Academic journal article South African Journal of Psychiatry

Major Depressive Disorder

Academic journal article South African Journal of Psychiatry

Major Depressive Disorder

Article excerpt

1. Introduction

This treatment guideline draws on several international guidelines: (i) Practice Guidelines of the American Psychiatric Association (APA) for the Treatment of Patients with Major Depressive Disorder, Second Edition; [1] (ii) Clinical Guidelines for the Treatment of Depressive Disorders by the Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT); [2] (iii) National Institute for Clinical Excellence (NICE) guidelines; [3] (iv) Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Depression (RANZCAP); [4] (v) Texas Medication Algorithm Project (TMAP) Guidelines; [5] (vi) World Federation of Societies of Biological Psychiatry (WFSBP) Treatment Guideline for Unipolar Depressive Disorder; [6] and (vii) British Association for Psychopharmacology Guidelines. [7]

Major depressive disorder (MDD) is frequently associated with comorbid psychiatric and medical conditions and carries with it a high risk of morbidity and mortality. For many an initial episode of depression evolves into a recurrent and debilitating chronic illness with significant and pervasive impairments in psychosocial functioning. [8-11] The recent Global Burden of Disease Study estimated that unipolar major depression is the fourth largest contributor to the global burden of disease (premature mortality and disability). [12] By the year 2020, unipolar MDD is projected to be the second largest contributor to the global burden of disease, after heart disease [13]

1.1 Prevalence and risk factors

MDD has a median lifetime prevalence of 16.1% (range 4.4-18%). [14] Twelve-month prevalence ranges from 5% to 10% in adults, with women at higher risk than men (ratio is approximately 2:1). [15-17] In South Africa, the lifetime prevalence of MDD documented in the South African Stress and Health (SASH) survey, the first nationally representative epidemiological survey of common mental disorders in South Africa, [18] was 9.8% across all age groups, with the highest prevalence (14.6%) in the Free State. The survey, conducted between 2003 and 2004 was a three-stage, area probability sample of 4 351 adults of all races and ethnic groups living in households and single-sex migrant labourer group quarters in South Africa. The 12-month prevalence rate of MDD during this period was 4.9%. The aforementioned SASH study found that females were 1.75 more likely to develop MDD than males.

The age of onset of MDD is difficult to assess because the first episode is frequently mild and untreated, and may be determined retrospectively many years after first onset. MDD can begin at any age, even in childhood and adolescence, but there are two peaks, in the twenties and forties. [1,19] The mean age of onset of MDD has been estimated around the age of 30. [14] Family and twin studies have indicated that MDD is a complex genetic disorder being 1.5-3 times more common among first-degree biological relatives of persons with this disorder than among the general population. [20,21] Female gender, a previous episode of major depression and a positive first-degree family history of depression are the most consistently described risk factors.

1.2 Comorbidity and consequences

Anxiety disorders are highly comorbid, occurring in about 58% of patients with MDD. [22] In addition, anxiety symptoms are highly prevalent in MDD, occurring in up to 80% of patients. [23] Studies investigating the effects of depression on health-related quality of life have demonstrated detrimental effects that equal or exceed those of patients with chronic medical illnesses, such as ischaemic heart disease or diabetes mellitus. [24-26] The most serious sequela of MDD is suicide. It has been estimated that about 50% of depressed patients make at least one suicide attempt during their lifetime. [27] It is well established that patients with mood disorders suffer a higher risk of suicide relative to the general population. …

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