How do you differentiate and treat reactive depression versus a major depressive episode?

Differentiating and Treating Reactive Depression vs Major Depressive Episode

The distinction between "reactive depression" and major depressive disorder (MDD) is not recognized in modern diagnostic systems; both are treated as MDD when diagnostic criteria are met, though treatment intensity may vary based on severity and precipitating factors rather than the reactive versus endogenous classification. 1

Diagnostic Framework

The DSM-5 defines MDD as requiring at least 5 symptoms during a 2-week period, including depressed mood or anhedonia, plus additional symptoms such as sleep disturbance, psychomotor changes, fatigue, concentration difficulties, and suicidal ideation—regardless of whether a clear precipitating stressor exists. 1 The historical binary model of "endogenous" versus "reactive" depression, introduced by Kurt Schneider in 1920, is no longer the dominant diagnostic framework, though clinicians still informally use these concepts in practice. 2

Key Diagnostic Considerations

• Both presentations meet MDD criteria when 5 or more symptoms persist for at least 2 weeks with functional impairment, making them diagnostically equivalent under current classification systems. 1

• Severity classification (mild, moderate, severe) is based on symptom count, intensity, and functional impairment—not on the presence or absence of precipitating stressors. 3

• Use standardized assessment tools including the PHQ-9, HAM-D, or MADRS to quantify severity and monitor treatment response, rather than relying solely on the reactive versus endogenous distinction. 1

Clinical Differentiation in Practice

Despite the unitarian diagnostic model, research shows psychiatrists do distinguish these presentations and modify treatment accordingly. 2

Features Historically Associated with "Melancholic" (Endogenous) Depression

• Psychomotor changes (agitation or retardation), marked self-reproach, and decreased concentration are more characteristic of what was traditionally called endogenous depression. 4

• Autonomy from environmental changes—symptoms persist regardless of positive external events or circumstances. 4

• Neurovegetative symptoms are typically more prominent, including early morning awakening, diurnal mood variation, and anhedonia. 2

Features Historically Associated with "Reactive" Depression

• Clear precipitating stressor with symptoms that are temporally related to and proportionate to the life event. 4

• Mood reactivity—symptoms improve temporarily in response to positive environmental changes or circumstances. 4

• Preserved capacity for pleasure in some situations, though overall functioning remains impaired. 2

Treatment Approach

For patients meeting MDD criteria, initiate either cognitive behavioral therapy (CBT) or second-generation antidepressants (SSRIs/SNRIs) as first-line treatment, selected based on severity, patient preference, and clinical features rather than the reactive versus endogenous distinction. 1

Treatment Selection Algorithm

Mild Depression (5-6 symptoms, mild impairment):

• Start with CBT alone as it has equivalent effectiveness to antidepressants with moderate-quality evidence. 1, 5
• Consider psychotherapy particularly when a clear precipitating stressor exists and mood shows some reactivity to environmental changes. 2
• Reserve pharmacotherapy for patients who prefer medication, have limited access to psychotherapy, or fail to respond to psychotherapy within 6-8 weeks. 3

Moderate to Severe Depression (≥7 symptoms or significant impairment):

• Initiate second-generation antidepressants (SSRIs or SNRIs) selected based on adverse effect profiles, cost, and patient preferences—not on the reactive versus endogenous classification. 3, 1
• Japanese psychiatrists prescribe antidepressants more readily for melancholic presentations (mean score 5.9/7) versus reactive presentations (mean score 3.6/7), though both may benefit. 2
• Combine with psychotherapy for optimal outcomes, particularly when psychosocial stressors are prominent. 5, 2

Severe Depression with High-Risk Features:

• Classify as severe regardless of symptom count if the patient presents with specific suicide plan/intent/recent attempt, psychotic symptoms, or severe functional impairment (unable to leave home). 3
• Initiate antidepressants immediately with close monitoring and consider psychiatric consultation. 3

Pharmacotherapy Specifics

• Assess response within 1-2 weeks of initiation, monitoring for therapeutic effects, adverse effects, and suicidality. 3

• Modify treatment if inadequate response by 6-8 weeks, including dose adjustment, switching agents, or adding augmentation strategies. 3

• Continue treatment for 4-9 months after satisfactory response for first episodes; longer duration (≥1 year) is beneficial for recurrent episodes. 3, 1, 5

Psychotherapy Specifics

• CBT has moderate-quality evidence supporting effectiveness equivalent to antidepressants and may be particularly useful when medication options are limited or patient preference favors non-pharmacological approaches. 1, 5

• Psychotherapy received higher appropriateness ratings for reactive presentations (mean 4.9/7) compared to melancholic presentations (mean 4.3/7) in clinical practice surveys. 2

Common Pitfalls to Avoid

• Do not withhold antidepressants solely because depression appears "reactive" or situational—if DSM-5 criteria for MDD are met with moderate-to-severe symptoms, pharmacotherapy is indicated. 1

• Do not assume reactive depression is less serious—both presentations carry significant morbidity and suicide risk when criteria for MDD are met. 6

• Avoid premature discontinuation before 4-6 weeks, as therapeutic effects typically require this duration regardless of whether depression appears reactive or endogenous. 1

• Do not diagnose MDD when symptoms are better explained by adjustment disorder (symptoms do not meet full MDD criteria) or mood disorder secondary to medical conditions/medications (address underlying cause first). 5

• Screen for bipolar disorder in all patients presenting with depression, as misdiagnosis leads to inappropriate antidepressant monotherapy; look for prior hypomanic/manic episodes, family history of bipolar disorder, early age of onset, and psychotic features. 7, 8