Depressive disorders Flashcards
Etiology for MDD - inherited factors
- First-degree relatives of patients with MDD have a 2-4x higher risk of MDD than the general population
- Patients with mood disorders also have an increased familial incidence of substance abuse.
Risk factors for MDD
- History of prior episode of depression
- Family history of depressive disorder especially in first degree relatives
- History of suicide attempts
- Postpartum period (especially first 4 weeks)
- Comorbid medical illness
- Absence of social support
- Negative, stressful life events
- Active substance abuse
- Female gender
- Neuroticism
- Adverse childhood experiences
Sleep disturbances in depression
- delayed sleep onset
- decreased sleep continuity with more awakenings
- decreased REM latency (time between falling asleep and first REM period)
- longer first REM period
- abnormal delta wave sleep (slow wave)
MDD - epidemiology
- 12-month prevalence of MDD in the U.S. = 7%
- Significant differences by age group – much more prominent in the 20s vs. 60s
- No ethnic differences in prevalence
- Rates of MDD in women are 1.5 - 3x higher than rates in men.
- Women typically experience sadness, worthlessness, and excessive guilt
- Men typically experience fatigue, irritability, anhedonia, and insomnia
- Higher incidence of MDD in separated or divorced people than in married individuals, especially men.
- Medically ill patients have a greater incidence of depression.
- Depression is associated with greater use of general health services.
Diagnosis of MDD
5 or more of the following symptoms, present most of the day, nearly every day, during the same 2-week period.
At least one of the symptoms is either:
(1) depressed mood, or
(2) loss of interest or pleasure
- Depressed mood most of the day
- Markedly decreased interest or pleasure
- Significant weight loss (or gain)
- Insomnia or hypersomnia
- Psychomotor retardation or agitation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive guilt
- Diminished ability to think or concentrate or - indecisiveness
- Recurrent thoughts of death
- The symptoms cause marked distress or impairment.
- The symptoms are not due to the direct physiological effects of a substance.
- The occurrence is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
- There has never been an episode of mania or hypomania.
Development and course of MDD
- Remission = 2 mon without qualifying sxs, or with only 1-2 sxs present to a mild degree
- 50% of patients experience a recurrence of MDE after their initial presentation
- Each new episode increases the risk for future recurrence
- Each recurrent episode is typically more severe and with more abrupt onset.
- The longer sxs are present, the harder they are to treat!
- Chance of remission is about 50% after 6 months of symptoms
- If symptoms persist to longer than 2 years, chance of remission is less than 5%
Greater chance of recurrent MDE if…
- Severe sxs in most recent episode
- Inadequate treatment
- Discontinuation of effective tx
- Young age
- Persistence of mild depressive sxs during remission
- Multiple previous episodes of depression
- High expressed emotion in the family
- Martial problems
- Psychotic sxs, prominent anxiety, co-morbid - personality disorder
Prognosis of MDD
Good prognostic indicators
- Mild sxs
- No psychosis
- Advanced age at onset
- No co-morbid psychiatric disorders
- Good social functioning for ~5 yrs before sx onset
- History of solid friendships during adolescence
Many bipolar illnesses begin with a depressive episode, so there’s a chance that your MDD patient actually has bipolar disorder but just hasn’t been manic yet!
BPAD is especially likely if:
- Depressive episode dx in adolescence
- Psychotic features present
- Family history of BPAD
Suicide in MDD
- The lifetime risk of suicide in mood disorders is 10-20%.
- The risk of attempted suicide is increased 41 times compared to people with other diagnoses.
- 80% of people who commit suicide have a mood disorder.
- Women attempt suicide more frequently than men, but men are more likely to die in the attempt because they tend to use more violent methods.
- As many as 4% of people who commit suicide murder someone else first.
- 10% of people who attempt suicide will eventually kill themselves.
- Suicidality is the feature of depressive disorder that poses substantial risk of mortality in the disorder.
- Prevention of suicide – more than any other goal, requires immediate intervention and may require hospitalization.
- The risk for subsequent completed suicide for an individual hospitalized for an episode of severe MDD is about 15%.
- Suicide is the #1 reason for malpractice suits against psychiatrists.
Factors suggesting an increased risk for suicide
Demographics
- male
- recent personal loss
- single, widowed, or divorced
- older age
- caucasian
Symptoms
- severe depression
- anxiety
- hopelessness
- psychosis, especially with command hallucinations
Suicidal thinking
- specific plan
- means to carry out the plan
- absence of protective factors
- rehearsal of the plan
- high lethality of method
History
- previous attempts, especially if many or severe
- family history of suicide
- active substance abuse
- previous psychiatric hospitalization for any reason
Protective factors against suicide
- Involvement of children or pets
- Support from loved ones, responsibility to family
- Religious prohibition
- Optimism about future
- Previous response to treatment
- Patient contracts for safety*
Other depressive disorders
- Depressive disorders caused by medical illnesses are not considered to be primary depressive disorders –> The diagnosis is Depressive disorder due to another medical condition.
- Depressive disorders caused by medications or psychoactive substances are not considered to be primary depressive disorders either –> The diagnosis is Substance/Medication-induced depressive disorder.
Diagnosis of Persistent Depressive Disorder
Depressed mood for most of the day for at least 2 years
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
- Hopelessness
During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
Criteria for a major depressive disorder may be continuously present for 2 years.
There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
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.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Prognosis of PDD
~20% of patients with persistent depressive disorder go on to develop BPAD I or II
Poorer long-term outcome predicted by presence of:
- Higher levels of neuroticism
- Greater sx severity
- Poorer global functioning
- Presence of anxiety d/o or conduct d/o
Diagnosis of Premenstrual Dysphoric Disorder
In the majority of menstrual cycles, at least 5 sxs must be present in the final week before onset of menses, start to improve within a few days after onset of menses, and become minimal or absent in the week postmenses.
One (or more) of the following must be present:
- Affective lability (mood swings)
- Irritability, anger, or increased interpersonal conflicts
- Depressed mood, hopelessness, or self-deprecating thoughts
- Anxiety, tension, and/or being “on edge”
One (or more) of the following must additionally be present, to reach a total of 5 sxs:
- Decreased interest in usual activities
- 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
***Symptom criteria must have been met for most menstrual cycles that occurred in the preceding year.
The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others.
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).
Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles.
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).
Statistics for and Prognosis of PMDD
12-month prevalence in U.S. is ~1.8% of menstruating women
Risk factors for development:
- High stress
- Interpersonal trauma
- Seasonal mood changes
- Heritability
Sxs can start any time after menarche, and may worsen as menopause approaches
Sxs can be reduced with OCPs
