Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Depression, Major


Related Terms

  • Clinical Depression
  • Depressive Psychosis
  • Endogenous Depression
  • Major Depressive Disorder
  • Psychotic Depression
  • Unipolar Depression

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Anxiety disorders
  • Autoimmune diseases (e.g., rheumatoid arthritis, lupus)
  • Cardiac conditions
  • Other general medical conditions
  • Personality disorder

Factors Influencing Duration

Length of disability may be influenced by the severity of the illness, the presence of complicating factors such as substance abuse or suicide attempts, response to therapy, and job requirements. Only in the most severe and unusual cases should major depression result in permanent disability.

Substance abuse will complicate treatment and may significantly delay returning to work. Suicide attempts that lead to hospitalization will also be associated with longer periods of disability.

Medical Codes

ICD-9-CM:
296.20 - Major Depressive Disorder, Single Episode; Unspecified
296.21 - Major Depressive Disorder, Single Episode; Mild
296.22 - Major Depressive Disorder, Single Episode; Moderate
296.23 - Major Depressive Disorder, Single Episode; Severe, without Mention of Psychotic Behavior
296.24 - Major Depressive Disorder, Single Episode; Severe, Specified as with Psychotic Behavior
296.25 - Major Depressive Disorder, Single Episode; in Partial or Unspecified Remission
296.26 - Major Depressive Disorder, Single Episode; in Full Remission
296.30 - Major Depressive Disorder, Recurrent Episode; Unspecified
296.31 - Major Depressive Disorder, Recurrent Episode; Mild
296.32 - Major Depressive Disorder, Recurrent Episode; Moderate
296.33 - Major Depressive Disorder, Recurrent Episode; Severe, without Mention of Psychotic Behavior
296.34 - Major Depressive Disorder, Recurrent Episode; Severe, Specified as with Psychotic Behavior
296.35 - Major Depressive Disorder, Recurrent Episode; in Partial or Unspecified Remission
296.36 - Major Depressive Disorder, Recurrent Episode; in Full Remission
311 - Depressive Disorder, Not Elsewhere Classified

Overview

Major depression is a serious psychiatric illness that negatively affects how an individual feels, thinks, and acts. It is one of several types of depression: reactive depression, the most common depressive state, resulting from reaction to illness or grief; bipolar or manic-depressive disorder, the least common depression characterized by episodes of mania and depression; and major or “endogenous” (arising from biological causes) depression, representing one-quarter of all cases of depression and attributed to genetic or biochemical causes. Major depression is responsible for more physical and social dysfunction than many chronic medical conditions. Individuals with major depression find it difficult to cope with normal life activities or to feel or enjoy the pleasures of life.

Everyone experiences depressed moods as a result of a change, either in the form of a setback or a loss. The sadness and depressed feelings that accompany the changes and losses of life are usually appropriate, necessary, and transitory and can present an opportunity for personal growth. However, depression that persists and results in serious dysfunction in daily life may indicate a depressive disorder that may need to be treated as a medical problem. The severity, duration, and presence of other symptoms are factors that distinguish normal sadness from a depressive disorder.

Major depression, known as major depressive disorder in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision), is a mood disorder distinguished by the occurrence of one or more major depressive episodes. A major depressive episode is diagnosed when an individual experiences persistent feelings of sadness or anxiety, with loss of interest or pleasure in usual activities (anhedonia). In addition, five or more of the following symptoms must be present for at least two consecutive weeks: changes in appetite that result in weight losses or gains unrelated to dieting; insomnia or oversleeping; loss of energy or increased fatigue; restlessness or irritability; feelings of worthlessness or inappropriate guilt; difficulty thinking, concentrating, or making decisions; and thoughts of death or suicide, or attempts at suicide. A cause or trigger for major depression may not be identified in all individuals. However, genetic predisposition and/or disturbances in levels of the neurotransmitters serotonin, dopamine, and norepinephrine are believed to be the underlying metabolic abnormalities in most cases.

Grief is a psychological and emotional reaction to a significant loss, including the loss of a spouse or loved one; grieving may lead to reactive depression from which the individual recovers uneventfully, or it can result in bereavement-related depression (BRD), a major depressive episode. Early bereavement-related responses may be disbelief, low mood, insomnia, and loss of appetite, accompanied by disrupted functioning. At one month after experiencing loss of a loved one, about 40% of individuals seeking medical care meet the criteria for major depression (Hensley). However, the DSM-IV-TR suggests not diagnosing bereavement-related depression until at least two months have passed after the loved one’s death. At two months, about 24% of grieving individuals meet the criteria for major depression, and at one year, about 15% (Hensley).

A depressive episode is diagnosed only if the symptoms described above are not associated with any other psychiatric conditions (such as bipolar disorder) or medical conditions (such as neurological or hormonal problems, cancer, or an individual's state of health after a stroke or a heart attack). In the latter case, the diagnosis is mood disorder due to a general medical condition, the general medical condition to be particularly specified. To be diagnostic for major depression, symptoms must not be due to side effects of medications or substance abuse.

The DSM-IV-TR divides major depressive disorder into two subtypes based on whether the individual has experienced a single depressive episode or recurrent depressive episodes. The DSM-IV-TR also adds specifiers to a diagnosis, rating severity along a continuum of mild, moderate, severe, and severe with psychotic features. The latter is sometimes known as depressive psychosis. Partial and full remissions are additional specifiers for major depressive episodes.

Incidence and Prevalence: Depression of all types affects 10% of the population; one-quarter of depressed individuals are diagnosed with major depression. In the US, the lifetime risk is 10% to 25% for women and 5% to 12% for men. An international study (17 researchers and 38,000 individuals from 10 countries) reported that the lifetime risk of depression ranged from 1.5% in Taiwan to 19% in Lebanon. Risks in other countries, in ascending order, were 2.9% in Korea, 4.3% in Puerto Rico, 5.2% in the US, 9.2% in Germany, 9.6% in Canada, 11.6% in New Zealand, and 16.4% in France (Weissman). The point prevalence (one-time occurrence) and lifetime prevalence of major depression were shown to be 2.7% and 9.6% in men over age 65 and 4.4% and 20.4% in women over age 65, respectively (Steffens). The exact prevalence is not known, however, since only one-third of adults experiencing depression seek treatment (Steffens).

Source: Medical Disability Advisor



Causation and Known Risk Factors

According to the DSM-IV-TR, anyone of any age, race, class, or gender can experience depression. It is estimated that up to 25% of individuals experiencing severe medical conditions (e.g., endocrine, neurological, or vascular conditions) will experience a concurrent major depressive disorder. Major risk factors are female sex, age, family history, bereavement, brain injury, and a history of previous depression. Women suffer from the disorder at least twice as often as men in societies around the world. The peak ages of onset are between 20 and 25 years and between 40 and 45 years. Although older individuals frequently seek treatment, there is no evidence that major depression is more common in older than in younger adults. Individuals who have parents or siblings with major depression have a greater risk (1.5 to 3 times) of developing this disorder. Grief is a risk factor because it may turn into major depression, especially in bereaved spouses, who often meet the criteria for major depression (Hensley).

Source: Medical Disability Advisor



Diagnosis

History: The individual may report sadness, anxiety, fatigue, loss of appetite, and insomnia, among other symptoms. A thorough history includes a review of current and previous symptoms, previous depressive episodes, recent disturbing thoughts or events, and psychological problems that could predispose to depression; an evaluation of mood, memory, and changes in relationships; a corroborative history from friends, family members, or employers; and any family history of depression or suicides. A careful, nonjudgmental inventory of substance abuse is made, as well as a review of all current and prior medications, especially antihypertensive agents (such as calcium channel blockers and beta blockers), analgesics, and certain migraine medicines, for which depression is a side effect. Because certain clinical conditions and diseases have been associated with depression, a thorough history includes an account of neurologic disorders (poststroke disorders, Parkinson's disease, Alzheimer's disease, multiple sclerosis, epilepsy, encephalitis, brain tumors), endocrine disorders (diabetes mellitus, hypothyroidism, hyperthyroidism and hyperparathyroidism), and other disorders (coronary artery disease, post–heart attack conditions, cancer, autoimmune diseases such as fibromyalgia, rheumatoid arthritis, and lupus, and chronic fatigue syndrome). Conversely, individuals with major depression may seek medical care for headache, abdominal pain, body aches, low energy, malaise, or problems with sexual function.

It is also important to consider the possibility, particularly in medicolegal contexts, that the history offered by the patient may not reflect the underlying facts. In cases in which there is such a consideration, careful inspection of the record for other signs of symptom exaggeration, such as the presence of positive Waddell signs, or a history that varies widely from one examiner to another, or erratic performance on a functional capacities evaluation, can be tip-offs. Psychological tests that contain internal validity scales and symptom validity tests can be useful in separating those people presenting with a depressive problem and those people merely representing themselves as presenting with a depressive problem.

Physical exam: Complete physical examination and medical workup are indicated to rule out underlying medical conditions (e.g., neurological, endocrine, or vascular conditions) that may disturb or deplete levels of serotonin and norepinephrine. Illnesses that are frequently associated with depression include hypo- and hyperthyroidism and other glandular disturbances, cancer, and post-stroke and post–heart attack conditions.

Tests: Major depression is diagnosed primarily through observation and history. However, routine laboratory tests (e.g., CBC, electrolytes, and serum calcium) may be done to evaluate metabolic disturbances and vascular disorders, TSH may be done to identify hypo- or hyperthyroidism, and more specialized endocrine tests may be helpful in establishing the diagnosis. EEG may be performed to exclude epilepsy, and CT imaging may also be requested to identify or rule out relatively rare causes such as brain tumor or a clinically silent stroke. Psychological tests such as the Minnesota Multiphasic Personality Inventory–2 (MMPI-2) and the Beck Depression Inventory (BDI) may be useful in establishing a baseline of reported symptoms and monitoring response to treatment. Specialized neurological testing may be recommended.

Source: Medical Disability Advisor



Treatment

Treatment choice depends on the outcome of the evaluation (history, physical exam, and tests). Treatment usually consists of some form of psychotherapy, antidepressant medications, or a combination of the two. One or more antidepressant medications may be prescribed, such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), or monoamine oxidase inhibitors (MAOIs). These medications work by correcting imbalances in the levels of brain chemicals (the monoamine neurotransmitters serotonin, dopamine, and norepinephrine). About two-thirds of individuals treated will respond to one or more medications. Generally, these medications take full effect 3 to 6 weeks after treatment has begun. Psychiatrists usually recommend that individuals continue to take the medication for five or more months after symptoms have improved.

Treatment of depression consists of three phases. Acute treatment, lasting 6 to 12 weeks, is aimed at remission of symptoms. Continuation treatment, lasting 4 to 9 months, is aimed at preventing relapse. During this phase, medication is continued at full dosage, and psychotherapy may be initiated. Maintenance treatment is aimed at preventing new episodes (recurrence) in individuals with prior episodes. Both maintenance medication and maintenance psychotherapy can prevent relapse or delay the next episode. Electroconvulsive therapy (ECT) is another treatment option that has been shown to be safe and effective in treating individuals of all ages who have not responded sufficiently to antidepressant medications and psychotherapy or whose depression is severe and prolonged. Although the precise mechanism of action of ECT is not understood, it is believed to work by increasing neurotransmitter levels in the brain, improving neurotransmission and elevating mood (Moore).

Psychotherapy, or talk therapy, may be used alone for treatment of mild depression. Antidepressant medications in combination with psychotherapy are used for moderate to major depression. The different types of psychotherapy include cognitive-behavioral therapy, psychodynamic psychotherapy, interpersonal therapy, and supportive psychotherapy. Research suggests that using a combination of antidepressants and talk therapy is more effective than either treatment alone for most individuals.

For individuals whose depressive episodes can be attributed to use of specific medications, changes in medication or changes in dosage may be required.

Psychiatric hospitalization is warranted when the individual neglects self-care or is at high risk of self-harm. Other forms of more intensive treatment, such as partial hospitalization and intensive outpatient care, may be considered for patients who fail to recover in a reasonable period of time with more standard treatments.

Before treatment, individuals and their families should be educated about the diagnosis, likely outcome, treatment options, cost of treatment, and potential side effects and complications.

Source: Medical Disability Advisor



Prognosis

Most individuals with a major depressive episode will get better, responding favorably to at least one antidepressant medication. Individuals may also benefit from psychotherapy. With time, recovery is usually complete, though the risk of relapse increases with each episode. More than half of all individuals with one episode of major depression will have another, while those individuals with a history of three previous episodes have a 90% likelihood of having a fourth. Because of this high relapse rate, it is recommended that individuals with a history of multiple depressive episodes receive medication for the rest of their lives.

Spontaneous recovery may take months, during which time the individual is at great risk of complications. According to the DSM-IV-TR, Risk of recurrence is about 70% at 5 years and at least 80% at 8 years. Among individuals with severe major depression, 76% on antidepressants recover, compared to 18% on sugar pills (placebo) or on psychotherapy without medication.

Poor outcome is associated with inadequate treatment, severe initial symptoms (including psychosis), early age of onset, greater number of previous episodes, incomplete recovery after 1 year, pre-existing severe mental or medical disorder, and family dysfunction.

Source: Medical Disability Advisor



Complications

Substance abuse, especially alcohol, frequently complicates a diagnosis of depression, although in some cases it may be difficult to determine which problem is primary. About 80% to 90% of individuals with major depression also have anxiety symptoms, such as anxiety, obsessive preoccupation, panic attacks, phobias, and excessive health concerns, and about one-third also have a full-blown anxiety disorder—usually panic disorder, obsessive-compulsive disorder, or social phobia. Anxiety symptoms may require special treatment but frequently respond to antidepressant medications, reinforcing the view that the two disorders share common brain chemistry imbalances. Approximately 1 in 10 individuals who have experienced a major depressive episode will subsequently be diagnosed as having bipolar mood disorder, a chronic condition with episodes of both depression and mania that may only partly respond to treatment. In some cases, an episode of bipolar mood disorder may emerge as the result of antidepressant medication use.

In extremely severe cases of major depression, psychotic symptoms may be present, such as hearing voices (auditory hallucinations) or having false beliefs (delusions).

Up to 15% of individuals with severe major depression die by suicide. The DSM-IV-TR states that the death rate is 4 times higher over age 55. Suicide attempts may paradoxically occur as the individual begins to respond to therapy because the extreme apathy sometimes seen in major depression before treatment may actually preclude committing suicide due to lack of motivation or energy.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Temporary work accommodations may include the avoidance of stressful situations. Some or all of the following may be necessary: (1) reducing or eliminating activities where the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, operating complex machinery, or handling dangerous chemicals; (2) introducing the individual to new or stressful situations gradually under individually appropriate supervision; (3) allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during employee's personal time); (4) promoting planned, proactive management of identified problem areas; and (5) offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote timely and safe transition back to full work productivity. Daytime work hours may be necessary for a period of time.

Individual may require regular time off from work for psychotherapy appointments.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was a thorough history obtained? Does individual have a history of prior depressive episodes? Does family have history of depression or of suicides?
  • Was substance abuse identified or ruled out?
  • Does individual have a history of psychological problems? Does individual have any physical conditions such as neurologic disorders (stroke, Parkinson's, epilepsy), endocrine disorders (diabetes mellitus, hypothyroidism, or hyperparathyroidism), or other disorders (cancer, coronary artery disease)?
  • Were endocrine tests done?
  • Were neurological tests done?
  • Were specific psychological tests, including symptom validity tests, carried out? What did they show?
  • Were brain scans performed to rule out brain tumor or prior silent stroke?
  • Is the physician an expert in diagnosis and psychopharmacology?
  • Was diagnosis confirmed?
  • Is it possible that individual was misdiagnosed?
  • Would individual benefit from a second opinion?

Regarding treatment:

  • Since major depression can be the result of biochemical imbalances in the brain, is the physician adequately trained in psychopharmacology?
  • Do drug dosages need to be adjusted to achieve therapeutic benefit?
  • Is individual responding favorably to current medication(s)? Is a change of medication warranted at this time?
  • If individual is experiencing side effects from current medication, is individual comfortable with and diligent in reporting side effects to doctor? If not, does individual trust family member or caregiver to share this information with physician?
  • Is psychotherapy being used as part of individual's treatment regimen?
  • Is individual learning to recognize and change behavior, thoughts, or relationships that cause or maintain depression? Is therapy helping individual to develop more healthful and rewarding habits?
  • Are underlying medical conditions that may complicate treatment or influence recovery being effectively addressed or treated?
  • If individual's depression is incapacitating, severe, and life-threatening, or if he or she cannot take or does not respond to antidepressant medications, is electroconvulsive therapy (ECT) being considered at this time?
  • Is individual seriously contemplating suicide? Has individual previously attempted it? Does the threat of self-harm or personal neglect put individual at risk?
  • Is individual frail because of weight loss or at risk for heart problems because of severe agitation?
  • Would individual benefit from hospitalization, partial hospitalization, or intensive outpatient care until self-care is possible?

Regarding prognosis:

  • Assuming diagnosis and treatment are accurate, can individual comprehend and follow medication treatment regimen, including proper dosage, time to take medication, and how to increase dosage when ordered? If individual is not capable, is another responsible individual available to oversee treatment? If not, would individual benefit from hospitalization until self-care is possible?
  • Was individual made aware of possible medication side effects and what to do if a side effect is experienced?
  • Does individual have a good working rapport with his or her physician?
  • Does individual know how often to see physician, and is transportation available? Is individual diligent about keeping appointments?
  • Has physician informed individual about how to improve response to treatment and which activities to avoid to increase the likelihood of improvement? Is individual engaged in psychotherapy?
  • What other support is available to individual? Family? Friends? Church? Support group?
  • Is there any evidence to suggest that the condition is prolonged for the purpose of some sort of financial or other gain?

Source: Medical Disability Advisor



References

Cited

Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Hensley, Paula, and Paula Clayton. "Bereavement-related Depression." Psychiatric Times 25 8 (2008): NA. 27 Feb. 2014 <http://www.psychiatrictimes.com/articles/bereavement-related-depression>.

Moore, David P., and James W. Jefferson, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia: Mosby Elsevier, 2008.

Steffens, D. C. "Prevalence of Depression and its Treatment in an Elderly Population: The Cache County Study." Archives of General Psychiatry 57 (2000): 601-607.

Weissman, Myrna M., et al. "Cross-national Epidemiology of Major Depression and Bipolar Disorder bipolar disorder." JAMA 293-299.

Source: Medical Disability Advisor






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