Major Depressive Disorder

Identifying and Reducing Professional Liability When Treating Older Adults, by Jacqueline M. Melonas, RN, MS, JD and Charles D. Cash, JD, LLM, ARM

A large percentage of youths use and abuse psychoactive substances. According to the 2007 Monitoring the Future (MTF) survey, the percentage of US adolescents who used illicit drugs or drank alcohol continued a decade-long drop, revealing that 19% of 8th grad­ers, more than 36% of 10th graders, and 47% of all 12th graders have taken an illicit drug (other than alcohol) during their lifetime.1 According to the National Survey on Drug Use and Health, the rate was 3.3% for misuse or nonmedical use of prescription drugs.2 The misuse of prescription drugs among adolescents was second only to marijuana use. In fact, prescription drugs increasingly have become a part of the repertoire of drug-using adolescents.

For some couples, the transition to parenthood is not filled with this rich mixture of great perplexity and great joy.

The substantial and often recurrent distress and impairment associated with major depressive disorder (MDD) in youth has prompted increased interest in the identification and dissemination of effective treatment models. Evidence supports the use of several antidepressant medications, specific psychotherapies, and, in the largest treatment study of depressed teenagers, the combination of fluoxetine and cognitive-behavioral therapy (CBT) as effective treatments.1-3 CBT is the most extensively tested psychosocial treatment for MDD in youth, with evidence from reviews and meta-analyses that supports its effectiveness in that population.3-5

The prospect of using computers to deliver psychotherapy has been intriguing a number of investigators who have been studying innovative methods of bringing technology into clinical practice.

Every life ends with death. For the elderly, death is the end of a long life that has been shaped by personal history and world events, various relationships, well-set personality characteristics and, of course, happenstance. Each of these, in addition to the specific circumstances that herald death, shapes the experience of dying in old age.

Suppose your new patient, Mr. Jones, tells you he is feeling “really down.” He meets all DSMIV symptomatic and duration criteria for a major depressive episode (MDE) after having lost his wife to cancer 2 weeks ago. Should you diagnose major depressive disorder?

Youths aged 6 to 16 years with any subtype of ADHD participated in the study. Comorbid bipolar disorder, pervasive developmental disorder, psychotic illness, anxiety disorders, and tic disorders were exclusionary criteria. Patients with other comorbid psychiatric disorders, including major depressive disorder, were allowed to participate if ADHD was the primary diagnosis.

Late-life depression is both underrecognized and undertreated, and the impact of medical comorbidity may mask depressive symptoms. Depression further complicates the prognosis of medical illness by increasing physical disability and decreasing motivation and adherence to prescribed medications and/or exercise or rehabilitation programs

Major depressive disorder has become psychiatry’s signature diagnosis. Depression is diagnosed in about 40% of patients who see a psychiatrist. This percentage is double that of just 20 years ago.

The FDA has cleared the first transcranial magnetic stimulation (TMS) device (Neuro-Star) for the treatment of major depressive disorder in adults who show no improvement after an adequate trial of a single antidepressant.

Although several studies indicate that psychotherapy (alone or in combination with medications) can help psychiatric patients reach recovery faster and stay well longer, a declining number of office-based psychiatrists are providing psychotherapy to their patients.

Late-life depression is both underrecognized and undertreated. The impact of medical comorbidity may mask depressive symptoms.

The National Comorbidity Survey estimates that approximately 50% of the population in the United States is exposed to traumatic events and that the lifetime prevalence of posttraumatic stress disorder (PTSD) is approximately 7.8%.

Reports of 1 in 5 military service members returning from Iraq or Afghanistan with posttraumatic stress disorder (PTSD) and/or depression and rising suicide rates have led researchers and military leaders to warn civilian psychiatric care providers of a “gathering storm”1 headed their way.

Reducing complex human experiences into a psychiatric diagnosis can be a daunting task. For children with developmental disorders, this process is even more complicated and requires distilling often incomplete and frequently contradictory scientific evidence.

Diagnostic assessment of psychiatric disorders and their comorbidities is a challenge for many clinicians. In emergency settings, there is no time to conduct lengthy interviews, and collateralinformation is often unavailable.

Gambling has become a major recreational activity in the United States. Formerly confined to a few states such as Nevada and New Jersey, legal gambling opportunities have exploded across the nation in the past 2 decades.

Two recent studies on the treatment of depression in children and adolescents will help guide clinicians’ treatment decisions.

I have been invited to write a clinical article on psychotherapeutic interventions for chronic depression.

Unipolar major depressive disorder is a debilitating condition with a lifetime prevalence of 17%. Recent epidemiological evidence indicates that MDD is the fourth leading cause of disease burden and the leading cause of disability-adjusted life years.

ADHD, the most common diagnosis in child psychiatry, appears to be more challenging to diagnose and treat when there is a comorbid depressive disorder.

In his review of my book, Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession (Psychiatric Times, June 2008, page 57), S.N. Ghaemi, MD, MPH, citing George Orwell, writes that I “seek to justify an opinion” rather than “seek the truth.” He claims that my “errors are numerous and fundamental.”

Here I will discuss several examples of recent, reasonable depictions of ECT in the media, and I will suggest how they could represent a shift in the way that this “controversial” therapy is regarded. I use the word “controversial” advisedly, because even on the day I write this, a newspaper article on deep-brain stimulation, in which ECT is described, reads: “New reports this month show that some worst-case patients-whose depression wasn’t relieved by medication, psychotherapy, or even controversial shock treatment-are finding lasting relief.

This article focuses on recent innovations in diagnostic issues, tactics, and strategy, and takes a brief look at the future.