Depressive disorder

Disease Description (Causes and Symptoms)

• Definition: Depressive disorder is a condition in which overall mental functions—including mood, thoughts, motivation, sleep, eating, and activity—remain impaired, causing significant disruption to daily life. It is distinguished from normal depressive feelings lasting for a short period.
• Causes and pathophysiology (summary): Neurotransmitter abnormalities (including serotonin, norepinephrine, and GABA), hormonal abnormalities (including the HPA axis), changes in biological rhythms, genetic predisposition, and environmental stress (such as loss and financial problems) act in combination.
• Main symptoms: A depressed mood lasting 2 weeks or more or loss of interest or pleasure, including changes in appetite (decreased/increased), insomnia/hypersomnia, low energy, psychomotor retardation/agitation, guilt/worthlessness, reduced concentration, and recurrent suicidal thoughts. Some people experience hallucinations or delusions (psychotic features) or diurnal mood variation (e.g., improvement in the afternoon).
• Diagnostic essentials (brief summary): According to DSM criteria, depression should be considered when 5 or more of 9 symptoms are present (including either depressed mood or loss of interest), persist for 2 weeks or more, and interfere with daily functioning.
• Emergency warning signs: Immediate evaluation and treatment are needed in cases of a suicide plan or specific suicidal thoughts, severe eating or sleep disturbances, or accompanying hallucinations or delusions.

Treatment Methods

• Medication treatment
  • Representative medications: SSRIs, SNRIs, and other classes (tricyclic antidepressants and MAOIs are used in specific situations). Effects usually begin 2–3 weeks after starting medication, and an adequate response is assessed at 4–6 weeks.
  • Maintenance period: Continue treatment for at least 6 months after symptoms improve (longer treatment may be recommended depending on the risk of relapse).
  • Effects and side effects: Antidepressant effects are observed in approximately 2/3 of all patients. Possible side effects include nausea, insomnia/drowsiness, sexual dysfunction, and weight changes. Discontinuation of medication should follow the doctor’s instructions.
• Psychotherapy
  • Cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), and other therapies are effective for symptom management and relapse prevention.
• Procedural treatments
  • Electroconvulsive therapy (ECT): Highly effective and can be expected to produce rapid effects when the risk of suicide is high, when rapid physical recovery is needed, or when there is inadequate response to medication.
  • Repetitive transcranial magnetic stimulation (rTMS): This is a noninvasive brain stimulation treatment, and effects have been reported in some patients.
• Lifestyle management
  • Maintain regular sleep and wake times, engage in appropriate exercise, eat a balanced diet, avoid alcohol and drugs, manage stress, and strengthen social support.
• Precautions
  • Close monitoring is needed because the risk of suicidal thoughts or behavior may worsen early in treatment.
  • Medication interactions (especially MAOIs and serotonin-enhancing medications) and certain physical conditions (such as thyroid disease) need to be checked.
  • Medication selection and dose adjustment are needed in special populations, including pregnant or breastfeeding individuals, people with cardiovascular disease, and older adults.
• Risk of complications: Suicide, reduced social and occupational functioning due to chronic illness, and physical complications (such as malnutrition).

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare and check
  • A list of currently used medications and their doses (including prescription drugs, over-the-counter drugs, herbal medicines, and supplements)
  • The symptom onset date and course (when they began and how they have changed)
  • Records of changes in sleep and appetite (e.g., sleep duration and amount of food eaten over the past 2 weeks)
  • Whether suicidal thoughts are present and how specific they are (plan, means, and any previous attempts)
  • History of psychiatric diagnoses, treatment, or hospitalization, and family history (depression or suicide)
  • Recent stressful events (such as loss or unemployment) and whether alcohol or drugs are being used
  • Previous test results (blood tests or imaging tests) or test-related materials currently being taken to appointments
  • Women: possibility of pregnancy, breastfeeding status, and menstrual history
• Examples of questions to write down in advance for the outpatient visit (for patients)
  • "When did the symptoms begin, and at what time of day are they worse?"
  • "Have you recently thought about self-harm or suicide? Do you have a plan or have you made preparations?"
  • "What medications and doses are you currently taking?"

Examples of General Questions to Ask the Doctor

• "When can I expect the recommended treatment (medication/psychotherapy) to take effect, and how much improvement can I expect?"
• "What are the common side effects of the prescribed medication, and what should I do if they occur?"
• "How should I stop treatment? What should I be aware of when stopping?"
• "What precautions should I take in daily life (driving, drinking alcohol, work, etc.)?"
• "What lifestyle habits and follow-up plan do you recommend to prevent relapse?"

Examples of Disease-Specific Questions

• "Do my symptoms meet the indications for ECT or rTMS? What are the advantages, disadvantages, and side effects of these treatments?"
• "I am pregnant or breastfeeding. Can I take antidepressants? What alternative treatments (nonmedication methods) would be appropriate?"