Psychoneuroendocrinology: the Story of Depression - Literature review Example

MAJOR DEPRESSIVE DISORDER (DEPRESSION LITERATURE REVIEW By ……… …….. Presented to Dr. ……. (Prof ….. of….. Due Abstract Major Depressive Disorder (MDD) affects millions of people worldwide and has emerged as a significant pathology that creates an increasing burden on personal and social life. Patient characteristics may vary considerably and there are specific criteria in order to diagnose the disorder. Accurate diagnosis is important because the available treatment interventions can be very effective. Furthermore, new assessment methods increase the efficiency of approaching the depressed patient. Finally, ongoing outcome studies allow for future modifications of the whole approach to the disorder, the ultimate objective being the reduction of incidence and morbidity. Depression ( Major Depressive Disorder-MDD) is a complex disorder with a biological ( Fava cited in Jabbi et al. 2008, p. 2) and psychological basis that affects millions of people worldwide and is defined as “a mental disorder with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.” (WHO 2010) According to the World Health Organization the number of people suffering from depression is 121 millions, resulting in 850.000 suicide deaths every year (WHO 2010). Since it affects both genders and can appear in any age group, the impact on personal and community life is severe. The aim of this essay is therefore to review the ongoing intense research efforts aiming to better understand, assess, diagnose and treat the disorder. Many scientists focus their attention to the factors that may predispose the individual to develop the disorder from an early age. Factors such as family structure, the quality of relationship with the parents, with peers and self-esteem appear important and influence the development of depression in adolescents (Brendgen et al. 2005, Costello et al. 2008). Other social parameters that influence the individual propensity to develop depressive symptoms include highly demanding careers, such as medicine (Voltmer et al 2008) and physical characteristics that affect self-image, such as being overweight or obese ( Wright et al 2010). Other important predisposing factors include chronic disease that can be life-threatening such as cancer. Ominous diseases like malignant neoplasms put the patient through a tremendous ordeal, making him vulnerable to depression at any age group (Seitz et al. 2010, Weinberger et al. 2010). In general, chronic somatic pain with a multivariate etiology is a major contributor to the development of the disorder (Kirsh 2010). Recent research efforts have elucidated the biological aspects of depression. Hypothalamic function was suspected for many years to participate in the development of the disease, by controlling adrenocortical hormone release (Plotsky et al. 1998). At cellular level, there is evidence for an altered function of the glucocorticoid receptor resulting in the hyperactivity of the hypothalamus-pituitary-adrenal axis (Anacker et al. 2010) and also of different cytokine function, due to the genetic variants of cytokines that exist (Janssen et al. 2010). Very recently, the decreased volume of the hypothalamus, that constitutes a structural anomaly, was found to be a high risk factor for the development of depression in young girls (Chen et al. 2010). There are specific diagnostic criteria that have to apply in order to diagnose a patient with MDD according to the “Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision” (DSM-IV-TR 2000, p. 369) : The patient has to report depressed mood or diminished interest or pleasure and also at least three of the following symptoms: significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, diminished ability to think or concentrate, indecisiveness recurrent thoughts of death, suicidal ideation/suicide attempt, or specific plan for suicide. These symptoms have to be present concurrently for at least two weeks and interfere with the patient’s everyday activities. It is important not to overdiagnose the disorder during a normal bereavement period and also to be able to suspect the diagnosis in a primary care facility where usually the reported symptoms are somatic and include fatigue, abdominal discomfort or headache (Bhalla & Bhalla 2010). Clinical assessment begins with the patient’s history and the physician is trying to elucidate all aspects by asking questions about existing medical problems, family health history, current medications, possible abuse of alcohol or drugs, developmental history (family composition, behavior during childhood, social role handling etc.), existence of suicidal thoughts ( ed. Porter 2010). Recently, there is an ongoing effort of developing assessment tools in order to achieve a “measurement-based care approach” to depression (Gelenberg 2010). These tools concentrate on patient self-reporting with the use of paper, computerized, or interactive voice response formats (Gelenberg 2010). As Trivedi analyzes in his paper (2009) there are very useful assessment tools such as the “Frequency, Intensity, and Burden of Side Effects-Rating (FIBSER) questionnaire” and the “16-item Quick Inventory of Depressive Symptomatology”. The use of these tools can improve the accuracy of assessing depressive symptoms, facilitate the application of treatment algorithms at initial presentation and during follow-up, and contribute significantly towards sustained remission. (Trivedi 2009). The treatment of depression consists of psychotherapy and/or antidepressants. As first-line treatment for patients with mild to moderate depression the use of medications or psychotherapy is recommended ,whereas in severe cases the combination of both modalities should be used (National Guideline Clearinghouse 2010). The therapeutic plan is then adapted according to the specific situation of each patient (full remission, failure of remission, suicidal ideation, single or multiple episodes of depression etc.) (National Guideline Clearinghouse 2010). Common medication prescribed for the depressed patient consist of selective serotonin reuptake inhibitors (such as fluoxetine, citalopram, sertraline), tricyclic antidepressants (such as clomipramine, amitriptyline) , serotonin norepinephrine reuptake inhibitors (such as venlafaxine, duloxetine) , norepinephrine reuptake inhibitors (such as mazindol, viloxazine) or dopamine agonists (such as ropinirole, pramipexole) (National Guideline Clearinghouse 2010). There is not enough evidence to recommend treatments such as right prefrontal transcranial magnetic stimulation (rTMS), Vagus nerve stimulation, or Folate/ Inositol supplementation (National Guideline Clearinghouse 2010). The patients should be monitored during treatment in the acute phase of the disorder and the minimum recommended follow-up frequency is one patient contact within the first month, and at least one additional patient contact four to eight weeks after the first contact (National Guideline Clearinghouse 2010). When symptom remission is achieved, at least one follow-up contact is recommended during the fifth-sixth month of treatment. The need for dosage or treatment adjustment should be evaluated during this contact (National Guideline Clearinghouse 2010). Asymptomatic patients, who are continuing on antidepressants beyond 12 months, should be scheduled for at least one annual follow-up contact during which there will be again an assessment of symptoms and the need for continuation of treatment and medication adjustment (National Guideline Clearinghouse 2010). The outcome in patients treated for depression is as diverse as the etiology of the disorder, and depends on several factors that may differ significantly from one patient to another.Hirschfeld describes in his thorough review paper (2000) the socioeconomic parameters that affect the occurrence and the outcome of depression: age at first presentation is very important and patients younger than 40 years of age are three times more likely that older individuals to develop the disorder. Other important factors that are analyzed in the same paper include gender, marital status, quality of marriage and family relationships, social support, socioeconomic status, personality traits and disorders, life events and bereavement, anxiety and substance abuse. There are many research efforts, such as “The ENRICHD Randomized Clinical Trial” (Cowan et al 2008) and “The Treatment Initiation and Participation (TIP) Program” (Sirey et al. 2010), in an attempt to further elucidate the aforementioned parameters in order to better understand, prevent and treat the disorder. In conclusion, Major Depressive Disorder is a multi-factorial entity, with great impact on personal, family and social life. Since the etiology of the disorder is complex and the patient characteristics vary significantly, the existence of specific diagnostic criteria and the development of effective assessment methods will aid in a more effective patient management. The input from trials that measure the outcome of the various intervention modalities will provide the insight for future directions in the prevention and treatment of depression, with the ultimate goal obviously being the reduction of the incidence and morbidity of the disorder. REFERENCES: Anacker, C, Zunszain, PA, Carvalho, LA & Pariante, CM (2010) The glucocorticoid receptor: Pivot of depression and of antidepressant treatment? Psychoneuroendocrinology. doi:10.1016/j.psyneuen.2010.03.007 American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision) 4th edition, Washington DC, American Psychiatric Publishing, Inc. Bhalla RN & Bhalla PM, (2010) Depression, eMedicine, [online] . Available from http://emedicine.medscape.com/article/286759-overview [Accessed April17, 2010] Brendgen, M, Wanner, B, Morin, AJ &Vitaro, F (2005) Relations with parents and with peers, temperament, and trajectories of depressed mood during early adolescence. Journal of Abnormal Child Psychology, 33(5):579-94 Cowan, MJ, Freedland, KE, Burg MM, Saab PG, Youngblood ME, Cornell CE, Powell LH, Czajkowski SM (2008) Predictors of Treatment Response for Depression and Inadequate Social Support - The ENRICHD Randomized Clinical Trial. Psychotherapy and Psychosomatics ,Vol. 77, No. 1 Costello, DM, Swendsen, J, Rose, JS & Dierker LC (2008) Risk and protective factors associated with trajectories of depressed mood from adolescence to early adulthood. Journal of Consulting and Clinical Psychology, 76(2):173-83 Chen, MC, Hamilton, JP & Gotlib, IH (2010) Decreased hippocampal volume in healthy girls at risk of depression. Archives of General Psychiatry, 67(3):270-6 Gelenberg AJ (2010)Using assessment tools to screen for, diagnose, and treat major depressive disorder in clinical practice. Journal of Clinical Psychiatry, 71 Suppl E1:e01. Hirschfeld, RM (2000) Psychosocial Predictors of Outcome in Depression [online]. Available from http://www.acnp.org/g4/GN401000107/CH105.html [assessed on April 24 2010] Jabbi, M, Korf, J, Ormel,J, Kema,IP, &den Boer JA (2008) Investigating the Molecular basis of Major Depressive Disorder etiology: a Functional Convergent Genetic Approach. Annals of New York Academy of Sciences, 1148: 42–56 Janssen, DG, Caniato, RN, Verster, JC &Baune, BT (2010) A psychoneuroimmunological review on cytokines involved in antidepressant treatment response. Human Psychopharmacology, 25(3):201-15 National Guideline Clearinghouse. (2010) Depression clinical practice guidelines. [Online]. Available from: http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999 [Assessed on 23rd April 2010] Plotsky, PM, Owens, MJ & Nemeroff CB (1998) Psychoneuroendocrinology of depression. Hypothalamic-pituitary-adrenal axis. Psychiatric Clinics of North America,21(2):293-307 Porter, R.S. (ed.), (2010) The Merck Manual Online,[Online], New Jersey, Merck Sharp & Dohme Corp. Available from http://www.merck.com [Assessed 23rd April 2010]. Seitz, DC, Besier, T, Debatin, KM, Grabow, D, Dieluweit, U, Hinz, A, Kaatsch, P & Goldbeck, L (2010) Posttraumatic stress, depression and anxiety among adult long-term survivors of cancer in adolescence. European Journal of Cancer, [Epub ahead of print], PMID: 20381339 Sirey, JA, Bruce, ML & Kales HC (2010) Improving Antidepressant Adherence and Depression Outcomes in Primary Care: The Treatment Initiation and Participation (TIP) Program. [Epub ahead of print] PMID:20220604 Voltmer, E, Kieschke, U, Schwappach, DL, Wirsching, M & Spahn, C (2008) Psychosocial health risk factors and resources of medical students and physicians: a cross-sectional study. BMC Medical Education, 8(2):46 Weinberger, T, Forrester, A, Markov, D, Chism, K & Kunkel EJ (2010) Women at a dangerous intersection: diagnosis and treatment of depression and related disorders in patients with breast cancer. Psychiatric Clinics of North America, 33(2):409-22. World Health Organization . (2010) WHO: Depression. What is depression? [Online]. Available from http://www.who.int/mental_health/management/ depression/definition [Accessed April 17, 2010] Wright, LJ, Schur, E, Noonan, C, Ahumada, S, Buchwald, D & Afari, NJ (2010) Chronic Pain, Overweight, and Obesity: Findings from a Community-Based Twin Registry.The Journal of Pain , doi:10.1016/j.jpain.2009.10.004 Appendix For the approach of the subject “Major Depressive Disorder: Literature review” the sources of information that were used consisted of medical databases on the internet, that are highly reputed for containing original and up-to-date research articles on various fields of modern medicine. These data bases are: a) www.pubmed.org b) www.medscape.com c) www.webmd.com The keywords used for database search were relevant to the demands of the literature review paper and included “depression and diagnosis”, “depression and assessment”, “depression and treatment”, “depression and outcomes”. Also, other combinations that were used in order to retrieve the necessary information for each section of the paper were “depression and cancer”, “depression and etiology”, “the biological basis of depression”. The Boolean operator that was the most useful was “AND”, because it was more helpful in the targeted approach of the different aspects of this paper. The use of these specific combinations of keywords retrieved the necessary research papers that contained information on the subject of this literature review. The information was then critically analyzed, synthesized and presented in an organized manner in order to effectively present all aspects of Major Depressive Disorder. Read More