Definition

Depression is a common mental disorder that presents with depressed mood, loss of interest or
pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor
concentration. It typically happens as a result of traumatic life events, such as the loss of a loved
one, an item, a relationship, or one's health, but it can also happen for no apparent reason. These
issues may become chronic or persistent, causing significant impairments in an individual's
ability to handle day-to-day responsibilities. The Oxford English Dictionary defines depression
as “a mental condition characterized by severe feelings of hopelessness and inadequacy,
typically accompanied by a lack of energy and interest in life.”

Mood disorders are treatable diseases, with different treatment methods and modalities needed
for each form. Antidepressant drugs and psychotherapies are popular treatments for the crippling
effects of depression. When mood problems like depression go untreated for a long time, the
crippling effects of depression cause needless pain that interferes with people's daily lives.

Natural history

Depression typically begins in early adulthood and is likely to recur. Women are more likely to
be affected than men, and unemployed people are also at a higher risk. Sadness, indifference or
apathy, or irritability can be present during an episode. Changes in a variety of neurovegetative
functions (such as sleep habits, appetite and weight, motor agitation or retardation, exhaustion,
decreased focus and decision-making), as well as feelings of remorse or guilt and thoughts of
death or dying, are all common symptoms. 6.14% only a small percentage of patients will
develop psychotic symptoms. Untreated crises can last anywhere from nine months to several
years.

Approximately eight out of ten individuals who experience their first episode of major
depressive disorder will have at least one more episode during their lifetime. A subsequent manic
episode affects 10% to 15% of patients, at which point they are reclassified as having bipolar
disorder.

Because of the essence of depression, people who are affected are unlikely to know they are
depressed and, as a result, are unlikely to seek treatment for themselves. They are also less
capable of following health-care providers' instructions for treatment. Depression has a
significant impact on the quality of treatment offered by patients and received by those in all
chronic conditions.

Comorbidities and risk factors

Depression is a widespread and significant cause of morbidity in the physically ill. People who
have a physical condition are more likely to experience MDD (Major depressive disorder).
According to surveys conducted in general hospitals, 10-20% of internal medicine in- and
outpatients suffer from so-called "depressive illnesses." Patients suffering from a recurrent
physical ailment had similar rates. Patients with diabetes, cancer, myocardial infarction, and
Parkinson disease all have elevated rates of depression, according to reviews and studies from
patients with particular disorders: 11 percent, 15 percent, 20 percent, and 17 percent,
respectively.

Depression is linked to inadequate care adherence, a poor prognosis, and a higher level of
impairment. Depression has been linked to an increased risk of death from a variety of diseases.
Depression and mortality have been linked in a variety of diagnostically mixed groups of
medically ill patients, including heart failure, HIV/AIDS, renal disease, cancer, and diabetes, as
well as after myocardial infarction and stroke.

According to a survey conducted in the Netherlands, about half of people aged 18 to 64 who had
severe depression in the previous year also had an anxiety disorder. Chronic somatic illnesses
often coexist with depression. According to studies, between 50% and 80% of primary care
patients with current major depression or dysthymic disorder may have a chronic somatic
disease. For example, a large-scale health survey of the adult Canadian population found that the
annual prevalence of major depression in people with one or more long-term medical conditions
was about 9%, more than twice the prevalence of people who did not have a chronic disorder (4
percent).

Head injury, schizophrenia and other mental illnesses, alcohol abuse, Parkinson disease, stroke,
acne, multiple sclerosis, and migraine are among the other comorbidities. Furthermore, recent
research has shown that genetic factors influence antidepressant response rates, suggesting that
these genetic factors could also serve as risk factors for developing depression or relapse. A
mixture of genetic, social, environmental, and biological factors are most likely to blame for
depression. Pregnancy, childbirth, (peri)menopause, hormonal factors and menstruation, (low
tolerance for) stress, impulsive behavior, alcohol or substance abuse, a family history of
depression, alcohol abuse, or suicide, sociocultural factors, poverty, severe or chronic medical
conditions, insomnia, being a female, intimate partner violence, (childhood) sexual abuse, and to
name a few are additional risk factors for depression.

Depression in young people

Depression is prevalent in teenagers and infants, affecting many people before they reach the age
of eighteen. A recent survey among 123 adolescents aged 13 to 18 years, showed that 11.7 % of
the sample met the criteria of a major depressive disorder or dysthymia. These results are in line
with other studies that indicate that mood disorders among children and adolescents are more
common than is generally believed.

Adolescent depression may have a negative impact on a teen's socialization, family relationships,
and academic performance, with serious long-term implications. Bad academic performance,
social dysfunction, teenage pregnancy, and drug abuse are all linked to depression. Young
people's depression can manifest differently than that of adults, with manifest behavioral
disorders (e.g., irritability, verbal violence, and misconduct), drug abuse, and/or associated
medical issues.

When compared to children with other mental health problems and children who do not have a
mental health disorder, adolescents with depression have substantially higher spending. In
addition, children with depression use inpatient and emergency care more often than other
children. Several different approaches for the treatment or prevention of depression in
adolescents have been shown to be cost effective.

Epidemiology and burden of depression

In 2010, 63.2 million (2.5 percent) DALYs (disability adjusted life years) were attributed to
major depressive disorder (MDD) around the world. In 2010, major depressive disorder caused
63 million years lived with disability (YLDs), up from 46 million in 1990, indicating a 37
percent rise over the previous two decades. In both 1990 and 2010, MDD was ranked second by
global YLDs. Its regional rankings in three European regions were identical to its global ranking
(second place). In 2010, it was ranked first in some Asian and Latin American areas. MDD
disease was responsible for 8.1 percent of all YLDs worldwide.

WHO on depression

The World Health Organization’s 2006 report (Dollars, DALYs and Decisions: Economic
Aspects of the Mental Health System) concluded on the following:

 “Long-term maintenance treatment of depression with antidepressant drugs has a much

larger impact on reducing the burden of depression than episodic treatment, and also
represents a cost-effective strategy.
 For people with depression or anxiety, psychotherapy is expected to be as cost-effective
as newer (generic) antidepressants.
 The most efficient interventions for common mental disorders such as depression and
panic disorder can be considered very cost-effective (each DALY averted costs less than
one year of average per capita income), In other words, there is just as much of an
economic rationale for investing in mental health as there is in other chronic, non-
communicable diseases such as diabetes or hypertension.”

Research gaps

Raising disease awareness, reducing stigma, and reducing discriminatory attitudes could all
be effective strategies for reducing disease burden. These interventions can aid in the
detection and/or diagnosis of MDD at an earlier stage. As a result, it would be worthwhile to
 look at the best way to communicate these topics to the general public in order to raise
awareness.

NICE (National Institute for Health and Clinical Excellence) has published research
recommendations in their 2009 guidelines on depression, and identified multiple research
gaps which are:

 Defining the best pharmacological treatment strategy for people with depression who
have had an inadequate initial response to an antidepressant.
 What the efficacy is of short-term psychodynamic psychotherapy compared with
cognitive-behavioral therapy (CBT) and antidepressants, in well-defined depression
of moderate to severe severity.
 Determining the cost effectiveness of combined antidepressants and CBT compared
with sequenced medication followed by CBT and vice versa for moderate to severe
depression.
 The efficacy of antidepressants and placebo compared with CBT for persistent
subthreshold depressive symptoms.
 Determining the efficacy of counseling compared with low-intensity cognitive
behavioral interventions and treatment as usual in the treatment of persistent
subthreshold depressive symptoms and mild depression.
 The efficacy of CBT and antidepressants compared with behavioral activation in the
treatment of moderate to severe depression.
 The cost effectiveness and efficacy of different systems for the organization of care
for people with depression.
 Determining the cost effectiveness and efficacy of CBT, interpersonal therapy (IPT)
and antidepressants in prevention of relapse in people with moderate to severe
recurrent depression.

There has been very little study on the effectiveness of various treatments for depression in
infants, teenagers, and the elderly, including medications and psychotherapies. To date, the
majority of research conducted on these age groups has focused on the short-term effectiveness
of pharmaceuticals. More research on these particular age groups is needed to fill in these gaps
and determine the best care plan for these populations. In order to explain the best cure for
depression in infants, teenagers, and the elderly, the effectiveness over time must also be
explained.

In conclusion, future research on the abovementioned gaps may demonstrate:

 Currently unknown biomarkers or biological pathways of MDD that can be targeted

pharmaceutically;
 The optimal treatment strategy for different stages of depression for different population
groups;
  The cost effectiveness of each treatment for MDD, including inter-treatment and different
combination therapy comparisons;
 The (long term) effectiveness of different treatment strategies for children, adolescents
and the elderly who suffer from depression;
 Differing responses, adverse reactions and adherence patterns related to genetic or other
factors;
 The disaggregated effect of treatment modality between psychotherapy and
pharmaceutical therapy;
 Determinants of response to different therapies between age groups and genders;
 The relation and correlation between statistically significant effects and the actual clinical
effectiveness of different treatment strategies;
 Optimized and standardized method and end points for measuring antidepressant
efficacy; and
 Evidence on clinically important differences of depression rating scales that have
implications on clinical practice.

Conclusions

Depression is a leading cause of high health-care costs and causes a huge burden of illness
around the world. Europe accounts for more than a quarter of all MDD-related DALYs
worldwide. In all three European regions, the burden of disease for major depressive disorder is
greater than the global burden proportion. This shows that Europe suffers from a higher
incidence of MDD disease than the rest of the world. MDD increased by 37% globally between
1990 and 2010 in terms of years lived with disability (YLDs). According to the global and
European YLDs rankings, MDD is ranked second.

Depression and antidepressants are currently the subject of a lot of studies, mostly in adults.
Specific age groups, on the other hand, have not been sufficiently researched, and the efficacy of
various treatment interventions for these patients remains unknown. Research on depression in
girls, teenagers, and the elderly account for a small percentage of all studies performed to date.
More (comparative) research on various treatment methods, specifically targeted at these
subgroups of patients, is required in order to enhance the treatment of depression in terms of
efficacy, efficiency, protection, and adherence.

Data Analysis and discussion

Figure 1 Burden of disease frequency by age group in the world.

Figure 2 Absolute DALYs caused by depression in the world, by age group.

Figure 3 Burden of disease in absolute DALYs by gender and region.
Source: Global Burden of Disease Study 2010 (GBD 2010) Results by Cause 1990-2010. Data
downloaded from Institute for Health Metrics and Evaluation (IHME)

Figure 4 Age distribution of adverse reactions to antidepressant drugs that have been reported
to the FDA’s Adverse Event Reporting System (MedWatch), between 2004 and 2011.
Source: http://www.cchrint.org/psychdrugdangers/medwatch_psych_drug_adverse_reactions.php
Figure 5 Adverse reactions to antidepressant drugs that have been reported to the FDA’s
Adverse Event Reporting System (MedWatch), between 2004 and 2011.
Source:
http://www.cchrint.org/psychdrugdangers/medwatch_psych_drug_adverse_reactions.php

Figure 6 Geographic map number of studies on depression, per region worldwide.

Source: clinicaltrials.gov
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