Major Depressive Disorder

Many refugees have been victims of severe violence that has profoundly affected their physical, psychological, and spiritual lives.

Currently the Veterans Administration (VA) is the world’s largest recipient of per patient funding for PTSD. The VA treats 200,000 veterans with this diagnosis annually at a cost of $4 billion. But research calls into question the very existence of the “PTSD” syndrome, and its diagnostic formulation remains invalid. We do not minimize the suffering of those who experience trauma or the need for comfort and restitution. We seek only to reexamine research evidence, to clarify the impact of culture on diagnosis, to reevaluate the consequences of trauma, and to ensure optimal allocation of resources.

As we begin this brief review of the neurobiology of major depressive disorder (MDD), we face these fundamental questions

Four recent studies have shed light on the effects of early childhood mood and behavioral problems on adulthood.

We would suggest that psychiatry has spent so many years taking its diagnostic categories as God-given that it has become inured to the fact that these categories tell us very little about the etiology and fundamental nature of the conditions they purport to encompass.

Alarmed by the rising suicide rate among soldiers returning from Iraq and Afghanistan and “wanting to help,” Matthew “Matt” Houseal, MD, a psychiatrist with the Texas Panhandle Mental Health Mental Retardation Center (TPMHMR), reenlisted as an Army Reservist and volunteered to serve in Iraq.

Transcranial magnetic stimulation produced improvements in key areas of cognition and in short-term verbal memory in patients with major depressive disorder, and no adverse cognitive effects were shown. The results of this research were presented by Mark Demitrack, MD, vice president and chief medical officer of Neuronetics, Inc, and colleagues at the annual meeting of the American Psychiatric Association in May.

The epidemiology and management of psychiatric disability have gained increased attention for a variety of reasons in the past 3 decades. There are issues of empowerment, advocacy, and reduction of stigma. There are also concerns about cost containment as well as reliability, validity, and efficacy of the determination process.

The FDA’s Psychopharmacologic Drugs Advisory Committee (PDAC) flashed partial green lights to 2 manufacturers of atypical antipsychotics. The committee recommended approval for 2 new uses for Seroquel XR (quetiapine fumarate) extended-release tablets and also gave first-time approval in this country for Serdolect (sertindole).

Patients who have had a myo­cardial infarction (MI) should be screened and appropriately treated for depression, according to a guideline recently issued by the American Academy of Family Physicians (AAFP).1 The group recommends use of a standardized depression symptom checklist during hospitalization and “at regular intervals” thereafter.

Cardiovascular disease kills more people worldwide than everything else combined, said Dean Ornish, MD, cardiologist and clinical professor of medicine at the University of California in San Francisco. Dr Ornish is well known for his lifestyle-driven approach to the control of cardiovascular disease. Depending on the extent of personalized lifestyle changes, disease progression can be stopped and even reversed.

I have been practicing psychodynamic psychotherapy for more than 30 years. During this time, there has been an accepted taboo against coupling psychotherapy with spirituality-despite a number of articles that have been written on this subject.

Forest Laboratories recently set aside $170 million in anticipation of eventually settling a federal government complaint about the company’s marketing and promotional practices.

Why do Drs Pies, Wakefield, and Horwitz feel that “blue” feelings after a major loss (such as death of a spouse) or, for that matter, any loss have to be either “grief” or “major depression”?

In “Major Depression After Recent Loss Is Major Depression-Until Proved Otherwise” (Psychiatric Times, December 2008, page 12), Dr Pies highlights one of the more provocative questions encountered when we train in clinical psychiatry: “Suppose your new patient Mr Jones, tells you he is feeling ‘really down.’ He meets all DSM–IV symptomatic and duration criteria for a major depressive episode (MDE) after having lost his wife to cancer 2 weeks ago. Should you diagnose MDD?”

The polemics between Drs Pies and Wakefield and Horwitz (“An Epidemic of Depression,” Psychiatric Times, November 2008, page 44) have validity, but their commentaries did not touch on the real bone of contention. Dr Pies does not believe that just because psychosocial precipitators of a depression-specifically, bereavement-are known, somehow the significance of the depression should be viewed differently.

“An Epidemic of Depression” by Wakefield and Horwitz (Psychiatric Times, November 2008, page 44) raised the issue that DSM does not take into account the context in which symptoms arise for the diagnosis of MDD. The authors opine that the diagnosis should require that symptoms be “excessive” or “unreasonable” relative to the context in which they arise, and that “the efficacy of these medications for the treatment of normal sadness is often overstated.”

To improve validity, we proposed extending the current MDD bereavement exclusion-which excludes “uncomplicated” (relatively brief, lacking certain severe symptoms) depressive bereavement from diagnosis-to also exclude uncomplicated reactions to other major stressors, such as romantic breakups, job loss, and serious medical diagnoses.

Social anxiety disorder (SAD), also referred to as social phobia, is a chronic and potentially disabling anxiety disorder characterized by the intense and persistent fear of being scrutinized or negatively evaluated by others. At its core, people with this disorder fear and/or avoid the scrutiny of others. Symptoms may occur only in circumscribed situations, such as a fear of speaking in formal or informal situations, or eating or drinking in front of others.

Acupuncture is associated with an increase in the level of neurobiologically active substances, such as endorphins and enkephalins. There are also data indicating that acupuncture induces the release of norepinephrine, serotonin, and dopamine.

For many antidepressants, the issue of brand-name versus generic has no practical significance. Elavil was first marketed almost a half century ago, and its patent has long expired. It lives on, however, but as generic amitriptyline. Today, only a few antidepressants are still fully protected by patents, namely, Cymbalta (2010), Lexapro (2012), and Pristiq (2022) for major depressive disorder (MDD); and Seroquel (2011) and Symbyax (2017) for bipolar depression.

Lecturing around the country has left us with the powerful impression that both psychiatrists and primary care physicians are hungry for new ways to think about and treat depression and the myriad symptoms and syndromes with which it is associated-including attention deficit disorder, insomnia, chronic pain conditions, substance abuse, and various states of disabling anxiety. Primary care physicians also seem especially excited to learn that depression is not just a psychiatric illness but a behavioral manifestation of underlying pathophysiological processes that promote most of the other conditions they struggle to treat-including cardiovascular disease, diabetes, cancer, and dementia.1,2

The assessment and treatment of psychiatric symptoms in persons with cognitive dysfunction are becoming increasingly important. Prevalence estimates of dementia in the United States range from 5% in those aged 71 to 79 years to 25% to 50% in those 90 or older.

Autism spectrum disorders (ASDs) are a group of 5 neuro developmental conditions (autism, Asperger syndrome, pervasive developmental disorder not otherwise specified [PDD-NOS], Rett syndrome, and disintegrative childhood disorder).1 Once thought to be rare, the incidence of these disorders is now estimated to be 1 in 150 children in the general population.2 Furthermore, the number of recognized cases has increased markedly in recent years.

Allegations of suppressed research, promotion of drugs for unapproved uses, payment of kickbacks to physicians, and ghostwriting of a major journal article surfaced recently when the Department of Justice unsealed a civil complaint against Forest Laboratories and Forest Pharmaceuticals, Inc.