Major Depressive Disorder

Present-day psychiatry has fallen into crisis because of the severe limitations of its conception of the person and, as a result, its conception of the patient. It objectifies the patient in a number of ways. Because of this reductionism, psychiatry fails to distinguish between healthy and pathological features of human life. It fails to consider adequately the psychological and social factors that cause and maintain each patient's problems.

The most common psychiatric sequelae following trauma include major depressive disorder, somatoform pain disorder, adjustment disorder and posttraumatic stress disorder (PTSD). In law, trauma that precipitates PTSD is viewed as a tort, which stems from the root word "torquere" (to twist), as does the word torture. In a sense, plaintiffs do allege torture in personal injury cases. A tort constitutes a civil or private wrong, as opposed to a criminal wrong, and rests on the general principle that every act of a person causing damage to a legally protected interest of another obliges that person, if at fault, to repair the damage (Slovenko, 1973).

More than 430 psychiatrists, research donors and others gathered in late October for the National Alliance for Research on Schizophrenia and Depression (NARSAD)'s awards dinner in New York City. The black-tie fundraising event was held in conjunction with the organization's 10th annual scientific symposium at which 15 selected NARSAD grantees presented their ongoing research over two days of sessions devoted to basic science, schizophrenia and depression.

Recent advances in the treatment of mental and addictive disorders, along with research findings in basic neuroscience, molecular genetics and molecular biology that contribute to the understanding of such disorders, were discussed at the American College of Neuropsychopharmacology's 37th annual meeting in Puerto Rico. The following are brief reports from selected presentations.

More than 80 medications are in development to treat mental illnesses, including 18 for depression, 15 for schizophrenia and 16 for anxiety disorders, according to the Pharmaceutical Researchers and Manufacturers of America (1998). Which ones will most likely come to market in the United States?

Psychogenic excoriation (also called neurotic excoriation, pathologic or compulsive skin picking, and dermatotillomania) is not yet recognized as a symptom of a distinct DSM-IV disorder.

This is the first in a series of articles summarizing research presented at the 1998 American College of Neuropsychopharmacology Annual Meeting.

Daniel F. Kripke, M.D. has studied the relationship between biological rhythms and depression since the early 1970s. He states that seasonal responses in many mammals are controlled by the photoperiod. Therefore, it seemed that depression might be analogous to winter responses and that light might be an effective treatment.

Despite the development of better-tolerated antidepressants and more effective applications of nondrug modalities like cognitive-behavioral therapy, depressive disorders are often chronic or recurrent. The researchers point out that there has been relatively little evaluation of chronic depression, with most studies addressing short-term treatment of acute episodes.

Insomnia, the subjective sense of having inadequate quantity or quality of sleep, occurs in 20% to 35% of the general population. Not surprisingly, many insomniacs describe a variety of difficulties in their personal and professional lives.

Warning of declining resources for mental health, Nelba Chavez, Ph.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), said mental health must become a top priority in public policy, health care services and coverage, training of health care professionals and community education.

A physician asks, via the Internet, for help in locating a resource to evaluate possible interactions between herbal remedies and Western medications. A Stanford researcher surveys 1,035 randomly selected people and reports that 40% of them have used such alternative health care as chiropractic, acupuncture or homeopathy during the past year (Astin, 1998). A survey of U.S. medical schools indicates nearly two-thirds of those responding (64%) now offer courses that include alternative medicine (Wetzel et al., 1998).

It is more cost-effective for psychiatrists to provide medication and psychotherapy to depressed patients than it is to split treatment between medical doctors and other mental health care providers

Although evidence shows that selective serotonin reuptake inhibitor (SSRI) antidepressants cause less orthostasis and interfere less with psychomotor function than do tricyclic antidepressants (TCAs), a recent pharmacoepidemiologic study found them comparable in increasing elderly patients' risk for falling.

In Western psychiatry, depression is considered a major cause of suicide. But research from China calls that assumption into question. More than 300,000 suicides occur annually in China, nearly 10 times the number of suicides in the United States.

Meeting the mental health needs of the millions of immigrants from diverse cultural backgrounds and homelands who now live in the United States may require more than a thorough knowledge of psychiatry or psychology, according to a number of cultural psychiatric practitioners.

Consider the following scenario: You are contacted by the major health plan with which you contract and are told that your average length of inpatient stay is longer than their standard. You believe this is because your patients are more severely ill than average. How do you respond?

Insufficient intake of essential fatty acids (EFAs) may contribute to the pathogenesis of mental diseases, while their supplementation may relieve some symptoms, according to researchers who attended the National Institutes of Health (NIH) Workshop on Omega-3 Essential Fatty Acids and Psychiatric Disorders held in Bethesda, Md., in September 1998.

This is the second of two articles regarding herbal medicines as discussed at the American Psychiatric Association's annual meeting in Toronto. Potential benefits and risks of kava, St. John's wort and hoasca were considered at the recent American Psychiatric Association's symposium on herbal medicine.

While managed care generally has limited inpatient care and contained short-term costs for mental health and substance abuse services, significant questions remain about how these changes in health care delivery affect the quality of care patients receive.

An investigational compound that blocks the neurokinin "substance P" has demonstrated robust antidepressant effect in preliminary clinical testing against paroxetine (Paxil) and placebo. This finding has been described by as "a breakthrough discovery" in mental health care.

The obvious sometimes bears repeating: Sick people have trouble thinking. They may be suffering from a delirium, a dementia or a more subtle disturbance of cognition caused by fever, drugs, infection, inflammation, trauma, hypoxemia, metabolic derangement, hypotension, tumor, intracranial pathology, pain and so forth.

Atypical antipsychotic treatment for borderline personality disorder (BPD) and augmentation therapy with olanzapine (Zyprexa) or estrogen replacement therapy (ERT) for patients with mood disorders were among the research questions addressed at the American Psychiatric Association's annual meeting in Toronto. Following are some brief reports of selected presentations.

New methods of conducting and evaluating research were as intriguing as their results at the National Institute of Mental Health (NIMH)-sponsored New Clinical Drug Evaluation Unit Program's (NCDEU) 38th annual meeting in Boca Raton, Fla., June 10-13. The meeting has grown from a forum of NIMH-funded researchers reporting on their progress into a convention of approximately 1,000 clinicians, industry and regulatory personnel, and investigators marking the progress in psychopharmacology.

The diagnostic criteria for sexual addiction are derived from the behaviorally nonspecific criteria for addictive disorder that were presented in Part 1 (Goodman, 1998b), by replacing "behavior" with "sexual behavior".

With advances in the neurosciences, and especially in imaging techniques, we stand at the threshold of demonstrating that psychotherapy is a powerful intervention that affects the brain. While it has been intuitively obvious to most clinicians that psychotherapy must work by affecting the brain (how else could it work?), recent breakthroughs in technology demonstrate what kinds of changes occur with psychotherapy.

As her patient leaves the consulting room, Susan Roth, M.D., picks up her computer's microphone and begins dictating. "Wake up. Open template recurrent major depression. Patient identification: Mr. Johnson is a 64-year-old married white male. Chief complaint: difficulty sleeping, loss of appetite and depressed mood with suicidal ideation for the last three weeks."

In the first study to compare the efficacy and tolerability of mirtazapine (Remeron) and fluoxetine (Prozac) in patients with major depression, David Wheatley, M.D., of The Royal Masonic Hospital, London, and colleagues from throughout Europe showed mirtazapine and fluoxetine to be similar in tolerability, with mirtazapine significantly superior in efficacy.

This is the fourth in a series of five articles regarding obsessive-compulsive spectrum disorders. The first three articles ran in the March 1997, June 1997 and January 1998 issues of Psychiatric Times. The first article gave an overview of spectrum disorders, the second discussed obsessive-compulsive disorder and the third examined body dysmorphic disorder.

For reasons researchers are still trying to understand, clinical depression appears to be almost twice as common in women as in men. Why females are more prone to this debilitating disease than their male counterparts is still under investigation, although significant progress has been made.