Class 1 Flashcards
Illnesses that can present with major depressive episodes
- Depressive disorders: Major Depressive Disorder (MDD), Persistent Depressive Disorder
- Bipolar I and II
- Schizoaffective disorder
Other conditions that can present with pronounced depressed mood (sadness)
- Other depressive disorders: Disruptive Mood Dysregulation Disorder, Premenstrual Dysphoric Disorder, Substance/Medication-Induced Depressive Disorder, Depressive Disorder Due to Another Medical Condition
- Schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
- Adjustment disorder
- Personality disorder
- Substance Misuse
- Grief
Disruptive mood dysregulation disorder criteria
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without
all of the symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
H. By history or observation, the age at onset of Criteria A–E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.
• Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive
event or its anticipation, should not be considered as a symptom of mania or hypomania.
J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder
• Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive
disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder,
attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals
whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional
defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an
individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood
dysregulation disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a substance or another medical or neurological condition.
Epidemiology Disruptive mood dysregulation disorder
2%–5%
• Predominantly male
Persistent depressive disorder criteria
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or
observation by others, for at least 2 years.
• Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
• Poor appetite or overeating.
• Insomnia or hypersomnia.
• Low energy or fatigue.
• Low self-esteem.
• Poor concentration or difficulty making decisions.
• Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never
been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for
cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional
disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition (e.g. , hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
specifications Persistent depressive disorder
- Specify if:
- With anxious distress
- With mixed features
- With melancholic features
- With atypical features
- With mood-congruent psychotic features
- With mood-incongruent psychotic features
- With peripartum onset
- Specify if:
- In partial remission
- In full remission
• Specify if:
• Early onset: If onset is before age 21 years.
• Late onset: If onset is at age 21 years or older.
• Specify if (for most recent 2 years of persistent depressive disorder):
• With pure dysthymic syndrome: Full criteria for a major depressive episode have
not been met in at least the preceding 2 years.
• With persistent major depressive episode: Full criteria for a major depressive
episode have been met throughout the preceding 2-year period.
• With intermittent major depressive episodes, with current episode: Full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode.
• With intermittent major depressive episodes, without current episode: Full criteria for a major depressive episode are not currently met, but there has been
one or more major depressive episodes in at least the preceding 2 years.
- Specify current severity:
- Mild
- Moderate
- Severe
Premenstrual Dysphoric Disorder criteria
A. the majority of menstrual cycles, at least five symptoms must be present in the final week
before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
B. One (or more) of the following symptoms must be present:
• Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
• Marked irritability or anger or increased interpersonal conflicts.
• Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
• Marked anxiety, tension, and/or feelings of being keyed up or on edge.
C. One (or more) of the following symptoms must additionally be present, to reach a total
of five symptoms when combined with symptoms from Criterion B above.
• Decreased interest in usual activities (e.g., work, school, friends, hobbies).
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite; overeating; or specific food cravings.
• Hypersomnia or insomnia.
• A sense of being overwhelmed or out of control.
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.
• Note: The symptoms in Criteria A–C must have been met for most menstrual cycles that occurred in the
preceding year.
D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).
E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).
F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).
Treatment Premenstrual Dysphoric Disorder
- SSRIs QD or for luteal phase (ie. 14 days beginning day 14 of cycle)
- If SSRIs are not tolerated, consider continuous OCP or with shortened pill free period
Specifiers – With Anxious Distress
- Anxious distress is defined as the presence of at least two of the following symptoms during the majority of days of a major depressive episode or persistent depressive disorder (dysthymia):
- Feeling keyed up or tense.
- Feeling unusually restless.
- Difficulty concentrating because of worry.
- Fear that something awful may happen.
- Feeling that the individual might lose control of himself or herself.
- Specify current severity:
- Mild: Two symptoms.
- Moderate: Three symptoms.
- Moderate-severe: Four or five symptoms.
- Severe: Four or five symptoms and with motor agitation.
High levels of anxiety have been associated with
higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse
Specifiers – With Mixed Features
• At least three of the following manic/hypomanic symptoms are present during the majority of days
of a major depressive episode:
• Elevated, expansive mood.
• Inflated self-esteem or grandiosity.
• More talkative than usual or pressure to keep talking.
• Flight of ideas or subjective experience that thoughts are racing.
• Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
• Increased or excessive involvement in activities that have a high potential for painful consequences (e.g.,
engaging in unrestrained buying sprees, sexual indiscretions, foolish business investments).
• Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).
• Mixed symptoms are observable by others and represent a change from the person’s usual behavior.
• For individuals whose symptoms meet full criteria for either mania or hypomania, the diagnosis should be bipolar I or bipolar II disorder.
• The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication or other treatment).
• Note: Mixed features associated with a major depressive episode have been found to be a
significant risk factor for the development of bipolar I or bipolar II disorder.
Specifiers – With Melancholic Features
- One of the following is present during the most severe period of the current episode:
- Loss of pleasure in all, or almost all, activities.
- Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens, even something highly desirable).
- Three (or more) of the following:
- A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
- Depression that is regularly worse in the morning.
- Early-morning awakening (i.e., at least 2 hours before usual awakening).
- Marked psychomotor agitation or retardation.
- Significant anorexia or weight loss.
- Excessive or inappropriate guilt.
Melancholic features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpatients; are less likely to occur in milder than in more severe major depressive episodes; and are more likely to occur in those with psychotic features.
Specifiers – With Atypical Features
- This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode or persistent depressive disorder.
- Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
- Two (or more) of the following:
- Significant weight gain or increase in appetite.
- Hypersomnia.
- Leaden paralysis (i.e., heavy, leaden feelings in arms or legs at least an hour a day but often lasts for many hours at a time.).
- A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.
- Criteria are not met for “with melancholic features” or “with catatonia” during the same episode.
With mood-congruent psychotic features:
The content of all delusions and hallucinations is consistent with the typical depressive themes of personal
inadequacy, guilt, disease, death, nihilism, or deserved punishment.
Specifiers – With Peripartum Onset
This specifier can be applied to the current or, if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.
Prevalence Peripartum Onset + characteristics
between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery. Fifty percent of “postpartum” major depressive episodes actually begin prior to delivery. Often have severe anxiety and even panic attacks. Mood and anxiety symptoms during pregnancy, as well as the “baby blues,” increase the risk for a postpartum major depressive episode. Postpartum mood (major depressive or manic) episodes with psychotic features may be more common in primiparous women. The risk of postpartum episodes with psychotic features is particularly increased for women with prior postpartum mood episodes but is also elevated for those with a prior history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a family history of bipolar disorders. Once a woman has had a postpartum episode with psychotic features, the risk of recurrence with each subsequent delivery is between 30% and 50%.
Specifiers – With Seasonal Pattern
• With seasonal pattern: This specifier applies to recurrent major depressive disorder.
• There has been a regular temporal relationship between the onset of major depressive episodes in major depressive disorder and a particular time of the year (e.g., in the fall or winter).
• Note: Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g., regularly being unemployed every winter).
• Full remissions also occur at a characteristic time of the year (e.g., depression disappears in the spring).
• In the last 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined above and no nonseasonal major depressive episodes have occurred during that same period.
• Seasonal major depressive episodes (as described above) substantially outnumber the nonseasonal major depressive episodes that may have occurred over the individual’s lifetime.
Major depressive episodes that occur in a seasonal pattern are often characterized by loss of energy, hypersomnia, overeating, weight gain, and a craving for carbohydrates.
Age is also a strong predictor of seasonality, with younger persons at higher risk for winter depressive episodes.
Specifiers – Remission
- In partial remission: Symptoms of the immediately previous major depressive episode are present but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a major depressive episode following the end of such an episode.
- In full remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.
Specifiers – Severity
• Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the
symptoms result in minor impairment in social or occupational functioning.
• Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”
• Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.
Major Depressive Episode criteria
(5 out of 9 symptoms for 2 weeks) Feeling 1. depressed mood* and/or 2. loss of interest or pleasure* *(at least one of these 2)
Physical
- sleep changes
- appetite/weight changes
- loss of energy/fatigue
- motor slowing/agitation
Cognitive
- poor concentration, indecisiveness, mental slowing
- worthlessness/guilt
- suicidal thoughts
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Exclusions: The episode is not attributable to the physiological effects of a substance or another medical condition.
Major depressive disorder
episode of depression and there isn’t any other explanantion for it
Disease Burden Associated with MDD
• Social factors (e.g., relationships and social activities) have a complex interrelationship with depressive disorders, including a substantial role in the causation of MDD
• Depressed mood, loss of interests, impaired concentration, and selfblame are the symptoms most associated with social impairment.
• Depression in parents may also affect the health of their children.
Perinatal maternal depression is associated with multiple adverse outcomes in children, including increased problems with emotional regulation, internalizing disorders, behavioural disorders, hyperactivity,
reduced social competence, insecure attachment, adolescent depression, and negative effects on cognitive development.
• Adverse effects in offspring are also observed in the case of paternal depression.
• Effective treatment and remission of maternal depression is associated with improved parenting and a reduction in psychiatric symptoms in the offspring.
• MDD is associated with many chronic medical conditions, including heart disease, arthritis, asthma, back pain, chronic pulmonary disease, hypertension, and migraine. Depression is an independent risk factor for
ischemic heart disease and cardiovascular mortality, and vascular risk factors are also associated with onset of depression in later life.
• The presence of depression substantially increases the level of disability and reduces quality of life in individuals with chronic medical illness.
• MDD can affect medical conditions via multiple mechanisms. Depression reduces adherence to treatment and interferes with participation in preventive health care.
• Depression is also associated with important risk factors for physical illness, including sedentary lifestyle, obesity, and cigarette smoking.
• MDD shares a complex and bidirectional relationship with obesity and associated metabolic problems and is associated with immuneinflammatory dysfunctions that are implicated in reduced neural plasticity and neuroprogression.
Major Depression - Epidemiology
Canada: 12 month prevalence – 4.0%, lifetime – 10.8%
• Females experience 1.5 – 3x higher rates than males beginning early adolescence
• Prevalence in young adults is 3x higher than in people over 60.
Non-Modifiable Risk Factors depression
Gender • Female : male ratio = 2 : 1
Age • Risk of depression decreases with age
Childhood socioeconomic status • parental occupation/education • deprivation, poverty, safety
Family history • genetic (2 to 4-fold increased risk)
• familial non-genetic – exposure to depressed
parent, compromised parenting, neglect
Childhood adversity • Parental loss • Neglect • Physical abuse • Antipathy • Psychological
Current life stressors • Bereavement
• Stressful life events
Modifiable Risk Factors depression
- Education
- Socioeconomic status
- Marital status
- Social support
- Coping
- Substance use/misuse
- Negative cognitive style
- Medical disorders (metabolic syndrome, diabetes, migraine, MI, stroke, cancer, chronic illnesses)
- Anxiety disorders
Major Depression Course
• Untreated: 6-13 months
• Treated: 3 months
• High probability of relapse if antidepressants are discontinued within 3 months of remission
• Increased risk of suicide for: History of suicide attempts of threats, male sex, being single or living alone,
hopelessness
• The more recent the episode, the more likely they will soon recover
• Patients who are maintained on pharmacotherapy and patients with only 1-2 episodes have less risk of relapse
• Bipolarity: 5-10% of patients with a first MDE will have a manic episode within 6-10 years of the first MDE.
Serotonergic neurons, dopaminergic
neurons and norepinephrine neurons have
their cell bodies in the
brainstem
The Monoamine Hypothesis
- A normal amount of dopamine, serotonin and norepinephrine = no depression
- If this ‘normal’ amount is reduced, depression may ensue
- No direct evidence to support it
Other hypothesis depression
- BDNF – brain derived neurotropic factor: sustains the viability of neurons. The activity of the gene for BDNF is decreased with chronic stress. This could affect neurons and lead to cell death and atrophy
- Chronic stress also causes an increase in HPA activity evident in 20- 40% of depressed outpatients, and 40-60% of depressed inpatients.
- Depressive disorders are associated with immune dysfunction
- Inflammation?
Most Common Presenting Symptoms of Depression
sadness, anxiety, guilt, fatigue, poor concentration
depression inducing/mood altering Rx
b-blockers, interferon, accutane, OCP,
steroids, inhalers
Depression standardized Rating scales
- The Patient Health Questionnaire (PHQ-9): pt or clinician rated, basically the dsm-5
- Hamilton rating scale for depression: clinician rated
- Beck Depression inventory: pt rated
How to interpret PHQ 9 scoring
• For initial diagnosis:
1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a depressive disorder. Add score to determine severity.
- Consider Major Depressive Disorder
- if there are at least 5 3s in the shaded section (one of which corresponds to Question #1 or #2)
- Consider Other Depressive Disorder
- if there are 2-4 3s in the shaded section (one of which corresponds to Question #1 or #2)
5-9 mild
10-14 moderate
15-19 moderately severe
20-27 severe
pt score 5-9 on PHQ-9, treatment
watchful waiting, repeat phq-9 at follow-up
pt score 10-14 on PHQ-9, treatment
tri plan, consider counselling, follow-up and or pharmacotherapy
pt score 15-19 on PHQ-9, treatment
immediate initiation of pharmacotherapy and or psychotherapy
pt score 20-27 on PHQ-9, treatment
immediate initiation of pharmacotherapy, referral to mental health specialist
