2010). The WHO has made its implementation guide for treating MDD and other mental illnesses available online at http://www.who.int/mental_health/mhgap/en/.
Conclusion
MDD affects millions of Americans, causing extraordinary damage at all levels of society. It manifests itself in different ways and strikes some groups more heavily than others. Fortunately, different evidence-based treatments exist, although some individuals cannot be helped by any of these treatments. After writing this paper and reflecting on my own abilities and experiences, I feel more confident in my ability to help clients with this disorder.
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