Depressive Mood disorders Flashcards
Major Depressive Disorder (MDD)
RF
Heritability 40%
First degree relative 2- 4x higher
Concurrent diabetes, obesity and CVD
Poor interpersonal relationships (divorce, isolated)
NO change with socioeconomic status
Major Depressive Disorder (MDD)
Prognosis
Course of MDD is variable as some individuals may never go into remission (absence of symptoms for 2 months)
Recovery begins within 3 months of onset in 40% of individuals and in 1-year in 80% of individuals
Lower recovery rates are seen with features including current episode duration, psychotic features, prominent anxiety, personality disorders, and symptom severity
Episodes can last 6-12 months without tx and 3-6 months with tx
Almost 25% relapse within 6 months, 30-50% within 2 years, 50-75% within 5 years
Major Depressive Disorder (MDD)
Criteria
Time frame
2+ weeks duration
Depressed mood or anhedonia (not enjoying things) PLUS 5+ SIGECAPS sxs
Causes significant distress
Not better explained by another disorder or substance
No history of mania or hypomanic episode
Major Depressive Disorder (MDD)
SIGECAPS
Sleep disturbance- too much or too little
Interest decrease
Guilt and feelings of worthlessness
Energy decrease
Concentration decrease
Appetite changes
Psychomotor agitation or retardation
Suicide
Major Depressive Disorder (MDD)
Major Depressive Disorder (MDD)
Major Depressive Disorder (MDD)
Major Depressive Disorder (MDD)
PHQ-9
Majro depressive disorder
DDx
Bipolar I/Bipolar II
Due to medical condition
Due to substance
Persistent depressive disorder
Premenstrual dysphoric disorder
DMDD
ADHD
Schizophrenia spectrum
Grief
Borderline personality disorder
Normalcy
MDD- Specifiers for depressive disorders
With anxious distress
At least two of the following symptoms for the majority of days of a major depressive episode
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
Severity
Mild – 2 symptoms
Moderate – 3 symptoms
Moderate-severe – 4-5 symptoms
Severe – 4-5 symptoms with motor agitation
MDD- Specifiers for depressive disorders
With mixed features
At least three of the following
- manic/hypomanic symptoms present nearly every day during most days of a major depressive episode
- Mixed symptoms are observable by others and represent a change from a person’s usual behavior
- If individuals meet criteria for either mania or hypomania diagnosis should be bipolar one and bipolar two disorder (4+ more plus enhanced mood)
- Mixed symptoms are not attributable to a substance or medical condition
MDD- Mixed
Mania Symptoms
Elevated, expansive mood
Inflated self-esteem or grandiosity
Pressure talking or more talkative than usual
Flight of ideas or racing thoughts
Increase energy or goal directed activity
Increase or excessive involvement in activities that have a high potential for painful consequences (i.e. buying sprees, sexual indiscretion, gambling, foolish business investments)
Decreased need for sleep
MDD-
With melancholic features
One of following present during most severe period of episode
- Lost of pleasure in all, or almost all, activities
- Lack of reactivity to usually pleasurable stimuli
Three or more of the following:
1. Distinct quality of depressed mood characterized by profound despondency, despair, empty mood
2. Depression that is typically worse in the morning
3. Early-morning awakening (at least 2 hours earlier than usual)
4. Marked psychomotor agitation or retardation
5. Significant anorexia or weight loss
Excessive or inappropriate guilt
MDD- Specifiers for depressive disorders
With atypical features
This specifier is applied when these features predominate during majority of days of the current episode
- Mood reactivity (mood brightens in response to actual potential positive events)
- Two or more of the following
Significant weight gain or increase in appetite
Hypersomnia
Leaden paralysis
Long-standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment - Criteria not met for with melancholic features or with catatonia
MDD
psychotic features
Psychotic features
Delusions and/or hallucinations are present
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
With mood-incongruent psychotic features
The concept of delusions or hallucinations does not involve typical depressive things of personal inadequacy, guilt, disease, death, nihilism, or deserve punishment, or the concept is a mixture of mood-incongruent to mood-congruent themes
MDD- specifiers
With catatonia
The catatonia specifier can apply to an episode of depression if catatonic features a present during most of the episode
Cataonia:
Mutism - does not interact with others
Negativism - resistant to any movement
Posturing
Waxy Flexibility
Echolalia - repeat last word multiple times
MDD
With peripartum onset
The specifier can be applied to the current or, if all criteria are not currently met for major depressive episode, most recent episode of major depression if one set of mood symptoms occurs during pregnancy or in the four weeks following delivery
3-6% of women will experience that wants a major depressive episode during pregnancy or in the weeks or months following delivery with 50% of postpartum major depressive episode beginning prior to delivery
MDD
With seasonal pattern (formerly Seasonal Affective Disorder)
Regular temporal relationship between the onset of major depressive episodes in major depressive disorder and a particular time of the year. (does not include cases in which there are obvious seasonally related psychosocial stressors such as an appointment every winter)
Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of year
In the last two years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined above and no non-seasonal major depressive episodes have occurred during that same period
Seasonal major depressive episodes substantially outnumber the nonseasonal major depressive episodes that may have occurred over the individual’s lifetime
MDD with seasonal depression
Tx
Tx- Bupropion, Light Box Therapy
MDD
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 two months, no significant signs or symptoms of the disturbance were present
MDD
Severity (can use PHQ-9 to categorize severity)
Mild- few if any more symptoms in excessive of full criteria are present, intensity of symptoms is distressing but manageable resulting in minor impairment of social or occupational functioning
Moderate- number of symptoms, intensity, and impairment are between “mild” and “severe”
Severe- excessively more symptoms are present than are required to meet full criteria, intensity is seriously distressful and unmanageable, and symptoms markedly interfere with social and occupational functioning
MDD
Tx options
Serotonin selective reuptake inhibitor (SSRI)
Serotonin norepinephrine reuptake inhibitor (SNRI)
Tricyclic antidepressants (TCA)
Monoamine oxidase inhibitors (MAOI)
Other antidepressants
Non-pharmacological treatments
Persistent Depressive Disorder (Dysthymia)
general and Tx
Depressed mood for most of the day, for more days than not, for at least 2 years
(for children and adolescents, mood can be irritable, and duration must be at least 1 year)
Tx: Same as MDD, however, improvements are less likely with dysthymia
Persistent Depressive Disorder (Dysthymia)
Criteria
2 or more of the following
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty to make decisions
Feelings of hopelessness
During the 2-year period (1 year for kids) there has not been a period of more than 2 months with having symptoms meeting criteria A and B
Criteria for MDD may be present continuously for the 2 years
There has never been a manic or hypomanic episode and criteria for cyclothymic disorder has not been met
Not better explained by another psych disorder (schizophrenia spectrum disorders or other psychotic disorders)
Causes significant distress and impairs social or occupational functioning
Premenstrual Dysphoric Disorder (PMDD)
general and criteria
- In the majority of menstrual cycles, at least 5 of the symptoms below must be present in the final week before onset of menses, start to improve a few days after starting menses, and become minimal or absent in the week postmenses
- At least one of the following must be present
a. Marked affective lability
b. Marked irritability, anger, or increased interpersonal conflicts
c. Marked depressed mood, hopelessness, or self-deprecating thoughts
d. Marked anxiety, tension, and/or feelings of being keyed up or on edge - At least one of the following along with the above symptoms to reach a total of at least 5
a. Decreased interest in usual activities
b. Subjective difficulty in concentration
c. Lethargy, easily fatigability, or marked lack of energy
d. Marked change in appetite, overeating, or specific food cravings
e. Hypersomnia or insomnia
f. A sense of being overwhelmed or out of control
g. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating or weight gain
Premenstrual Dysphoric Disorder (PMDD)
Tx
Tx
FDA approved drugs
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Antidepressants can be taken everyday, or only during day 14 of cycle through day 1 of menses OR higher dose during luteal phase (Prozac is great for this!)
OCPs
Disruptive Mood Dysregulation Disorder (DMDD)
Criteria
A. Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to situation or provocation
B. Outbursts are inconsistent with developmental level
C. Outbursts occur, on average, 3 or more times per week
D. Mood between outbursts is persistently irritable or angry most of the day, nearly every day, and is observable to others
E. A-D are present for 12 or more months without a period without these symptoms lasting 3 or more months
F. A-D are present in at least 2 of three settings (home, school, with peers) and severe in at least one setting
G. Diagnosis should not be made before age 6 or after age 18
H. By history or observation, age of onset of A-E is before age 10
I. No distinct period longer than 1 day which meet criteria (except duration) for manic or hypomanic episode
J. Behaviors do not occur exclusively during MDD episodes and are not better explained by another mental disorder
a. Cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder
K. Symptoms are no attributable to substance or medical condition
Disruptive Mood Dysregulation Disorder (DMDD)
Tx
Tx
Pediatric antidepressants
Fluoxetine (Prozac)
Escitalopram (Lexapro)
Therapy, both individual and family
Jamie is a 19yo college student presenting to the OP student clinic stating she has not been “feeling like herself”. She has had trouble adjusting since moving away from home and has had difficulty making friends. She used to love drawing but can’t find the energy to finish any of her artwork. She is sleeping 12+ hrs per day and skipping class. Her grades have started to reflect it. She admits to only eating 1 meal per day and can’t focus. She says she feels guilty about feeling sad as her parents are helping her pay for college.
What else do you want to know about Jamie?
When did her symptoms start? Any psychomotor slowing? Low energy?
Mania hx? Drug/alcohol use?
Any previous hx of anxiety or depression? Medications?
Any suicidal thoughts? Thoughts of not wanting to be here? AVH?
Medical hx - anemia, sleep apnea, thyroid, other concerns?
Family hx of mental illness?
Social hx - does she have any social interaction? Hobbies, leaving her dorm room?
Jamie is a 19yo college student presenting to the OP student clinic stating she has not been “feeling like herself”. She has had trouble adjusting since moving away from home and has had difficulty making friends. She used to love drawing but can’t find the energy to finish any of her artwork. She is sleeping 12+ hrs per day and skipping class. Her grades have started to reflect it. She admits to only eating 1 meal per day and can’t focus. She says she feels guilty about feeling sad as her parents are helping her pay for college. Appearance: neat
Speech: Normal
Eye Contact: Normal
Motor Activity: Normal
Mood: depressed
Orientation: x4
Memory impairment: none
Attention: Distracted
Hallucinations: none
Suicidality: none
Homicidality: none
Delusions: none
Behavior: cooperative
Insight: good
Judgement: good
ymptoms have been consistently present for 1 month. She has never experienced symptoms like this before, medication naive.
Denies any hx of anemia, thyroid problems or snoring.
Denies SI/HI/AVH
Denies mania, drug/alcohol use
Mom has a hx of anxiety, older brother has hx of depression
She has 1 friend who she trusts and confides in.
Appearance: neat
Speech: Normal
Eye Contact: Normal
Motor Activity: Normal
Mood: depressed
Orientation: x4
Memory impairment: none
Attention: Distracted
Hallucinations: none
Suicidality: none
Homicidality: none
Delusions: none
Behavior: cooperative
Insight: good
Judgement: good
PHQ-9: 16, moderately severe
TSH: WNL
CBC: WNL
Vitamin D: WNL
Major Depressive Disorder, single episode, moderate
How do you want to treat her?
Start fluoxetine (Prozac) 10mg QD for depression. F/U in 1 week. Refer to CBT
