A considerable number of people may suffer from a persistent depressed mood, disinterest in the surroundings, apathy, anxiety, and temper outbursts that are accompanied by physiological and cognitive impairments. The aforementioned symptoms are primary hallmarks of various depressive conditions specified in Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which are a persistent depressive disorder, major depression, premenstrual dysphoric disorder, depressive disorder due to another medical condition, substance/medication-induced depressive disorder, and disruptive mood dysregulation disorder. They drastically aggravate the quality of life and thwart social communication and interaction of a person. Depressed people frequently prefer avoidant pattern of behavior that may intensify the symptoms and trigger suicidal behavior and thinking or cause outbursts of rage and anger. Multiple studies and research disclosed genetic, biochemical, and physiological predisposing factors that increase an individual’s chances of developing depressive conditions. Such abnormalities are associated with significant cognitive, behavioral and physiological impairments. Psychotherapy in combination with appropriate life modifications and drug treatment can substantially reduce and alleviate depressive symptoms and minimize the risk of recurrences.
Everyone experiences mood alterations as a response to various stressors which may transform into different depressive disorders. In the past, nobody perceived a depressive disorder as some kind of abnormality that had potentiality to worsen a quality of human life and even jeopardize it. Presently, most psychologists and psychiatrists stick to the opinion that depressive disorders have significant destructive and deleterious effects on people’s lives. In fact, they present a considerable health concern in many developed countries due to a high rate of people suffering from depression and consequent economic burden they incur. The disregard of depressive symptoms, incompetent diagnosis and inappropriate treatment may cause serious health and life implications. Thus, this paper will provide an overview of depressive disorders and their variety. It will highlight pathophysiology and etiology of the stated conditions along with present therapeutic approaches that can be beneficial for understanding and managing diverse depressive symptoms.
Overview of Depressive Disorders
The variety of depressive disorders comprises a group of the most common mood abnormalities in the United States. Various mental and mood irregularities peculiar for depressive conditions may attack different groups of the population with prevalence among the elderly and adolescents. The aforementioned disorders are characterized by “severe or persistent sadness that can interfere with function and by decreased interest or pleasure in activities” (Coryell, 2016). Individuals under the influence of depressive disorders become indifferent to daily routine and previously enjoyable activities. Moreover, they cannot be socially active that, consequently, precludes them from creating new relationship or maintaining contacts. Patients with depressive symptoms experience “severe and long-lasting psychological pain that may eventually intensify” (Comer, 2014). Mental, behavioral, and cognitive impairments caused by depressive disorders hamper normal social functioning and have a destructive effect on personality. Predisposing genetic factors, physical inabilities, presence of chronic or incurable diseases, dissatisfaction, low self-esteem, and previous depressive episodes facilitate the development of various depressive conditions. Certain biologic and psychosocial factors may also cause depression (Mirza, 2016).
The development of depressive disorders in women and males varies. Most females are prone to undergoing sadness, melancholy and excessive guilt whereas men are more predisposed to demonstrating fatigue, disinterest, displeasure, anger and irritability. Furthermore, men are in a risk group of premature death due to cardiovascular diseases.
Depression became “one of the leading causes of disability” among Americans and worldwide (McCance & Huether, 2014). Different depressive disorders may affect people of different age, racial, ethnic and socioeconomic groups. Multiple researches affirm that approximately “7% of the adult population experience at least one major depressive episode” throughout one’s life (National Alliance on Mental Illness, 2017). However, high incidence rate of most depressive disorders results from inappropriate social or marital status, unemployment, and financial calamity. In accordance with the Journal of the American Medical Association, “the incidence of depression in the United States reaches 20-26% for women and only 8-12% for men” (Lieber, 2017). Thus, females are more vulnerable and more prone to acquiring depressive symptoms than males due to certain precipitating “biologic, life cycle and hormonal factors that are unique for women” (“Depressive Disorders,” 2015). According to the statistics, “the prevalence of depression comes to 16,2% of the general population with 2% to 6% cases among children and adolescents” in the United States (McCance & Huether, 2014). Various surveys indicate that the quantity of depressed patients raises by 20% annually, and 80% of them do not receive adequate and comprehensive treatment either due to failure in diagnosis or personal avoidant behavior. Thus, it demonstrates that recovery rate could be higher than it is presently.
Symptoms and Signs
The variety of symptoms that reflect diverse emotional, motivational, behavioral, cognitive and physical impairments represent depressive disorders. Affected people frequently suffer from a feeling of misery and aloofness, overwhelming sadness and dejection, and anxiety and anger. There are some clinical cases reporting anhedonia that is “an inability to experience any pleasure” (Comer, 2014). Persistent depressed or prevalent pessimistic mood that lasts more than two weeks and can be accompanied by a feeling of hopelessness, helplessness, worthlessness, and the inferiority complex is the primary hallmark of most depressive disorders. Afflicted individuals frequently experience frustration, agitation, and irritation that imply their growing emotional instability.
The scrutinized conditions are largely associated with physical irregularities such as a considerable weight gain or loss, extreme exhaust, and sleep disturbances. They appear in cognitive impairments such as decreased concentration and poor memory along with low energy, reduced activity and insufficient productivity. People frequently suffer from physical ailments such as headaches, abdominal cramps, and gastrointestinal impairments, which may accompany a certain depressive disorder. Furthermore, the effects of depressive disorders can vary from mild and moderate annoyance to death. Patients experiencing the discussed disorders commonly demonstrate insufficient coping skills, immune deficiency, and sexual dysfunction. In addition, they may be inclined to self-mutilating behavior and anxiety disorders. Untreated depression, particularly a major depressive disorder, may cause serious health-related consequences and even entail premature death. There are high chances that the named abnormalities may cause diabetes, hyperthyroidism, obesity, anorexia, and various cardiovascular diseases. Moreover, some of them are strongly associated with dementia and Alzheimer’s disease.
Etiology and Pathophysiology
The exact etiology of depression remains unknown. However, it is a well-known fact that various genetic, biochemical and biologic factors largely contribute to the development of depressive disorders. Furthermore, unfavorable environmental factors such as chronic or fatal diseases, comorbid disorders or disabilities, life occurrences and difficulties, and bereavements and social disadvantage facilitate depressive conditions. Genetic scientists by involving knowledge from molecular biology and conducting studies established the interconnection between certain genes on chromosomes and depressive disorders (Comer, 2014). What is more, eating disorders, excessive consumption of alcohol, drug and harmful substance abuse, and the intake of specific medications are favorable for the acquisition of the named psychological irregularities. Thus, various physiological, psychological and socioeconomic factors provoke depression-associated impairments.
Significant neurochemical, neuroendocrine and cellular alterations in combination with anatomical and functional abnormalities are associated with depressive symptoms. Improper functioning of the brain nerve cells in peculiar areas of brain and their consequent insufficient connection deteriorates mood-controlling ability. A deficiency of serotonin, norepinephrine, and dopamine and decreased “monoamine metabolites in the cerebral spinal fluid” reveal neurochemical alterations that may cause depressive disorders (McCance & Huether, 2014). Simultaneously, investigators believe that correlation between serotonin and norepinephrine activity or any other neurotransmitters is favorable for unipolar depression. Presently, there is a research on possible “role of other neurotransmitters, such as acetylcholine, glutamate, and gamma-aminobutyric acid (GABA)” in misbalancing emotional stability (Swan & Hamilton, 2017). Additionally, there exists an opinion that deficient proteins and insufficient amount of other chemicals in the neurons can compromise the neurons’ health and lead to depression. However, the introduced issue requires further sophisticated research. Furthermore, elevated glucocorticoid release, increased cortisol and melatonin released by the endocrine system as well as serious changes in the hypothalamic-pituitary-adrenalin system accompany the reviewed disorders. The atrophied neurons sited in the hippocampus, decreased number of new hippocampal neurons, and poor “hippocampal brain-derived neurotropic factor levels” elucidate inadequate behavior specific to depression (McCance & Huether, 2014). The described conditions are tightly connected with thyroid abnormalities and compromised hypothalamic-pituitary-thyroid system. Therefore, “changes in neurotransmitter levels, including abnormal regulation of cholinergic, catecholaminergic and serotonergic neurotransmission, and neuroendocrine dysregulation” largely demonstrate biochemical nature of depressive disorders (Coryell, 2016). Moreover, a reduced activity and low cerebral blood flow in some parts of the prefrontal cortex, the decreased frontal and temporal lobes’ volume, and glucose metabolism in the brain prefrontal cortex reveal anatomical changes peculiar to depressive disorders. Some studies promote the idea that “immune system dysregulation” assists in producing depression due to “increased amount of C-reactive protein” (Comer, 2014).
Genetic predisposition, frequent psychosocial stressors as well as multiple stressful life events, biologic misbalance, sick eating and behavioral habits in combination with negative thinking provoke considerable “physiologic and chemical changes in the brain” that interfere in mood stability maintenance and cause depressive abnormalities (Swan & Hamilton, 2017).
The Variety of Depressive Disorders
The American Psychiatric Association developed Diagnostic and Statistical Manual of Mental Disorders (DSM-V) that is beneficial for the identification of various types of depressive disorders. Chronic major depression and dysthymic disorder presently constitute a persistent depressive disorder (PDD). It is a mild form of a major depressive disorder associated with “chronic depressed mood that is present most of the time, revealed subjectively or by observation of the others, with no evidence of psychotic symptoms” (Swan & Hamilton, 2016). It may last approximately 2 years in adults whereas in children and adolescences, it progresses within one year and is accompanied by substantial irritability. In fact, patients affected by PDD are commonly “gloomy, pessimistic, humorless, passive, lethargic, introverted, hypercritical of self and others, and complaining” (Coryell, 2016). They are prone to anxiety and personality disorders as well as substance misuse. They are subject to hospitalization in case of suicidal ideation.
A major depressive disorder (MDD) is “a complex and frequent psychiatric condition that poses significant challenges to the patients who undergo it and the physicians who treat them” (Culpepper, Muskin, & Stahl, 2015). Delusions and hallucinations that do not correspond to reality, certain psychotic symptoms and suicidal ideation are distinguishing features of MDD. It is characterized by “an overwhelming feeling of sadness, isolation, solitude, and despair” as well as disinterest in earlier enjoyable things that last more than 2 weeks (Bressert, 2017). Depressed people may be detected by a gloomy appearance and impaired social interaction. Thus, a major depressive disorder primarily triggers psychological and cognitive inabilities and certain physiological impairments.
Premenstrual dysphoric disorder is differentiated by mood and anxiety symptoms which occur during the premenstrual phase and a symptom-free period after menstruation. It resembles premenstrual syndrome but manifests itself in a more severe form. Women affected by PMDD typically suffer from irritability, discomfort, anxiety and depression one week prior to menstruation. Mood swings, prevalent depressed mood, persistent self-depreciating thoughts, tension and disturbance alternatively reveal the aforementioned condition. Premenstrual dystrophic disorder may cause a variety of physiological abnormalities such as sleep disturbances, fatigue, headaches, joint and muscle pain, and appetite disorders that significantly worsen daily functioning and social interaction of the affected. Therefore, PMDD primarily develops due to the hormonal alterations and substantial changes in the brain chemistry. Apparently, chemical and hormonal impairments are responsible for emotional instability.
A substance/medication-induced depressive disorder is characterized ‘by a prominent and persistent depressed mood and a strikingly decreased interest or pleasure” in most activities (Swan & Hamilton, 2017). The disorder primarily develops due to physiological consequences caused by drug or alcohol abuse, medication misused, or toxic exposure. As a result, these substances drastically impair social interconnection and occupational functioning. Intoxication or withdrawal “from substances such as alcohol, opioids, sedatives, and hypnotics” and other drugs as well as depression-causing medication predispose a person to the acquisition of the stated disorder (Swan & Hamilton, 2017).
A depressive disorder due to another medical condition is common among people affected by various serious diseases that cause distress and torments. This disorder is symptomatically similar to a major depressive episode. Depression of this kind is basically accompanied by neurological, respiratory, endocrine, cardiovascular, cancerous, gastrointestinal, and contagious conditions.
A disruptive mood dysregulation disorder (DMDD) has recently appeared in the DSM-5 chapter on depressive disorders. DMDD is characterized “by severe and recurrent temper outbursts” that are different in their intensity and duration and occur primarily in children and adolescences (Swan & Hamilton, 2017). In fact, such anger attacks manifest themselves either in verbal or behavioral forms. “Symptoms of aggressive behavior, rule-breaking, social problems, anxiety or depression, attention and thought problems” are ultimately reported by the caregivers of young people affected by DMDD (Youngstrom, HYPERLINK "https://www.ncbi.nlm.nih.gov/pubmed/?term=Youngstrom%20JK%5BAuthor%5D&cauthor=true&cauthor_uid=26745325" Youngstrom, Freeman, & Findling, 2016).
Diagnostic Modalities of Major Depression
Various imaging studies and tests are helpful for differentiating and diagnosing multiple depressive disorders. Brain imaging studies contribute to the detection of anatomical alterations in the brain whereas electrocardiography demonstrates cardiac changes. Neuropsychological and cognitive screening is relevant to the establishment of diagnosis (Taylor, 2014). A complete blood cell count, a complete blood chemistry screen, the thyroid-stimulating hormone level assessment, a urinary analysis as well as vitamin B12 and folate rates can assist in discovering impairments associated with depression. Diagnostic and Statistical Manual of Mental Disorders (DSM-V) also facilitate while differentiating various depressive conditions from similar mood disorders. In fact, all available diagnostic techniques and tools are applied to distinguish unipolar depression from bipolar and anxiety disorders and similar neurocognitive abnormalities. The indicated manual represents certain criteria according to which health care providers can recognize depressive conditions and prescribe appropriate treatment and therapy. Differentiating diagnosis is critical for upcoming treatment.
Diverse pharmaceutical and non-pharmaceutical therapies in combination with appropriate psychotherapeutic techniques are effective in enhancing health condition of the depressed patients. Non-pharmaceutical treatment signifies definite life modifications. Vitamin-rich nourishment, regular physical activity, smoking cessation, and increased social communication can largely relieve depressive symptoms.
Monoamine oxidase blockers (MAOI), selective serotonin-reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), and antidepressants can significantly reduce depressive signs. The SSRI drugs effectively suppress serotonin reduction in the brain that improves mood and normalizes sleeping patterns. Serotonin-norepinephrine reuptake inhibitors are designed for the similar reason but are involved as the second-line medication should SSRI fail. Atypical and tricyclic antidepressants are alternatives, which are adopted should the previous medication occur inefficient. The ultimate drugs reduce depression by “acting on neurotransmitter’s reuptake mechanisms” (Comer, 2014). Selective serotonin-reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are among drugs of new generation as far as they produce fewer side effects. It is crucial to remember that antidepressant medication should not be stopped at a slight symptoms’ relief or reduction. The reason is that abrupt withdrawal from antidepressants increases a risk of having a relapse and, consequently, symptoms aggravation. Individuals with a depressive disorder may have difficulties responding to antidepressants if they additionally do not attend or avoid psychotherapeutic sessions. Any drugs involved in treatment course should be taken carefully and according to the prescriptions, considering the reported adverse effects.
Cognitive behavioral, problem-solving, and interpersonal therapies are actively applied to treat mood and mental impairments. Cognitive therapy is beneficial while it helps to involve the depressed people into enjoyable social activities and simultaneously “identifies and reframes destructive thoughts” (Taylor, 2014). The problem-solving therapy assists in decreasing such traces as embarrassment and indecisiveness. The represented treatment options are efficient for patients with “a poor response to antidepressant medications” (Taylor, 2014). The interpersonal therapy is also capable of reducing depressive signs. Present psychotherapeutic methods assist in detecting internal conflicts and providing solutions to depression-related situations. Furthermore, psychotherapeutic techniques are developed for reviving emotional state of the afflicted patient, “treating acute symptoms and decreasing the likelihood of relapse” (Coryell, 2016). Should depressed individuals demonstrate worsening of depression, unresponsiveness to drug therapy, continuing suicidal ideation, and overall health aggravation, health care providers are required to approach the electroconvulsive therapy (ECT) and brain stimulation, which are more aggressive brain stimulating therapies (Taylor, 2014). ECT is efficient treatment for severe cases of depression. In fact, electroconvulsive therapy provides brain seizures that are designed for relieving aggravated and even life-threatening depression. With regard to brain stimulation, it involves three biological approaches such as vagus nerve stimulation (VNS), deep brain stimulation (DBS), and transcranial magnetic stimulation (TMS), which are FDA-approved methods for treating complicated cases. Brain stimulation through activated vagus helps to reduce depressive symptoms whereas transcranial magnetic stimulation is aimed at depression relief by increasing neuron activity in the under-activated zones of the prefrontal cortex. The procedure of deep brain stimulation activates the brain via the electrodes implanted in Area 25. This kind of treatment is recently developed and requires further research and surveys. However, until today, this treatment modality designed for depression management shows considerable achievements. Therefore, life modifications, the intake of antidepressant drugs, psychotherapeutic sessions, counseling, electroconvulsive therapy and brain stimulating procedures can efficiently treat depressive disorders.
The variety of depressive disorders is primarily associated with mood swings and cognitive impairments, emotional instability and challenging behavior patterns. Persistent melancholic mood, disinterest, dissatisfaction, anhedonia, anger attacks, and even suicidal ideation are the primary symptoms of depression-related disorders. They demonstrate significant physical, mental and psychological lapses that deteriorate the quality of life of the affected as well as of their close environments. Critical alterations in the neurochemical level, neuroendocrine and hormonal dysregulations, and specific anatomical changes are characteristic peculiarities of most depressive disorders. Medical, psychological and psychiatric scientists have developed various treatment models that can considerably relieve and lessen depressive symptoms. A comprehensive approach and present therapeutic settings can provide long-term remission to all patients and reduce the number of recurrences. Escalating mortality, incidence, and prevalence rates implicate that such abnormalities cannot be ignored and further sophisticated research is required.