|Preskorn.com||Printed from: http://www.preskorn.com/books/omd_s2.html|
|Outpatient Management of Depression
2 - Why Identify and Treat Major Depression
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.
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:
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:
To fully appreciate the impact of depression, the following would also have to be quantified:
Major depression (Table 2.4):
|TABLE 2.4 — Risk Factors for Major Depression|
|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:
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.