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Outpatient Management of Depression
2 - Why Identify and Treat Major Depression |
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The number of people in the United States with major depression
is estimated to be between 5% and 11% of the total population.4,61,98
Over half of these individuals will have recurrent episodes
periodically throughout their lives (Table
2.1). In terms of the associated mortality, morbidity,
and societal costs, the impact of clinical depression is astounding
(Table 2.2).
The cost to American society of depressive disorders is estimated
to be $26 billion annually. This estimate does not include
the effect of depression on the family.
Forty thousand to 50,000 Americans die annually because
of suicide (Table 2.3). Suicide is the
seventh leading cause of death in the United States. Of patients
with untreated recurrent major depression, 15% will die of
suicide. In up to 70% of these cases, clinical depression
will be the proximal cause of death. These figures place clinical
depression in the same league as leukemia as a cause of death
in the United States. Suicide is the third leading cause of
death among teenagers and young adults. Suicide also has an
impact on the lives of the relatives, friends, and coworkers
of the suicide victim. Deaths also occur as a result of accidents
caused by the impaired concentration and attention characteristic
of major depression.
Having major depression also increases the risk of alcohol
abuse and cigarette smoking. These conditions
in turn increase health problems.
TABLE 2.1 — Unipolar Depression
in the United States |
- High rate of occurrence:
– 5% to 11% lifetime
prevalence
– 10 to 14 million in
the United States depressed in
any year25
- Episodes can be of long duration (years)
- 50% rate of recurrence following a single
episode; higher if patient has had multiple
episodes or a positive family history
- Morbidity comparable to angina and advanced
coronary artery disease
- High mortality from suicide if untreated
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TABLE 2.2 — The Hidden
Cost of Not Treating Major Depression |
Mortality
- 30,000 to 35,000 suicides per year103
- Fatal accidents due to impaired concentration
and attention
- Death due to illnesses which can be a sequelae
(eg, alcohol abuse)
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Patient Morbidity
- Suicide attempts
- Accidents
- Resultant illnesses
- Lost jobs
- Failure to advance in career and school
- Substance abuse
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Societal Costs
- Dysfunctional families
- Absenteeism
- Decreased productivity
- Job-related injuries
- Adverse effect on quality control in the
workplace
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TABLE 2.3 — Suicide and
Major Depression: The Rule of Seven |
- One out of seven people with recurrent depressive
illness commit suicide72
- Seventy percent of suicides have depressive
illness206
- Seventy percent of suicides see their primary-care
practitioner within 6 weeks of suicide207
- Suicide is the seventh leading cause of death
in the United States103
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Patients with major depression frequently
self-medicate with alcohol to help themselves sleep and/or
to reduce associated anxiety. Tragically, alcohol provides
only fleeting relief and then aggravates the underlying biochemistry
of clinical depression, setting up the potential for a downward,
vicious spiral.
The incidence of cigarette smoking is higher in depressed
individuals and may be a harder habit to break in this population.
In a prospective study of almost 3,000 patients, depression
was found to be associated with a 5 times greater number of
disability days in employed individuals. Other studies have
found depression to be associated with:
- Poorer physical health
- Increased health-care utilization.
Based on a 15-year prospective outcome study, 80% of depressed
individuals who are not treated will have a poor outcome,
either remaining ill or experiencing recurrence(s) of their
illness. The disability due to major depression is on par
with or worse than that of chronic medical illnesses such
as coronary artery disease, hypertension, diabetes mellitus,
and arthritis, adversely affecting:
- Health-care utilization
- Absenteeism at work
- Productivity
- Job-related injuries
- Quality control in the workplace due to impaired concentration
and attention.
To fully appreciate the impact of depression, the following
would also have to be quantified:
- The cost of decreased work productivity by depressed individuals
suffering functional impairment due to major depression
- The impact on the individual and their family of:
- Failure to advance in one's education
- Failure to advance in one's career
- Lost jobs
- Marital strife
- Family dysfunction.
Major depression (Table 2.4):
- Is twice as likely to occur in women
- Has a peak age of onset from 20 to 40 years of age
- Runs in families-if there is a family history of major
depression, a person has a three-fold higher likelihood
of developing this disorder in comparison to the general
population
- Has a greater incidence among separated and divorced
people (which is cause versus which is effect is not known,
since major depression may cause separation and divorce)
- Is more likely to be reported in unmarried than married
men (again, the causal relationship is unclear)
- Is more likely to be reported in married than unmarried
women (again, the causal relationship is unknown since depressed
women with chronic low self-esteem may settle for abusive
and dysfunctional mates)
- Has an increased risk of occurrence for women during
the last trimester, the first 6 months following childbirth,
and during the onset of menopause as well as an increase
in symptoms prior to menses (suggesting a possible role
for fluctuations in sex hormones as pathophysiologically
important "triggers" for the expression of the
illness). Of interest, neuronal systems (norepinephrine
and serotonin) that have been implicated in the pathophysiology
of the illness are influenced by fluctuations in estrogen
levels.
TABLE 2.4 — Risk
Factors for Major Depression |
Risk Factor |
Association |
Gender |
Major depression
is twice as likely in women |
Age |
Peak age of onset
is 20 to 40 years of age |
Family history |
3 times higher risk
with positive history |
Marital
status |
Separated and divorced
persons report higher rates |
Married males lower
rates than unmarried males |
Married females
higher rates than unmarried females |
Postpartum |
An increased risk for the 6-month
period following childbirth |
Negative life events |
Possible association |
Early parental death |
Possible association |
Women are more likely to experience a depressive
episode, while men are more likely to suffer from alcohol
abuse and dependence. In fact, a subset of males who abuse
alcohol may do so because of having undetected major depression.
Effective treatment of their alcoholism may require concomitant
treatment of their depressive illness.
Fortunately, advances have been made in the understanding
of what constitutes appropriate and effective treatment, such
as:
- The development of eight pharmacologically unique classes
of antidepressants with varying spectra of antidepressant
activity (Chapters 6 through 8)
- Better definition of what constitutes a therapeutic trial
of an antidepressant in terms of dose and duration (Chapter
9)
- An enhanced knowledge of clinically meaningful pharmacokinetics
and pharmacodynamics to increase the safety and efficacy
of these antidepressants (Chapters 6
and 10).
As a result of these developments, the prognosis of clinical
depression is among the best of any major medical illness.
Approximately 50% of patients with major depression fully
remit when treated with any antidepressant. Of the remaining
50%, the majority will respond to monodrug treatment with
an antidepressant from a mechanistically different class (Chapters
6 through 8).
Tragically, many patients are not treated.241
In one study, only 3.5% of over 6,000 cases of newly diagnosed
depressed patients had received appropriate antidepressant
treatment (eg, dose, duration). Hence, many "treatment
refractory" cases are actually cases of inadequate treatment.
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