Major Depressive Disorder Flashcards
Diagnostic Criteria of Major Depressive Disorder
A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.
Note: Criteria A–C represent a major depressive episode.
D. At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
List the severity/course specifiers of ‘MDD’
Mild/Moderate/Severe With psychotic features In partial remission In full remission Unspecified
When can you consider a major depressive episode recurrent?
For an episode to be considered recurrent, there must be an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode.
Determine the order in recording the name of a diagnosis (MDD)
Major depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers, followed by additional specifiers.
Determine the additional specifiers of ‘MDD’
With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern (applies to pattern of recurrent major depressive episodes)
When can a symptom be considered to count towards the a diagnosis of MDD?
To count toward a diagnosis of a major depressive episode, a symptom must either be newly present or have clearly worsened compared with the individual’s pre-episode status.
Which symptoms are more and less common in MDD?
Fatigue and sleep disturbance are present in a high proportion of cases; psychomotor disturbances are much less common but are indicative of greater overall severity, as is the presence of delusional or near-delusional guilt.
How often and in which way does anhedonia manifest in clinical practice? (MDD)
Diminished interest or pleasure in usual activities is nearly always present, at least to some degree. Individuals may report feeling less interested in hobbies, “not caring anymore,” or not feeling any enjoyment in activities that were previously considered pleasurable.
How does appetite change manifest in clinical practice? (MDD)
Appetite change may involve either a reduction or an increase. Some depressed individuals report that they have to force themselves to eat. Others may eat more and may crave specific foods (e.g., sweets or other carbohydrates). When appetite changes are severe (in either direction), there may be a significant loss or gain in weight, or, in children, a failure to make expected weight gains may be noted.
How does sleep disturbance manifest in clinical practice? (MDD)
Sleep disturbance may take the form of either difficulty sleeping or sleeping excessively. When insomnia is present, it typically takes the form of middle insomnia (i.e., waking up during the night and then having difficulty returning to sleep) or terminal insomnia (i.e., waking too early and being unable to return to sleep). Initial insomnia (i.e., difficulty falling asleep) may also occur.
How does psychomotor changes manifest in clinical practice? (MDD)
Psychomotor changes include agitation (e.g., the inability to sit still, pacing, hand-wringing; or pulling or rubbing of the skin, clothing, or other objects) or retardation (e.g., slowed speech, thinking, and body movements; increased pauses before answering; speech that is decreased in
volume, inflection, amount, or variety of content, or muteness). The psychomotor agitation or retardation must be severe enough to be observable by others and not represent merely subjective feelings. Individuals who display either psychomotor disturbance (i.e., psychomotor agitation or retardation) are likely to have histories of the other.
How does decreased energy manifest in clinical practice? (MDD)
An individual may report sustained fatigue without physical exertion. Even the smallest tasks seem to require substantial effort. The efficiency with which tasks are accomplished may be reduced. For example, an individual may complain that washing and dressing in the morning are exhausting and take twice as long as usual. This symptom accounts for much of the impairment resulting from major depressive disorder, both during acute episodes and when remission is incomplete.
How does sense of worthlessness or guild manifest in clinical practice? (MDD)
The sense of worthlessness or guilt associated with a major depressive episode may include unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations over minor past failings. Such individuals often misinterpret neutral or trivial day-to- day events as evidence of personal defects and have an exaggerated sense of responsibility for untoward events. The sense of worthlessness or guilt may be of delusional proportions (e.g., an individual who is convinced that he or she is personally responsible for world poverty). Blaming oneself for being sick and for failing to meet occupational or interpersonal responsibilities as a result of the depression is very common and, unless delusional, is not considered sufficient to meet this criterion.
How does mentation problems manifest in clinical practice?
Many individuals report impaired ability to think, concentrate, or make even minor decisions. They may appear easily distracted or complain of memory difficulties. Those engaged in cognitively demanding pursuits are often unable to function. In children, a precipitous drop in grades may reflect poor concentration. In elderly individuals, memory difficulties may be the chief complaint and may be mistaken for early signs of a dementia (“pseudodementia”). When the major depressive episode is successfully treated, the memory problems often fully abate. However, in some individuals, particularly elderly persons, a major depressive episode may sometimes be the initial presentation of an irreversible dementia.
What may be the motivations behind suicide?
Motivations for suicide may include a desire to give up in the face of perceived insurmountable obstacles, an intense wish to end what is perceived as an unending and excruciatingly painful emotional state, an inability to foresee any enjoyment in life, or the wish to not be a burden to others.
What can compromise the report of symptoms of an individual with MDD?
The individual’s report of symptoms may be compromised by difficulties in concentrating, impaired memory, or a tendency to deny, discount, or explain away symptoms. Information from additional informants can be especially helpful in clarifying the course of current or prior major depressive episodes and in assessing whether there have been any manic or hypomanic episodes. Because major depressive episodes can begin gradually, a review of clinical information that focuses on the worst part of the current episode may be most likely to detect the presence of symptoms.
What are the associated features in MDD?
- Major depressive disorder is associated with high mortality, much of which is accounted for by suicide; however, it is not the only cause. For example, depressed individuals admitted to nursing homes have a markedly increased likelihood of death in the first year.
- Individuals frequently present with tearfulness, irritability, brooding, obsessive rumination, anxiety, phobias, excessive worry over physical health, and complaints of pain (e.g., headaches; joint, abdominal, or other pains). In children, separation anxiety may occur.
What are the neuroanatomical, neuroendocrinological, and neurophysiological correlates of major depressive disorder?
- HPA axis hyperactivity (associated with melancholia, psychotic features, risk for eventual suicide)
- Genetic variants in neurotrophic factors and pro-inflammatory cytokines.
- Abnormalities in specific neural systems supporting emotion processing, reward seeking, and emotion regulation.
Epidemiology of MDD
- Twelve-month prevalence of major depressive disorder in the United States is approximately 7%, with marked differences by age group such that the prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals age 60 years or older.
- Higher prevalence in females (peaks in adolescence).
- Women report more atypical symptoms of depression characterized by hypersomnia, increased appetite, and leaden paralysis compared with men.
When can you consider a diagnosis of MDD in remission?
A period of 2 or more months with no symptoms, or only one or two symptoms to no more than a mild degree.
When does MDD usually appear?
Major depressive disorder may first appear at any age, but the likelihood of onset increases markedly with puberty.
What is the course of MDD?
The course of major depressive disorder is quite variable, such that some individuals rarely, if ever, experience remission (a period of 2 or more months with no symptoms, or only one or two symptoms to no more than a mild degree), while others experience many years with few or no symptoms between discrete episodes.
What does the presentation of chronic depressive symptoms affect?
Chronicity of depressive symptoms substantially increases the likelihood of underlying personality, anxiety, and substance use disorders and decreases the likelihood that treatment will be followed by full symptom resolution.
What is the recovery data of individuals affected by MDD?
Recovery from a major depressive episode begins within 3 months of onset for 40% of individuals with major depression and within 1 year for 80% of individuals.
What features are associated with lower recovery rates? (MDD)
Features associated with lower recovery rates, other than current episode duration, include psychotic features, prominent anxiety, personality disorders, and symptom severity.
What does affect the risk of recurrence of MDD?
- The risk of recurrence becomes progressively lower over time as the duration of remission increases.
- The risk is higher in individuals whose preceding episode was severe, in younger individuals, and in individuals who have already experienced multiple episodes. The persistence of even mild depressive symptoms during remission is a powerful predictor of recurrence.
What are the temperamental risk factors of MDD?
Negative affectivity (neuroticism) is a well-established risk factor for the onset of major depressive disorder, and high levels appear to render individuals more likely to develop depressive episodes in response to stressful life events.
What are the environmental risk factors of MDD?
- Adverse childhood experiences, particularly when they are multiple and of diverse types, constitute a set of potent risk factors for major depressive disorder (e.g. sexual abuse).
- Low income
- Limited formal education
- Racism
- Stressful life events
What are the genetic and physiological risk factors of MDD?
- First-degree family members of individuals with major depressive disorder have a risk for major depressive disorder two- to fourfold higher than that of the general population.
- Heritability is approximately 40%, and the personality trait neuroticism accounts for a substantial portion of this genetic liability.
- Women may also be at risk for depressive disorders in relation to specific reproductive life stages, including in the premenstrual period, postpartum, and in perimenopause.
What are the course modifiers in MDD?
Essentially all major nonmood disorders (i.e., anxiety, substance use, trauma- and stressor-related, feeding and eating, and obsessive-compulsive and related disorders) increase the risk of an individual developing depression.
Major depressive episodes that develop against the background of another disorder often follow a more refractory course.
Substance use, anxiety, and borderline personality disorders are among the most common of these, and the presenting depressive symptoms may obscure and delay their recognition
MDD increases the risk for suicide by …
An earlier review of the literature indicated that individuals with depressive illness have a 17-fold increased risk for suicide over the age- and sex-adjusted general population rate.
What has a strong association with suicidal ideation in MDD?
Anhedonia
Differential diagnosis (MDD)
- Manic episodes with irritable mood or with mixed features.
- Bipolar I disorder, bipolar II disorder, or other specified bipolar and related disorder.
- Depressive disorder due to another medical condition.
- Substance/medication-induced depressive disorder.
- Persistent depressive disorder.
- Premenstrual dysphoric disorder.
- Disruptive mood dysregulation disorder.
- Major depressive episodes superimposed on psychotic disorders,
- Schizoaffective disorder.
- Attention-deficit/hyperactivity disorder.
- Adjustment disorder with depressed mood.
- Bereavement.
- Sadness
Bereavement vs. MDD
Bereavement is the experience of losing a loved one to death. It generally triggers a grief response that may be intense and may involve many features that overlap with symptoms characteristic of a major depressive episode, such as sadness, difficulty sleeping, and poor concentration. Features that help differentiate a bereavement-related grief response from a major depressive episode include the following: the predominant affects in grief are feelings of emptiness and loss, whereas in a major depressive episode they are persistent depressed mood and a diminished ability to experience pleasure. Moreover, the dysphoric mood of grief is likely to decrease in intensity over days to weeks and occurs in waves that tend to be associated with thoughts or reminders of the deceased, whereas the depressed mood in a major depressive episode is more persistent and not tied to specific thoughts or preoccupations. It is important to note that in a vulnerable individual (e.g., someone with a past history of major depressive disorder), bereavement may trigger not only a grief response but also the development of an episode of depression or the worsening of an existing episode.
Comorbidity of MDD
Other disorders with which major depressive disorder frequently co-occurs are substance-related disorders, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, obsessive- compulsive disorder, anorexia nervosa, bulimia nervosa, and borderline personality disorder.
What percentage of youth with clinically significant mania meet the criteria for bipolar spectrum disorder?
25%
What are the characteristics of seasonal affective disorder?
- major depression that occurs in the fall and remits in the spring
- hypersomnia
- fatigue
- carbohydrate craving
What trait in childhood predicts anxiety and depression in adulthood?
High levels of irritability
How can substance abuse mimic mood disorders?
- by distrupting sleep/concentration/motivation/appetite
What are the special aspects of diagnosing depression in eating disordered patients?
- patients with eating disorders often show lassitude and dysphoria WHICH in part can be attributed to poor nutritional status
- diagnosis of depression should NOT be made until adequate nutritional status has been restored.
What percent of youth with depressive disorders also have other psychiatric comorbidities?
- between 40-90%
What can comorbidity result from in youth (in depressive disorders)?
- shared etiology (eg.: behavioral disorders)
- cause of depression (eg.: anxiety)
- consequence of depression (eg.: substance abuse, though it is bidirectional relationship)
