Major Depressive Disorder

1 1.0

Introduction Mood disorders have been recognized and written since the beginning of the history

of medicine. Mood disorders are mental disorders characterized by periods of depression, sometimes alternating with periods of elevated mood. Mood disorders or affective disorders, is a category of mental health problems which include all types of depression and bipolar disorder (Ohio State University Medical Center, 2007).

One of the most noticeable features of mood disorder is their episodic quality. The nature of the episode and its duration can determine the diagnosis and treatment. Major depressive episodes will occur over a period of several weeks or several months. The episode itself typically last several months and ends, as it began, gradually (Coryell, Akiskal, Leon, et al,. 1994). Major depressive episode patients undergo deep changes in their life. These changes include: mood, motivation, thinking, physical and motor functioning. The features of major depressive episode describe by DSM-IV-TR as follow; depressed mood, loss of pleasure or interest in usual activities, disturbance of appetite, sleep disturbance, psychomotor retardation, or agitation, loss of energy, feeling of worthless and guilt, and difficulties in thinking.

Manic episode normally occurs out of a sudden for a few days and it is shorter than major depressive disorder. Mania is a severe medical condition characterized by extremely elevated mood, energy, and unusual thought patterns (CSS Mania, 2004). Individual who simultaneously meet diagnosis criteria for both manic episode and major depressive episode are diagnosed with mixed episode. Typical examples include

2 tearfulness during a manic episode or racing thoughts during a depressive episode. DSMIV-TR describes the prominent 8 features; elevated, expansive, or irritable mood, inflated self-esteem, sleeplessness, talkativeness, flight of ideas, distractibility, hyperactivity, and reckless behavior. Manic episode will be diagnosed if the condition lasted at least a week and must have seriously interfered with the person’s functioning.

This combination is called a mixed episode and is not uncommon (Alloy, Lauren B., 2004). Whichever type of manic episode a person has solely elated or mixed, subsequent episodes tend to be of the same kind (Woods, Money & Baker, 2001). One may also feel incredibly frustrated in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states can be the most dangerous period of mood disorders, during which substance abuse, panic disorder, suicide attempts, and other complications increase greatly (WrongDiagnosis.com, 2007). As affirmed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a mixed state must meet the criteria for a major depressive episode and a manic episode nearly every day for at least one week. However, mixed episodes rarely match these qualifications; they may be described more practically as any combination of depressive and manic symptoms (Akiskal & Pinto, 1999; Goldman, 1999; Perugi et al., 1999).

According to the DSM-IV-TR, a hypomanic episode includes, over the course of at least 4 days, three or four of the following symptoms, depending on whether the predominant mood state is elated or irritability: inflated self-esteem; decreased need for sleep; being more talkative than usual; flight of ideas; distractibility; psychomotor

3 agitation; and excessive involvement in pleasurable activities that have a high potential for harmful consequences. In the hypomanic state, people may feel as though they can't slow their mind down.

Bipolar disorder involves both manic and depressive phases. It first appears in late adolescence in the form of manic episode. One episode may be followed immediately by its opposite, with normal intervals occurring only between such manic-depression pairs (Rehm, Wagner, & Ivens-Lyndal, 2001). In the Bipolar I disorder, the patient has just one Manic Episode and do not have Major Depressive Episode. In Bipolar II disorder, the person has had at least one major depressive episode and at least one major depressive episode but has never met the diagnostic criteria for manic or mixed episode.

Major depressive disorder is undergoing one or more major depressive episodes, without intervening period of mania. Major depressive disorder is a state of intense sadness, melancholia or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living. It is now the forth leading cause of disability and premature death worldwide (Davis, 1996).

2.0

Diagnostic Features Mental health professionals and physicians need to be cautious in diagnosing their

clients for clinical depression. A professional should gather as much information as possible about the person, perform a medical evaluation, clinical interview and possibly administer additional assessments. Mental health professionals then identify the disorder

4 through the diagnostic criteria of the symptoms. For major depression, the common references used are The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10).

2.1

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) The latest version, DSM-IV-TR, which was published in May 2000, saw changes

being made to several parts including, clarifying the uncertainty of the time frame in the Major Depressive specifiers (coding of the fifth digit). DSM is an excellent resource for aiding the diagnosis of psychiatric and psychological problems, rating of occurrences and traits (psymed.com).

According to the DSM-IV-TR, Major Depressive Disorder (MDD) shows the occurrence of at least a single depressive episode without any manic, hypomanic or mixed episodes. The occurrence of the depressive episodes can further categorize MDD into single or recurrent episodes. Presence of two or more major depressive episode (Appendix 1) is classified as recurrent episodes. Within the two categories, there are also specifiers such as severity/psychotic/remission specifiers, chronic, catatonic features, melancholic features, atypical features and postpartum onset. There are also longitudinal course specifiers and seasonal patterns which only apply for recurrent episodes.

2.2

International Statistical Classification of Diseases and Related Health Problems (ICD-10)

5 ICD has its origins set back to the 1850s, where the current ICD-10 came to use in 1994. The ICD is used to organize diseases and other health problems recorded on various vital records for storage and retrieval of diagnostic purposes, typically death certificates and hospital records. These records also supply the origin for the compilation of national death count statistics by WHO Member States (World Health Organization, 2004).

Similar to the DSM-IV-TR, ICD-10 also originates from the depressive episodes, which is further categorized based on the severity of the episodes. Differentiation of mild, moderate and severe depressive episode lies on a complex finding involving number, types and severity of symptoms present. The occurrence of further depressive episodes would be classified under recurrent depressive disorder (Appendix 2). Recurrent depressive episodes can be further divided through specifying the type of current episode followed by the predominate type in all episodes.

2.3

Arguments The terms and codes in DSM-IV are mostly attuned with ICD-10, and diagnosis of

major depressive disorder is basically similar in both classifications except for a few aspects (Melartin, 2004). One of it is based on the clinical significance. In DSM-IV, the symptoms cause a large amount of stress or impairment in social, occupational or other vital parts of functioning. This is compared to the variation in the ICD-10, where it varies from some difficulty to continue normal work and social activities in mild depressive

6 disorder, to substantial pain and anxiety, and highly improbable of continuing social, work or domestic activities (Gruenberg, Goldstein, & Pincus, 2005).

The two diagnostic criteria also differ in their duration of symptoms. DSM-IV states that a person with MDD will show the symptoms most of the day, and persisting almost each day for a period of two weeks. ICD-10 on the other hand, requires at least two weeks for diagnosis of all three rank of severity (Gruenberg, Goldstein, & Pincus, 2005).

DSM-IV also varies from ICD-10 based on the severity. In DSM-IV, five or more of the stated symptoms, including the symptom of either depressed mood or anhedonia (Gruenberg, Goldstein & Pincus, 2005). The ICD-10 diagnoses the severity of the depressive episode based on the most typical symptoms available. (Appendix 3)

A research study that compared clinical diagnostic criteria has shown a significant difference in the percentage of prevalence for major depression. By using ICD-10 criteria, 4.9% of people are diagnosed with major depression compared to 27.4% when using the DSM-IV (Vilalta-Franch, 2006). We can say that the DSM-IV is more prone in diagnosing a person with ICD-10.

3.0

Subtypes

3.1

Major Depressive Disorder, Single Episode The disorder is categorized under single episode with the presence of a single major

depressive episode. The major depressive episode is not better described for by

7 schizoaffective disorder and is not applied to on schizophrenia, schizohreniform disorder, delusional disorder, or psychotic disorder not otherwise specified. There has never been a manic episode, mixed episode or a hypomanic episode, but if the manic-like, mixed-like or hypomanic-like episodes are induced by substance, treatment or physiological effects of general medical conditions, the exclusion will not apply (DSM-IV).

3.2

Major Depressive Disorder, Recurrent The major depressive disorder, recurrent is somewhat similar to the major

depressive disorder, single episode except for the number of major depressive episodes encountered. The presence of two or more major depressive episodes is considered the major depressive disorder, recurrent. Each episode should be separated by an interval of at least two months to be counted as distinct episodes (DSM-IV).

3.3 3.3.1

Specifiers Severity/ Psychotic/ Remission specifiers The severity of the disorder can be categorized into three groups, which is mild,

moderate and severe (with or without psychotic symptoms). Mild category is illustrated by a few symptoms beyond the minimal requirements to formulate a diagnosis, GAF 61 – 70 (CommunityFirst, n.d). Patients need extra effort to function normally. As for moderate depression, the severity is between mild and acute. Moderate severity poses greater degree of functional impairment, GAF 51 – 60 (CommunityFirst, n.d). (Appendix 4)

8 Severe depression is divided into two which is severe without psychotic symptoms and severe with psychotic symptoms, GAF ≤ 50 (CommunityFirst, n.d). A person without psychotic features shows the presence of most symptoms and has little or no ability to function. Patient with psychotic features on the other hand, experiences hallucinations or delusions and often putting themselves in harms way. It needs immediate medical attention and perhaps hospitalization. 15% of major depressives may lead to psychoses (DSM-IV).

Remission can be divided into partial and full remissions, where partial remission shows the presence of symptoms of major depressive episode but not meeting the full criteria or a period without any obvious symptoms for two months. As for full remission, there are no symptoms of disturbances present during the past two months (DSM-IV).

3.3.2

Chronic According to DSM-IV, the presence of symptoms in a person, this meets the criteria

of major depressive episode for a period of at least two years.

3.3.3

With catatonic features The patients show unusual patterns of behavior or movement such as excessive

movement that is aimless, immobility, rigid posturing, imitating the behavior or words of others (DSM-IV).

3.3.4

With melancholic features

9 Melancholia is characterized by the loss of pleasure (anhedonia) in most activities, even in the presence of something pleasurable (DSM-IV). Patients with melancholia features show a distinct depressed mood which worsens in the morning, also experiences early morning waking, psychomotor retardation, or excessive guilt. Both male and female have equal tendencies of this feature, but it is more common in older people. It is also more likely to occur in severe depressive episodes. This specifier is debatable as there are no found differences in co-morbidity of the melancholic and non-melancholic (Melartin, Leskela, Rytsala, Sokero, Lestela-Mielonen & Isometsa, 2004).

3.3.5

With atypical features Atypical depression is a subtype where the person reacting in a temporary

brightening of mood in positive events or social interactions. There should be presence of at least two of the following: significant weight gain or appetite, sleeping too much (at least a total of 10 hours or two hours beyond normal), persistent sensitivity to rejection by others, or body feeling heavy (DSM-IV). Atypical features occur two or three times more often in women as well as depression with early onset (teenagers) and more chronic depressive episodes.

3.3.6

With postpartum onset The postpartum onset is categorized by depressive episodes that occur within the

four weeks of giving birth (DSM-IV). In Malaysia, the incidence of postnatal depression is merely a 3.9% with the Indians topping the list (Kit, Janet, Jegasothy, 1997).

10 3.3.7

Longitudinal course specifiers (with and without interepisode recovery) These specifiers are used to describe a long-term course of recurrent clinical

depression or bipolar disorder. It implies whether a person recovered from their indicator between the two most recent episodes (DSM-IV).

3.3.8

With seasonal pattern Seasonal-related depression is a pattern of depressive episode in major depression

or bipolar disorder. People with season-related depression are usually depressed during fall and winter however; they get better in spring and summer. It is resulted by the decrease of melatonin secretion in the brain which is activated by sunlight (DSM-IV). Sunlight during fall and winter are relatively short. Therefore, the light therapy is usually suggested (MayoClinic.com, 2006).

4.0

Etiology of Major Depressive Disorder There is no one cause of major depression. It is said that psychological, biological

and environmental plays a role, but with substantial research stating that major depression is a biological, medical illness (Duckworth, 2006). Researchers believed that chemical imbalance in the neurotransmitters such as serotonin, dopamine and norepinephrine results in depression. This is where the antidepressants are useful in increasing

the

availability

of

neurotransmitters

(Duckworth,

2006).

Genetic

predispositions may also lead to depression as the family ties increases the vulnerability or susceptibility of a person in developing depression (Duckworth, 2006).

11 As for environmental factors, physical changes are sometimes accompanied by mental changes, making them depressed and unwilling to look after their physical self, thus prolonging the recovery period (NIMH, 2006). Besides that, people who have a low self-esteem tend to be more vulnerable to depression due to their pessimistic thinking of the world and easily overcome by stress (NIMH, 2006).

Therefore, depression may be different for different people as it may suddenly come out of the blue or may be caused by a combination of several factors (ISMHO, 2004).

5.0

Symptoms In major depressive disorder, the patients will usually suffer from depressed mood,

loss of interest and enjoyment, and reduced energy leading to increased fatigue and diminished activity (Long, 2005).

Besides the symptoms above, there are also other common symptoms such as reduced concentration and attention, lower self-esteem and self-confidence, ideas of guilt and unworthiness (even in mild episodes), gloomy and pessimistic views of the future, ideas or acts of self-harm and suicide, disturbed sleep, and diminished appetite (Long, 2005).

The lowered mood varies little from day to day and is usually unresponsive to circumstances, and the patient might show diurnal variation as the day goes by (Long, 2005). In some cases, anxiety, distress, and motor agitation may be more prominent at

12 times, and the mood changes may also be covered by additional features such as irritability, excessive consumptions of alcohol, histrionic behavior, and obsessional symptoms, or by hypochondriacal preoccupations (Long, 2005).

Apart from that, the diagnosis of depressive disorder requires at least two weeks but shorter period might be reasonable if symptoms are usually severe and of rapid onset (Long, 2005). Furthermore, there must be the presence of at least four somatic syndrome which is loss of interest or pleasure in activities that are normally enjoyable, lack of emotional reactivity to normally pleasurable surroundings and events, waking in the morning two hours or more before the usual time, depression worsen in the morning, objective evidence of definite psychomotor retardation or agitation, marked loss of appetite, weight loss, and marked loss of libido (Long, 2005).

6.0

Prevalence Major depressive disorder has become one of the greatest health problems in our

society. It affects about 16% of the populations on at least one occasion in their lives (Weitz & Luxenberg, 2006). One of the greatest mental health problems in United States, major depression, poses a 17% of lifetime risk for Americans (Utsun, 2001). According to Olfson and Mechanic, depression is known as the second after Schizophrenia for the frequency of admissions to Americans mental hospitals. From 1991-1992 to 2001-2002, the prevalence of major depression among U.S. adults increased from 3.33% to 7.06% (Compton, Conway, Stinson & Grant, 2006). Across the Asia Pacific region, rates of current major depression ranged from 1.3% to 5.5%, rates of major depression suffered in

13 the past year ranged from 1.7% to 6.7%, and lifetime rates ranged from 1.1% to 19.9%, with a median of 3.7% (Chiu, 2004). In Malaysia, around 20% of patients in primary care are acquainted with anxiety and depression (Parameshvara, 2005).

Researches had shown that there are some gender differences in the risks of getting major depressive disorders. The study showed that women are more likely to have depressions compare to men. This can be showed by the study where women are about twice to develop depression compare to men. For example, in some countries like Australia, it has been reported that there are one in four women and one in eight men will suffer from depressions. Even though the results show that females are prone to have major depressive disorders compare to males, studies have showed that teenagers between fourteen and fifteen, in both genders share the equal risk. (Hankin & Abramson, 2001; Nolenhoeksema, 2001).

Even when women are twice as likely as men to experience major depressive disorder; they are more probable to receive treatment. It has been reported that there are about 60% of people with major depressive disorder received treatment especially for the disorder, with mean treatment age at 33.5 years (News-Medical.Net, 2007). Among the people who experienced major depressive disorder, nearly one-half wanted to die, onethird considered suicide, and 8.8% reported a suicide attempt (National Institutes of Health, 2005).

14 The onset of major depression usually stems at an average age of 25 years old, but it may begin at any age (Long, 2005). In a research done by Malaysia Medical Association, states that from the 18% of elderly people suffering from psychological problems, 20% of them suffer from depression (Krishnaswamy, 2002).

7.0

Methods of Treatment Depression has become one of the common illness of society, according to the

recent report by World Health Organization (WHO), depression will be the leading cause of disability and premature death in the industrial world by the world 2020 (Long, 1998). Without treatment, 10 to 15% of people suffering from major depressive disorder will commit suicide, and majority patients with this illness recover with treatment (Long, 1998).

Generally there is several therapies discovered to treat major depressive disorder such as psychosocial therapies which includes interpersonal therapy, cognitive behavioral therapy, personality oriented therapy, and family therapy. Besides this, medical therapies also show effectiveness on major depressive disorder patients. Finally, electroconvulsive therapy also showed effectiveness to the patients.

7.1 Psychosocial Therapies 7.1.1 Interpersonal Therapy Interpersonal Therapy (IPT) is a short-term therapy which normally consists of 12 to 16 weekly session and is developed for the treatment of major depression which is

15 focuses on correcting current social dysfunction. IPT also focuses primarily on the “hereand-now” factor that is directly related with social relationship. Besides, National Institute of Mental Health (NIMH) studied IPT as one of the most promising type of psychotherapy. (Weissman, & Markowitz, 1994).

7.1.2 Cognitive Behavioral Therapy Cognitive Behavioral Therapy (CBT) is also one of the most promising types of psychotherapy studied by National Institute of Mental Health (Long, 1998).

From the cognitive behavioral therapists’ perception, the major depression is mainly causes by the patient’s excessive self-rejection and self-criticism. This therapy focuses on correcting negative thoughts or dysfunctional attitudes in order to overcome the patient’s pessimism and hopelessness (Long, 1998). Thus, homework assignments are given to depressive patients with the purpose to break patient’s negative thinking (Long, 1998).

Recent research suggests that pharmacotherapy is superior to cognitive behavioral therapy at 8 and 12 weeks for severely depressed patients (Watkins, Leber, Imber , Collins, Elkin, Pilkonis, Sotsky, Shea, & Glass, 1993). Critics of CBT have argued that the patient’s negative attitude such as pessimism, negative thoughts and self-critic results from depression and is not its cause. Recent research shows that pharmacotherapy is able to remove these negative attitudes (Fava, Bless, Otto, Pava, & Rosenbaum, 1994).

7.1.3 Psychoanalytically Oriented Therapy

16 Unlike other psychotherapy which focuses on hypothesized unconscious phenomena, such as defense mechanisms or internal conflicts, this therapy analyses the historical reasons of patients self-criticism attitude leading to depression (Long, 1998). This therapy is centers on the patient’s history where it differentiates from IPT and CBT (Long, 1998).

The therapy is time consuming and expensive because psychoanalytical psychotherapy for major depression usually continues with one or more weekly session for several years (Long, 1998). Although lacking in research showing the effectiveness of psychoanalytical psychotherapy, the effectiveness of the modified form of this technique which is short-term psychodynamic psychotherapy has been scientifically proven (Svartberg, & Stiles, 1991).

7.1.4 Family Therapy Family therapy is not always viewed as the primary therapy for major depressive patients but it is specified to two situations which is the depression appeared to be serious, causes by the patient’s marriage and family functioning, or promoted and maintained by marital and family interaction patterns.

This therapy studies the role of the depressed member in the overall psychological well-being of the whole family. Besides this, it also examines the role of the whole family in persistence of the depression (Long, 1998). Patients with mood disorders have a very high rate of divorce and about 50% of spouses reported that they would not have married

17 a patient with or soon to have mood disorders (Beardslee, Hoke, Wheelock, Rothberg, van de, Swatling &, 1992)

7.2 Medical Therapies Besides the psychosocial therapies, medical therapies are another common treatment for major depressive disorder. 80% of the patients show improvement after taking antidepressant (Mental Health Channel, 2007). Usually, treatment for first depressive episode may last for 6 moths to a year, 2 years is needed to those who are suffering from recurrent depression and life long treatment is needed to those who are suffer from chronic disorder (Mental Health Channel, 2007).

Normally, antidepressant takes 1 to 8 weeks to show effectiveness, but it also depends on the dosage and the patient’s self. Most treatments begin with low dosage and if the patients show difficulties in adjusting to the drug, they will then be treated with an even lower dosage. In most cases, the dosage will increase slowly according to the patient’s ability to adapt the drug increases (Mental Health Channel, 2007).

Antidepressant medications increases the levels of monoamine neurotransmitters (i.e., serotonin, dopamine, norepinephrine) to elevate mood and restore a sense of wellbeing (Mental Health Channel, 2007).

Antidepressant medication includes SSRIs

(selective serotonin reuptake inhibitors), atypical antidepressants (also call non-SSRIs), TCAs (tricyclic antidepressants) also called as tricyclics, and MAOIs (monoamine oxidase inhibitors).

18 Major depression is caused by the lack of monoamine neurotransmitters in the brain, and this is supported by the antidepressant drug treatment. Signals from the brain are transported by neurotransmitters across the synaptic cleft (“gap” between nerve cells). The function of the antidepressant is to increase the concentration of neurotransmitters in the synaptic cleft. (e.g. SSRIs increase concentrations of serotonin). Through this treatment, the levels of neurotransmitters can be sustained at the level that improves neurotransmission and raise mood (Mental Health Channel, 2007).

Generally, medical therapies need to take few weeks to take effect, so patients might experience the side effects of the drugs before any effects. SSRIs include drugs such as Citalopram, Fluoxetine, Fluyoxamine, Paroxetine, and Sertraline. The side effect of these drugs are sun sensitivity, slight weight loss, and one-half of patients reported that they are loss of libido, inability to experience orgasm, erectile dysfunction (for men), and vaginal dryness (for women) (Mental Health Channel, 2007). A study stated that children and adolescents under age 18 should not be given SSRIs as it would increase suicidal thoughts and attempts to harm themselves (Ramchandani, 2004).

Atypical antidepressant which contains Bupropion, Mirtazapine, and Velafaxine HCl brings the side effect of dizziness, dry mouth, nausea, and sleepiness. The other antidepressant Tricyclics, which would not be the first choice for major depressive treatment because it brings dangerous side effect such as seizures, stroke and heart attack and other side effect such as blurred vision, changes in appetite, dry mouth and nausea. Amitriptyline,

Amoxapine,

Clomipramine,

Desipramine,

Doxepin,

Imipramine,

19 Maprotiline, Nortriptyline, Protriptyline, and Trimipramine are examples of tricyclics (Mental Health Channel, 2007).

Finally, MAOIs also brings side effects similar to Tricyclics but potentially lead to a deadly condition called tyramine-induced hypertensive crisis (Mental Health Channel, 2007).

7.3 Electroconvulsive Therapy Electroconvulsive Therapy (ECT) is a technique whereby applying electrical shocks to the brain under controlled circumstances in order to relieve severe depression (Alloy, Riskind, & Manos, 2004). ECT involves applying a shock of approximately 70 to 130 volts to the patients under controlled condition. This therapy involves 9 to 10 treatment and after several weeks, the total might much lower or higher (Alloy, Riskind, & Manos, 2004).

Although this treatment shows its effectiveness to major depression, it also brings some side effect. The most common side effect of this treatment is memory dysfunction. This memory dysfunction includes anterograde which the patients are not able to learn new material; and retrograde which the patient fail to recall the experience before treatment (Alloy, Riskind, & Manos, 2004). Another research shows that this side effect can be lessened if ECT is applied to the frontal lobes rather than the temporal lobes which is an equally effective approach (Bailine, Rifkin, Kayne, et al., 2000). Although this

20 treatment shows the effectiveness and is painless (the patient is anesthetized before the shock is applied), many patients are scared of it (Alloy, Riskind, & Manos, 2004).

8.0

Challenges in assessment and treatment Major depressive disorder is one of the most hospitalized mental illnesses around

the world. It is characterized by the experience of one or more major depressive episodes, with no mania (DSM-IV).

On of the challenges faced when assessing and treating major depressive disorder is the reluctance or negligence of the patients to seek treatment. This is because they think that it is only a feeling of ‘blue’ or just lack of energy. People do not think that it is a problem and refuse to be treated. The statistics announced by the mental health department does not represent the actual number of the patients.

Misdiagnosis is also one of the major challenges faced when assessing and treating major depressive disorder. The major depressive disorder has many physical symptoms, such as pain and fatigue (Fink, Rosendal, & Toft, 2002). Thus, people tend to look for help and medication to treat these symptoms rather than seeking the truth about the occurrence of these symptoms.

Besides that, depression is a commonly missed diagnosis (Deardorff, 2004). This is so because of two reasons. Firstly, the patients themselves do not realize they have major depressive disorder. Secondly, the doctors are not looking for depression. As an example,

21 the chronic back pain patients (Deardorff, 2004). They usually regard their problem as strictly physical and medical reasons. They feel that they won’t feel depress anymore if they can get rid of the back pain.

The major depressive disorder also has many underlying conditions. This made the assessment and treatment of the major depressive disorder harder and more difficult. Sometimes, illnesses can bring about major depressive disorder. Hormonal disease such as thyroid diseases can cause hormonal imbalance, resulting in major depressive disorder.

There are also racial disparities in diagnosing and treating major depressive disorder. Different culture holds different view towards the same thing. Thus, the cultural difference is also an issue here. Same assessing method or treatment may not work out for different client. Thus, the therapist should be well aware of the cultural factor in assessing and treating this disorder.

The therapist may also over emphasize on certain symptoms, leading to misdiagnose of major depressive disorder (Fink, Rosendal, & Toft, 2002). The therapist might have a certain mind set that the occurrences of certain symptoms are the signs of depression. Thus, they only looked for these symptoms, and they tend to overlook certain symptoms that might indicate different diagnosis (Fink, Rosendal, & Toft, 2002).

9.0

Suggested method of treatment

22 We suggest combining antidepressant drugs and therapy in order to get an effective method of treatment. The therapy in particular, interpersonal therapy would be best used. We support our suggestion with a study conducted in 1990, annually cost for treatment from 11 million people in United States who suffering from major depressive disorder is 44 billions dollar. Thus, treatment in major depressive disorder is a billion dollar industry in United States and there are some researches have been done on the effectiveness of the different treatment for depression (Long, 1998).

This research did by conducting a randomized controlled clinical trial and patients assigned to treatment and control group. Both of the patient and investigators are kept blind to whether the patient is in the treatment group or control group. The control group will receives a placebo therapy, and the clinical trial then waits see if the treatment groups are better than the control group (Long, 1998).

The results are divided to five categories which is unknown (no randomized controlled clinical trials to support any claims), poor (0-24% improvement, no better than placebo therapy), fair (25-49% improvement, mildly better than placebo therapy), good (50-74% improvement, moderately better than placebo therapy), and excellent (75-100% improvement, markedly better than placebo therapy).

There are four types of treatment are fall in the good category which is antidepressant medication, electroconvulsive therapy, Lithium, and anticonvulsant medication. Only interpersonal psychotherapy falls into the fair category and there are

23 two treatments are under poor category which is antianxiety medication and cognitive therapy. The rest treatment which is antipsychotic medication, stimulant medication, psychoanalytic psychotherapy, family therapy, group therapy, and self-help group (Long, 1998).

10.0 Conclusion

Major depressive disorder is now a common psychological disorder whereby many research have been done regarding this topic. Various treatments have been identified as to find the best way in order to deal with the increasing number of cases. Therefore, the importance of being equipped with knowledge of major depression will benefit all. This is because the occurrence of major depressive disorder may increase as the years go by due to the increasing stressors in life.