Major depressive disorder (MDD), also known as clinical depression is a medical condition that affects many areas of a person’s life. MDD can affect mood, behavior, and physical functions like appetite and sleep. Individuals with major depressive disorder often lose interest in activities that they once enjoyed. They also have trouble performing activities of daily living. Medical experts and health scientists agree that major depressive disorder is one of most common types of depression affecting millions of people in the United States and the leading cause of disability throughout the world. There are concerns, however, that major depressive disorder is improperly diagnosed, with higher recurrent rates, and unsatisfactory treatment outcomes. Thus, this paper attempts to examine symptoms of major depressive disorder, clinical approaches to treating and managing the disorder, including antidepressant drugs for the MDD, healthcare costs and resource utilization, social and economic implications of this complex form of medical condition.
Major depressive disorder, Treatment patterns, Antidepressants, Healthcare costs, Social and economic burden.
Major depressive disorder (MDD) is one of the most common type of mental illness and the leading cause of psychiatric disability. About 16% of people in the United States suffer from MDD at some point during their lives. Women are twice diagnosed with MDD than men. Major depressive disorder is the most complex psychiatric condition that is recurrent and sometimes can be chronic, with a wide range of symptoms, such as hopelessness, sadness, indecision, loss of appetite, trouble sleeping, inability to concentrate, recurrent thoughts of suicide, et cetera. Gauthier et al. (2017) stated that in 2010, the economic burden of MDD in the United States was about $210 billion dollars, with healthcare and suicide related costs contributing to the total financial burden. Individuals with major depressive disorder often present with somatic complaints of pain and fatigue, including suicide thoughts, emotional distress, and problems with normal function. Major depressive disorder has close association with suicidality, and people with MDD are likely to report anxiety, insomnia, hopelessness, and many other symptoms. Better treatment outcomes for MDD has been very challenging due to the inability to identify specific treatment option for each patient at the early onset of the disorder.
Somatic symptoms of major depressive disorder are managed by psychological and pharmacological therapy throughout the course of the condition (Gauthier et al., 2017). MDD treatment is generally tailored to individual patient based on personal and family history, severity of the disorder, functional level, as well as comorbid conditions. Pharmacotherapy, such as selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants for MDD and are often the first line of treatment. These second-generation antidepressants can ease symptoms of moderate to severe depression and are considered relatively safe with fewer side effects than other types of medications used to treat depression. Essentially, treatments for major depressive disorder has four key steps, and they include dose optimization, therapy switch or replacement with an alternative pharmacotherapy, combination therapy, and augmentation therapy. The provider decision to implement the four key treatment steps is mostly influenced by a combination of important factors, such as patient safety, tolerability to the antidepressants, and patient-physician relationship.
While primary care physicians are the very first points of contact for patients with major depressive disorder, they have often failed to properly examine and identify the physical symptoms of MDD in their patients. This apparent failure has resulted in lower detection of major depressive disorder by primary care physician. In a recent study conducted by Pal, Oswal, & Vankar (2018), primary care physicians were unable to precisely diagnose a significant percentage of patients with major depressive disorder, which resulted in lower number of referrals to psychiatrists or no referrals at all. In addition to lower of rates of detection of MDD by primary care providers, several studies have found a close link between major depressive disorder and sociodemographic factors, such as income, financial stress, environmental and life stressors. For example, individuals in the low-income level tend to experience financial stress and are more likely to develop major depression. Likewise, those with life stressors, such as unemployment, setbacks in life, and other personal issues are more likely to be diagnosed with major depression. Environmental stressors, such as prolonged abuse and molestation at home, loss of a loved one or traumatic events can potentially cause serious major depressive disorder.
The manifestation of major depressive disorder may come with serious cognitive deficits. In many cases, people with MDD may experience memory loss, problems with concentration, lack of decision-making ability, including reduced psychomotor skills (e.g. thought and action skills), slow thinking process, difficulty remembering and solving basic tasks. Ebert et al. (2017) mentioned that cognitive symptoms are a common feature of major depressive disorder that contributes to increased economic and social burden. Empirical research also found that cognitive symptoms can impact a person’s performance at workplace, may continue long after MDD has decreased, as a form of residual cognitive symptoms (Ebert et al., 2017). Despite the overwhelming evidence of the devastating and long-term effects of cognitive symptoms associated with major depressive disorder, treatments of MDD has been directed toward managing mood symptoms, with little or no attention given to the treatment of cognitive symptoms in patients with major depressive disorder.
According to the World Health Organization (WHO), major depressive disorder is the 14
most common cause of death. Furthermore, about 15% of people with recurrent major depressive disorder commits suicide. Li et al. (2017) stated that suicidality is a significant cause of mortality in the world. For example, in China, suicide among adolescents and young adults with MDD is the fifth most common cause of death. However, in the United States, suicide is the 10
most common cause of death among people with major depressive disorder. According to Li et al. (2017), there has been a strong association between MDD and suicidality Hence, it is important to properly screen and identify MDD in patients at the very onset of its manifestation.
Major depressive disorder causes rapid changes in mood that presents in both primary care patients and people with chronic medical conditions. While there are treatment options to relieve major depressive disorder, many people with the condition are inadequately treated. Research on the effects of major depressive disorder has confirmed that MDD can complicate a patient’s medical prognosis, increase the physical symptoms, impede self-care and treatment, increase healthcare resource utilization, and may increase rate of suicides. Other studies have also revealed that individuals with major depressive disorder are likely to be women, young adults and unmarried. In addition, MDD patients may report sense of hopelessness, anxiety, sleeplessness, pain and fatigue, including living alone, and poor living conditions. Major risk factors for MDD may include personal or family history of depression, major life changes, including trauma, stress, certain illnesses and medications.
Several studies have shown that patients with major depressive disorder are among the highest consumers of healthcare resources. The economic burden of MDD (direct and indirect medical costs) amounts to billions of dollars each year. As a result, healthcare organizations nationwide are encouraging providers across the country to prescribe lower-cost drugs for MDD, including the use of generic drugs when they become available to curtail costs. With changes in prescription policy, and as Food and Drug Administration (FDA) approves the use of generic antidepressants medication in patients with major depressive disorder, acquisition costs of antidepressants are expected to fall in no distant future. Treatment persistence contributes to cost-effectiveness of antidepressants and to therapeutic success of major depressive disorder. According to Wu et al. (2011), treatment persistence improves patient outcomes, prevents recurrent events, and reduces resource utilization, and costs associated with comorbidity.
Despite the billions of dollars spent annually for treatment of major depressive disorder, O’Shields, Purser, Mowbray, & Grinnell-Davis (2017) pointed out that major depressive disorder is projected to be the second leading cause of disability by the year 2020. Regrettably, decades of treatments for MDD have shown mixed results, lower remission rates, and less than remarkable outcomes. Medical experts are suggesting that physicians should conduct more targeted screening to match symptoms of major depressive disorder to specific therapeutic interventions. Physicians should also adopt patient-centered approach in examining and treating MDD patients, classifying the disorder based on symptom profiles, severity of illness, and risk for suicidality.
A nationwide survey conducted from 2001 to 2003 suggested that the lifetime prevalence of major depressive disorder is about 16.6%, and its 12-month prevalence is about 6.7% in the United States (Sato & Yeh, 2013). World Health Organization also found that 12-month prevalence of MDD disorders is 9.6% in the United States, 4.2% in Europe, 2.6% in Korea, 3.1% in Japan, 2.5% in Beijing, and 1.7% in Shanghai. In addition, a survey conducted by the Ministry of Health, Welfare and Labor in Japan indicated that the number of patients with major depressive disorder has increased tremendously. In the United States and across the world, the number of patients diagnosed with MDD also has increased greatly. Sato & Yeh (2013) stated that the prevalence of MDD in South Korea has increased more than in other countries.
Research on the prevalence of major depressive disorder in South East Asia found that an estimated 50% of MDD patients have severe depression and over 60% have severe cognitive impairment. Sequencing Treatment Alternatives to Relieve Depression (STAR*D) study conducted in the same region (South East Asia) indicated that about 30% of patients with major depressive disorder did not achieve remission after four antidepressant treatments. The major depressive disorder patients were clinically determined to have treatment-resistance depression. They were also determined to have residual physical and psychological symptoms and more likely to relapse than patients without residual symptoms.
There is a consensus among medical experts that effective treatment for MDD should focused on comorbid physical diseases and rehabilitation, with a focus on restoring social and cognitive functioning. Pharmacotherapy treatments should be directed toward complete remission of psychological and physical symptoms, and total cognitive functional recovery. Improving MDD treatment may require targeted diagnosis, appropriate referral and direct psychiatric care. Early intervention is essential, especially for patients at high risk for suicide.
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