Major depressive disorder is a disorder involving moods, in which feelings of loss, anger, frustration or sadness interfere with daily life for either a week or longer. The disorder is diagnosed in axis I of the multi-axial system. The disorder is also known as unipolar depression, major depression, clinical depression or melancholia (Guay, 2012).

Axis I of the multi-axial system involves the assessment of clinical disorders and other conditions which are focused on the attention of the clinic. The axis is the top level diagnosis of the DSM multi-axial system representing acute symptoms that need treatment. The clinical disorders include: the adjustment disorders related with anxiety, conduct disturbance, depressed mood, mixed disturbance of conduct and emotions. It also includes mixed depressed mood and anxiety, dementia, amnestic, delirium and other cognitive disorders. It also includes eating disorders; dissociative disorders; impulse control disorders; factitious disorders; mood disorders; mental disorders; schizophrenia and other psychotic disorders; substance-related disorders; sexual and gender identity disorders; substance-related disorders; somatoform disorders; other conditions, which may be a focus of the clinical attention; and disorders that are first diagnosed in infancy, childhood or adolescence without including mental retardation, which is diagnosed in axis II. An example of axis I diagnosis is the greatest depressive disorder, single episode, severe without features of psychotic (First & al., 1997).

Axis II of the multi-axial system involves assessing intellectual disabilities and personal disorders like mental retardation, that is, noting prominent features of maladaptive and mechanisms of defense personality. The disorders are usually problems of long life that arise first in childhood, distinct from the axis I clinical disorders which are often axis II symptomatic (Millon, 1981). For example, an adult patient suffering from depression, which is an axis I disorder as a result of paranoid personality disorder, which is an axis II disorder like in the case of Tina. She is depressed for being left by her husband and relating the situation with her childhood incident, where her father left her and her mum. The disorders in this diagnosis are accompanied by social stigma, which is considerable because it is a suffering in people who fail to adapt well to the society often. Disorders diagnosed in this level include: dependent personality disorder; antisocial personality disorder; avoidant personality disorder; borderline personality disorder; mental retardation; histrionic personality disorder; paranoid personality disorder; narcissistic personality disorder; obsessive-compulsive personality disorder; schizoid personality disorder; personality disorder not  specified otherwise; and schizotypal personality disorder (O'Donohue, Fowler, & Lilienfeld, 2007).

Axis III of the multi-axial system involves general medical conditions and description of physical problems, which are relevant to diagnosing and treating mental disorders. Disorders related to this level include infections and parasitic diseases; diseases of blood and blood-forming organs; diseases of the digestive system; neoplasm’s; diseases of the nervous system and sense organs; endocrine, nutritional and metabolic diseases and immunity disorders; diseases of the musculoskeletal system and connective tissue; diseases of the circulatory system; diseases of genital-urinary system; diseases of the respiratory system; congenital anomalies; injury and poisoning; pregnancy child birth complications and the puerperium; certain conditions originating in the period of perinatal; and diseases of the skin and subcutaneous tissue.

Axis IV of the multi-axial system involves reporting of the environmental and psychosocial stressors that lead to the diagnosis, treatment and prognosis of mental disorders being affected. The level mostly involves recording the events of life especially those that occurred within the past twelve months. The problems associated with this level include problems with the primary support groups like death of a family member, disruption of family by separation. Tina was also affected by this problem for being separated from her husband. Sexual or physical abuse, health in the family, discord with siblings, divorce or estrangement, child neglect was another problem affecting Tina when she thought of how her father neglected her and her mother's removal from home, birth of a sibling, over protection, and inadequate discipline. Another set of problems are the ones related to the social environment like death or loss of a friend, life-cycle transition adjustment such as retirement, inadequate social support, discrimination. These also afflict Tina and they are reaching her through her friend who have been discriminating her and left her alone. Additionally, according to Tina, problems such as absence of her husband and lack of somebody to talk to as a result of her sisters death, and difficulty with acculturation, educational problems like inadequate school environment, academic problems, occupational problems like the threat of losing a job, change of a job, stressful work schedule affected her marriage.

Axis V of the multi-axial system involves global assessment of functioning scale, which is a reflection of the judgmental evaluation of the clinician, in relation to the patients' ability to function in daily life. The scale of 100 points measures social, psychological and occupational functioning. Global assessment of functioning takes a practical view of the mental health of a patient from a perspective of a diagnostic. Its ratings are applied over time for progress monitoring and are given for time frames that are different. Global assessment of functioning also provides information that is quantifiable which is used to measure programs treatment eligibility, benefits of insurance, benefits of disability and others from the perspective of health care management. According to the scale, rating of 91-100 is the highest rating, identifying a person without symptoms. The middle rating of 41-50 is for the symptoms leading to antisocial or social dysfunction, which is the inability to sustain a job. This rating describes Tina’s situation because she is not able to work anymore and she has become antisocial by enclosing herself in her apartment all day, every day. The bottom scale of 1-10 describes a rating for those patients posing themselves a threat or others, those who maintaining personal hygiene is a problem and who have suicidal thoughts. This scale also describes Tina who has been thinking of committing suicide. The patients are mostly dysfunctional.

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Major depressive dysfunction has a lot of symptoms as seen in the situation of Tina. Those associated with the disorder include feeling guilt and having excessive self blame. Tina blames herself for not giving her husband and marriage quality time, and this is what led to her husband leaving her. She feels guilty for not being attractive, hardworking, pretty and sexy enough to keep her husband to herself.

The other is being in a helpless and hopeless state. Tina has no hopes for being loved by anyone or getting in any other relationship again. One also feels fatigued or enthusiastic and with no energy. Tina has certainly changed from being aggressive and quick to being slow and sluggish, because she has no energy left in her, and fatigue has become her daily thing, because she never gets enough rest.

One also lacks interest for things that he or she enjoyed previously. In Tina’s case, she loved going to the local gym for at least three times in a week but now she has over four weeks since she appeared for the exercises. A person with the disorder also suffers insomnia or hypersomnia. This is reflected by Tina who during the first day of her situation she slept for twelve hours, and later she barely sleeps even for four hours.

Another symptom is the weight loss or gain. Tina, even with her maintaining her eating habits, she is still losing weight. One also becomes isolated. Tina has no friends to talk to because they all got tired of her complains after the separation with the husband and withdrew from her. The person she could talk to was only her sister, but it is unfortunate because she had already passed away four yeas ago. The disorder also causes the patient to have suicidal thoughts. Tina’s sister committed suicide due to depression and Tina herself thinks of committing suicide.

A person develops trouble in concentration, remembrance or making decisions. Tina is trying to remember where she went wrong to cause her husband to leave her. She is also unable to decide whether she has to commit suicide or not. The disorder also causes retardation or psychomotor agitation. One also feels worthless like Tina, who feels worthless even after working so hard just to support herself and her husband, whose work was moving out with friends and later left her.

Major depressive disorder is diagnosed by a psychologist or a doctor, when the symptoms significantly interfere with individual’s normal functioning wherever he or she is. The abnormality of Tina in job attendance and her behavior made possible for her to be diagnosed with the disorder. The disorder is thought to cause by the occurrence of a major depressive episode(s). Diagnosis of an episode occurs, when majority of the functions are experienced for more than two weeks like in the case of Tina, whose changes have been detected for more than four weeks.

A person with major depressive disorder has all the symptoms of depression as described above. The depressed moods represent a person’s change from the normal moods. The disorder is hard to diagnose if the history of a person is of manic, hypomanic or of mixed episodes such as bipolar disorder. Else if, the depressed mood is accounted for better by schizoaffective disorder and not superimposed on schizophrenia, delusional disorder or psychotic disorder.

The major treatments for the major depressive disorder are medications and talk therapy. Medications include Selective Serotonin Reuptake Inhibitors (SSRI) which are sertraline (Zoloft), fluroxamine (lexapro), paroxetine (Paxil), and citolppram (celexa); Serotonin Norepinephrine Reuptake Inhibitors (SNRI), which are dervenlafaxine (pristiq), venlafaxine (effexor), and duloxetine (cymbal ta); tricyclic antidepressants; bupropion (well butrin); and monoamine oxidase inhibitors (Seligman & Reichenberg, 2007).

Lithium and thyroid hormone supplements may be added to the medications to help the antidepressants to work better. If no outcome is seen upcoming from the talk therapy and depressants, one is requested to have treatment-resistant depression, where higher doses of antidepressants are also included, and they are not harmful.

Talk therapy involves counseling, where the concerned patient talks about his or her thought and feelings and getting to know how to deal with them. The therapy involves cognitive-behavioral therapy that teaches the patient how to fight away thoughts that are negative. That patient learns how to become aware of his or her symptoms and how to spot things that make the depression worse. The patient is also taught the skills of problem solving.

The other talk therapy is psychotherapy or pharmacotherapy which helps a patient to understand the issues behind the feelings and thoughts. The other is group therapy, which involves joining support groups of people who share the same situations or problems related to patients or problems same with the concerned.

Other treatments that may help in treating the major depressive disorder besides the major known treatments include Electro Convulsive Therapy (ECT), which is a single most effective treatment for the depression disorder which is known to be severe. The treatment may improve the moods in people who do not get better with other treatments especially those with suicidal thoughts or severe depression. The treatment also helps the patients who have psychotic symptoms (Nydegger, 2008).

Transitional Magnetic Stimulation (TMS) is another treatment that uses energy pulses to stimulate brain nerve cells, which are believed to affect a person’s moods. The light therapy is another treatment that may relieve symptoms especially in the winter periods, though it is not used as a treatment therapy in most cases.

Anti-personal psychotherapy helps in understanding the here and how factors that are known to interfere directly with the social relationships of a person. Psychoanalytic psychotherapy is a treatment therapy that focuses on hypothesized unconscious phenomena like internal conflict and mechanisms. Family therapy is another form of treatment which helps in examining the role of the depressed family member in the psychological well- being overall of the family as a whole and the role of the entire family in the maintenance and treatment of depression. Others include anticonvulsant medication for prevention, anti-anxiety medication, antipsychotic medication and stimulant medication.

The disorder may be prevented through avoiding alcoholic drinks and taking medications as required. Other activities that help in feeling better include maintaining good habits of sleeping, getting more exercises, trying to be around people who are caring and positive, getting involved or volunteering in group activities, talking to someone trustable about one’s feelings, and seeking out activities that bring pleasure.

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