Brief Treatment Strategies for Major Depressive Disorder: Advice for the Primary Care Clinician

Ivan Valdivia, PhD Candidate; Nadine Rossy, BAC, PhD Candidate


Topics in Advanced Practice Nursing eJournal. 2004;4(1) 

In This Article

Introduction: Epidemiology and Risk Factors for MDD

Karen's case illustrates common symptoms of MDD. MDD is a relatively widespread, potentially debilitating mood disorder that is associated with significant costs to the community. Data collected by the World Health Organization revealed that MDD is the most frequently encountered mental health problem in primary healthcare settings.[1] American and Canadian data have shown that the costs associated with MDD are greater than those from hypertension and equivalent to those of heart disease, diabetes, and back problems.[2] While there are a number of different depressive disorders (eg, dysthymic disorder, depressive disorder not otherwise specified) and specifiers (eg, with catatonic, melancholic, or atypical features; with postpartum onset), this article will describe MDD in general.

Estimates of the prevalence rate of MDD have varied. At any point in their lives, between 10% and 25% of women and between 5% and 12% of men will experience a major depressive episode. At any given time, however, between 5% and 9% of women and between 2% and 3% of men have diagnosable MDD.[3] The disorder occurs about twice as often in adolescent and adult females than males, and the peak period of development is between the ages of 25 and 44 years; onset most often occurs in the mid-20s, and less often after the age of 65 years. Prepubertal girls and boys are equally affected.[3]

Common factors such as education, ethnicity, income, and marital status do not appear to be risk factors for the development of MDD. Instead, MDD often emerges subsequent to a significant (biologic or psychological) life stressor, such as the death of a loved one, and substance abuse. In addition, first-degree biological relatives of people with MDD are 1.5 to 3 times more likely to develop MDD than the general population.[3]

MDD often presents comorbidly with other physical and mental health conditions. Pincus and colleagues[4] showed that upwards of 84% of cases presented alongside another illness on Axis I, II, or III of the Diagnostic and Statistical Manual of Mental Disorders.[3] Between 20% and 25% of individuals with a chronic general medical condition will develop MDD, which makes treatment of the primary medical disorder more difficult. Approximately 15% of individuals with MDD will die from suicide, and there is a 4-fold increase in the death rate in people older than 55 years of age who suffer from MDD.

Common comorbid Axis I disorders include: eating disorders, substance-related disorders, panic disorder, and obsessive-compulsive disorder; up to 25% of people developing MDD have a pre-existing dysthymic disorder.

Left untreated, a typical episode of major depression will run approximately 6 months; about 20% of episodes can last 2 years or more. However, after 6 months, when the major depressive episode often remits, 20% to 30% of patients retain residual symptoms, which can be distressing and associated with disability. Only 50% of depressive episodes remit spontaneously. In addition, between 50% and 85% of people who experience 1 major depressive episode will experience another in the future.[5]

Of the majority who experience subsequent episodes, 20% to 35% of patients will continue to have residual symptoms that may remain until the onset of the next full-blown episode. Interepisode residual symptoms are predictive of additional episodes. Further, the more episodes experienced, the greater the chance the disorder will re-emerge. Fifty percent to 60% of people with one episode will experience a second, individuals with 2 episodes have a 70% chance of having a third, and 3 or more episodes lead to a 90% chance of additional episodes. Although interepisode periods vary in length, they tend to shorten as one ages.[3]


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