The very nature of mankind guarantees that every now and then an individual will have a bad day either due to a biological, social or professional problem; it is therefore common to hear someone state ‘I am depressed’ in the morning and be in a very good mood by evening. This general (mis)use of the word is however only the very tip of the iceberg that is depression, also known as major depressive disorder (MDD) or clinical depression (Villanueva & Corporation, 2013). MDD is a serious psychological condition that contributes to over 60% of the total number of suicides in the United States. Due to the propensity of this disorder a lot of time, effort, and money has been committed to its research but very little is yet conclusively known regarding it (Paris, 2014; Schreiner, 2014). It is therefore becoming a gradually accepted hypothesis that albeit by its very nature, science does not allow for enigmas, just as cancer, MDD is a riddle that albeit gradually understood, may never really be cracked.
Statistics relating to MDD
Generally, MDD develops between the ages of eighteen to thirty years with a diminished onset between thirty and forty years. MDD prevalence is approximately 6.7% of the general US adult population which amounts to about 14.8 million individuals. As many of the sufferers become disabled for certain duration of the illness, this accounts for about 40% of the mentally related disability among the working populace (Villanueva & Corporation, 2013). Normally, most of these sufferers are neither diagnosed nor treated but 40% manage to recover within 3 months, 50% to recover within 6 months and 80% within one year. When MDD becomes severe, the prevalence of suicide rises to 15% from the normal 3.4% with suicidal susceptibility occurring from sufferers who are over 55 years. Recurrence is also common in MDD with 60% of first time sufferers suffering recurrence, 70% of second time sufferers having a recurrence and 90% of third time sufferers having a recurrence 5% to 10% of MDD sufferers eventually develop bipolar disorders (Villanueva & Corporation, 2013).
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Causes
One of the enigmas relating to MDD is what causes it. Contemporary research has come up with several varying and sometimes overlapping explanations for what causes MDD. In many cases, MDD is occasioned by a combination of two or more of these factors; however, research is still ongoing to establish the actual causes. The factors generally agreed upon include:-
Biological factors
The relationship between MDD and biological factors was initially considered when it was realized that a physical damage to the cerebellum made patients more susceptible to MDD. Research in New Zealand has given an empirical foundation to this hypothesis as it confirmed that those a high cross-section of MDD sufferers also have a variation in their serotonin transporter (5-HTTT). All people go through stressful situation but this research showed that of an individual genetically has shorter alleles of the 5-HTT as aforesaid, they are more likely to develop MDD from the same set of circumstances and stresses that will not cause MDD in a person with genetically longer alleles of 5-HTT. Another support for this hypothesis is founded on the fact that in 40% of female sufferers and 30% of male sufferers, there a history of MDD in their respective families (Kupfer, Frank, & Phillips, 2012) .
Another hypothesis for the biological causes of MDD is the Monoamine hypothesis which claims that MDD may be caused or promoted by the deficiency of serotonin, norepinephrine and dopamine in the synaptic cleft between neurons in the brain. This hypothesis finds foundation in the fact that most antidepressant medications reduce the effects of MDD by increasing the levels of the aforesaid compounds, which are naturally available in the brain (Schreiner, 2014). However, this hypothesis should also be understood from the aspect that it is used by pharmaceutical companies to market their drugs and may therefore be hyped.
Another biological hypothesis of MDD cause has emanated by the careful study of MRI scans performed on already diagnosed patients which has shown that majority of them have a difference in brain structure from the rest of the population. They tend to have an increased volume of lateral ventricles and the adrenal gland as well as smaller volumes of basal ganglia, thalamus, hippocampus and the frontal lobe(Villanueva & Corporation, 2013). It is not yet known how these factors contribute to MDD but their consistent prevalence in diagnosed patients creates the basis for this hypothesis.
Psychological causes
Since MDD is a psychological disorder, there is a difficulty in assessing its psychological causes due to inability to decide the sequence of cause and effect between issues that bring about MDD, and issues that happen after the advent of MDD as most research is conducted on already diagnosed patients. However, it is generally agreed various aspects of personality and its development in an individual are integral to the development of MDD. If two people undergo adverse effects, the person whose personality has developed a law self-esteem, self-defeating mentalities and/or distorted thinking is more likely to suffer MDD that the other individual who has a more positive personality. Even after the onset of MDD, the negative personality individual described above with be less likely to quickly recover than the positive personality character defined (Kupfer, Frank, & Phillips, 2012) .
Social causes
As MDD onset is more prevalent in early childhood, research has confirmed that those who individuals who grew up under social trains occasioned by poverty, social isolation and lower social classes are more susceptible to MDD. Extreme negative circumstances like physical, emotional and/or sexual child abuse and neglect can also cause a young adult to be susceptible to MDD.
Symptoms of MDD
The Symptoms of MDD mirror those of other chronic medical conditions such as diabetes which many a time leads to its misdiagnosis. MDD generally affects family and friendships, school or work, sleep and general health. The general symptoms as outlined by inter alia in the DSM 5 criteria include relentless and very low mood in all aspects of life both in formal-like work and informal-like family (Schreiner, 2014). Lack of interest, love and enjoyment of activities that erstwhile brought so much joy with negative feelings taking center stage in the individuals mind including worthlessness, baseless guilt and regret, helplessness, hopelessness and self- hatred is also manifested. This may develop into psychosis in extreme cases (Schreiner, 2014). Furthermore, delusions which in extreme cases may develop into unpleasant hallucinations in extreme cases is experienced (Schreiner, 2014). Other symptoms include lack of concentration and memory loss, withdrawal from social activities and functions, reduced sex drive, suicidal thoughts and thinking about death, and insomnia or hypersomnia (Schreiner, 2014).
Diagnosis
There are many criterions MDD diagnosis which are standardized by the DSM 5 Criteria in the US. However, as there are no physiological signs and symptoms of MDD, the initial clinical tests involve elimination of other probable conditions that exhibit similar symptoms like those of MDD. Once all the other illnesses are ruled out proper screening for MDD can begin. There are two main types of diagnosis which include:-
Clinical assessment
This is mainly conducted by primary care clinicians, trained practitioners, psychiatrist or a psychologist. It involves a careful examination of the those closest to the patient in order to farther relevant information regarding background of the patient as well as the signs and symptoms they have seen in the patient leading to the current state. It also involves a careful study of biological and family history of the patient. Generally, this study is meant to establish the relevant psychological, biological and social factors impacting the person’s mood and the ways and means the individual uses to combat or escape from the negative moods including alcohol or drugs (Villanueva & Corporation, 2013) . Finally, the diagnosing person will seek to find the current mental state of the patient which includes factors such as pessimism, hopelessness, propensity for self-harm or suicide and the absence of positive plans and thoughts. It is the totality of this factors that enable the practitioner to decide on whether not the patient is suffering from MDD (Schreiner, 2014) .
DSM-IV-TR and ICD-10 criteria
DSM-IV-TR is the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association whereas ICD-10 the World Health Organization's International Statistical Classification of Diseases and Related Health Problems. The two documents are however designed to conform to one another. DSM-IV-TR is generally used in the US while ICD-10 is used within the European Union. Generally, this criterion describes in depressive episodes with one initial episode being the first diagnosed instance. When there is more than one instance, it is referred to as recurrent depressive disorder (Kupfer, Frank, & Phillips, 2012) .
Both diagnostic systems map out ten typical symptoms for a patient to be diagnosed with MDD with the variation being in that ICD-10 considers the primary symptoms to be depressed mood, anhedonia and reduced energy while DSM-IV-TR considers two primary symptoms being depressed moods and anhedonia. The ten symptoms must include one of these primary symptoms for MDD to be diagnosed (Kupfer, Frank, & Phillips, 2012) .
These episodes may vary depending on the symptoms with the variations thereof creating subtypes of MDD such as melancholic depression: the dominant symptom is lack of pleasure in everything, atypical depression with the main symptoms of low mood and paradoxical anhedonia. Catatonic depression; this is severe and involves immobility while postpartum depression is common immediately after childbirth. Seasonal affective disorder (SAD): this comes and goes according to seasons and it begins in autumn, augments in winter and resolves in spring.
Prevention
Preventative efforts may reduce the risk of either the onset or recurrence of MDD by between 22% and 38%. Behavioral interventions, leading among them being cognitive-behavioral therapy and interpersonal therapy are effective preventative measures. Some dietary measures such as eating a lot of fish have also been suggested. Generally, preventative measures are more effective when conduct on groups, rather than on individuals.
Treatment Strategies
There are three major types of MDD treatment to wit psychotherapy, medication, and electroconvulsive therapy. According to the American Psychiatric Association the initial treatment regimen should be tailor-made according to the specific circumstances of the patient including the nature and severity of symptoms, c-existing disorder, prior treatment and the reactions thereof as well as the preferences of the patient. Most regimens are however divergent levels of combinations of the three main major treatments and may be styled as pharmacotherapy, psychotherapy, electroconvulsive therapy (ECT), trans-cranial magnetic stimulation (TMS) or light therapy (Kupfer, Frank, & Phillips, 2012) .
Psychotherapy
Psychotherapy in MDD seeks to reduce the symptoms and effects of MDD using psychological procedures which include Psychodynamic Therapy, Interpersonal Therapy and Cognitive Behavioral Therapy for Depression and is generally part of the initial treatment regimen for MDD and commonly simply referred to as ‘therapy’ (Kupfer, Frank, & Phillips, 2012) .
Psychotherapy seeks to help the patient
As a way of providing help to the patient, it is essential to understand the character, emotional elements and ideas that contributed to the onset on the MDD (inner environment), appreciate and recognize the situations, circumstances and events that may have triggered the MDD (outer environment). Further, the patient is helped to understand which aspects of these circumstances got out of hand to the extent of occasioning the MDD. It is also important to learn ways of restructuring thought patterns and overcome negative attribute and attitudes towards the self to prevent and reverse the elements that brought about the MDD, regain control and reestablish pleasure in life and learn mechanisms to cope with life’s issues and acquire problem-solving skills.
Medication
There are various regimens of pharmaceutical treatment for MDD which include:-
Tricyclic antidepressants (TCAs)
These are used in severe instances and are known to be very effective albeit they carry a very high risk of adverse overdose. They include amitriptyline (Elavil, Endep), clomipramine (Anafranil), doxepin (Adapin, Sinequan), nortriptyline (Pamelor, Aventyl), and desipramine (Norpramin) (Kupfer, Frank, & Phillips, 2012) .
Monoamine oxidase inhibitors (MAOIs)
These are also as effective as TCAs but may be reactive when used with several other medications and even foods and therefore require very careful training prior to usage. Common examples include phenelzine (Nardil) and tranylcypromine (Parnate) (Kupfer, Frank, & Phillips, 2012) .
Selective serotonin reuptake inhibitors (SSRIs)
These are among the new generation of drugs and are very common in the initial stages of MDD treatment. They include fluoxetine (Prozac), citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) (Kupfer, Frank, & Phillips, 2012) .
Electroconvulsive therapy (ECT)
ECT is the process of electrically inducing seizures on an MDD patient as a psychiatric treatment used with the informed consent of the patient and as a last line intervention for extreme cases of MDD and has a rated success rate of 50%. Unfortunately research has shown that despite the seemingly good initial response, most patients treated with ECT relapse within 12 months of successful treatment. It is however the least harmful and is therefore commonly used to treat pregnant women since the relapse can be better handled later when the child is no longer at risk (Kupfer, Frank, & Phillips, 2012) .
Educational Needs for EDD patients
There two major educational elements for EDD patients upon diagnosis, this is education with regard to the curative aspects of the condition and education with regard to the recurrence aspects of EDD
Curative Education
It is worthy of notice that by the time a patient is diagnosed with MDD, they are already experiencing acute mental illness and will require to be taught even elementary issues like of medication, proper nutrition and other elements of their treatments regimen. This should be conducted in a simple, repetitive fashion to ensure that it is properly understood as it may have life or death implications more so if medication forms part of the treatment regimen. Psychodynamic Therapy, Interpersonal Therapy and Cognitive Behavioral Therapy for Depression which are key elements of psychotherapeutic treatment of MDD also have educational features that ought to be taught to the patient (Kupfer, Frank, & Phillips, 2012) .
Preventative education
This is commonly contained in the psychotherapeutic treatment so MDD as involves Psychodynamic Therapy, Interpersonal Therapy and Cognitive Behavioral Therapy for Depression. It entails teaching the patient how they acquired MDD and how to avoid a repeat of the circumstances that would cause a repeat of the same situation. MDD relapses and common and usually worse that the initial episode those preventative education is important both for the patient and those interacting closely with the patient even after the end of the initial episode of MDD (Kupfer, Frank, & Phillips, 2012) .
Legal Issues relating to MDD
As earlier indicated, ECT can only be conducted upon a patient pursuant to informed consent from the patient. This creates a legal complication since MDD is categorized as a mental disorder which means upon diagnosis, it can be argued that the patient is non-compose mentis yet at the same time the patient ought to give not just consent but also informed consent meaning the basic elements of the treatment as well as the possible immediate and future side effects thereof need to be explained to the patient prior to the giving of the consent for commencement of treatment. The aforesaid grey area leaves room for possible suits by patients who may claim that they were not qualified to give consent for treatment (Paris, 2014) .
Possible Ethical Issues
The nature of MDD, its diagnosis and treatment is not precisely a science since it contains many variables. It is easy and possible for an unscrupulous practitioner to take advantage of walk in patients, diagnose them with MDD even when they are simply undergoing a normal moody spell and prescribe expensive treatment regimens with a view of deriving maximum pecuniary advantages over the patients. Unfortunately, unlike other purely medical conditions, it is practically impossible to disprove a diagnosis or treatment to a level strong enough to lunch a complaint against a practitioner. The best solution for this is a strong peer organization that has checks and balances for evaluating the conduct of colleagues and avoids such instances (Paris, 2014) .
Conclusion
The enigmatic nature of MDD can prevalently be seen in every aspect of the condition right from the causes, diagnosis, treatment and probability of recurrence. Perhaps as science grows, many of these enigmatic elements will become better understood which will ease control and perhaps possible elimination of the condition once and for all. Until then, it behooves the general public to attempt to learn as much as possible about the signs of an onset and the right responses upon realization that the loved one may be suffering. The professionals and academia must also step us research and study to better understand this predicament to enable its better handling.
References
Kupfer, P. D. J., Frank, E., & Phillips, M. L. (2012). Major depressive disorder: New clinical, neurobiological, and treatment perspectives. The Lancet , 379 (9820), 1045–1055. doi:10.1016/S0140-6736(11)60602-8
Paris, J. (2014). The mistreatment of Major Depressive disorder. Can J Psychiatry, 59(3), 148–151.
Schreiner, M. (2014). Major Depressive Disorder DSM 5 criteria . Retrieved from <http://evolutioncounseling.com/major-depressive-disorder-dsm-5-criteria/>
Villanueva, R. & Corporation, H. P. (2013). Neurobiology of Major Depressive disorder. Neural Plasticity, 2013, 1-7. doi:10.1155/2013/873278
