Major Depressive Disorder Flashcards
criterion A of MDD
FIVE (or more) of the following symptoms have been present during the same TWO WEEK period and represent a change from previous functioning
at least one of the symptoms must be either depressed mood or loss of interest or pleasure
*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 (eg feels sad, empty, hopeless) or observation made by others (i.e tearful)–> in kids and adolescents can be irritable
- 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 by observation)
- significant weight loss when not dieting or weight gain (i.e a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feeling 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
criterion B for MDD
the symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning
criterion C for MDD
the episode is not attributable to the physiological effects of a substance or another medical condition
what qualifies as a “major depressive episode”
criteria A-C in the DSM for MDD
criterion D for MDD
the occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified and unspecified schizophrenia spectrum and other psychotic disorders
criterion E for MDD
there has never been a manic episode or hypomanic episode
what is considered a “significant weight loss”
change of more than 5% of body weight
list the possible specifiers with 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
what is a common presenting complaint that ends up being MDD
insomnia or fatigue
what type of insomnia is most common with MDD
middle insomnia or terminal insomnia
how does being depressed affect an individuals mortality when entering a nursing home
depressed individuals admitted to nursing homes have a markedly increased likelihood of death in the first year
what neuroendocrinological correlate of depression has been the most extensively investigated abnormality?
hypothalamic-pituitary-adrenal axis hyperactivity
in the case of depression, HPA axis hyperactivity is associated with that features
melancholia
psychotic features
risks fo eventual suicide
fMRI studies of those with depression have provided evidence for functional abnormalities in what neural systems
those supporting emotion processing, reward seeking and emotion regulation
what is the 12 month prevalence of MDD in the USA
about 7%
how does prevalence of depression differ between younger cohorts and older cohorts
the prevalence in 18-29 year olds is 3x higher than in individuals over 60
what is the gender difference in terms of rates of depression
1.5-3x higher in females than males beginning in early adolescence
when does incidence of depression peak in the USA
in age 20s
(first onset late in life is not uncommon; can first appear at any age though likelihood increases markedly with puberty)
what is the course of MDD
quite variable
some people rarely, if ever, experience remission
others experience many years with few or no symptoms between discrete episodes
chronicity od depressive symptoms substantially increases likelihood of what?
underlying personality, anxiety and substance use disorders
*also decreases the likelihood that treatment will be followed by full symptom remission
what is considered “remission” in terms of depressive illness
a period of two or more months with no symptoms or only one of two symptoms to no more than a mild degree
when does recovery typically begin for most people with MDD
within 3 months of onset for 2/5 people
within 1 year for 4/5 people
*many people who have been depressed for only several months can expect to recover spontaneously
list features of MDD associated with lower recovery rates
current episode duration longer that a few months
psychotic features
prominent anxiety
personality disorders
symptoms severity
name a “powerful” predictor of recurrence of MDD according to the DSM
presence of even mild depressive symptoms during remission
list features that increase suspicion that the person will eventually go on to be diagnosed with bipolar illness rather than unipolar depressive illness
younger age at onset of depression–> in adolescence
psychotic features
family history bipolar illness
“with mixed features” specifier criteria are met
*MDD, particularly with psychotic features, may also transition into schizophrenia
does gender seem to affect the phenomenology, course, or treatment response to MDD
no (despite the differences in prevalence between genders)
what symptoms of MDD are more common in younger people
hypersomnia and hyperphagia
what symptoms of MDD are more common in older individuals
melancholic features
particularly psychomotor disturbances
how does suicide risk in MDD change with age
likelihood of suicide attempt lessens in middle and late life, BUT risk of completed suicide does not
what is a temperamental risk factor for developing MDD
neuroticism (negative affectivity)
well established risk factor for the onset of MDD
high levels appear to render people more likely to develop depressive episodes in response to stressful life events
name environmental risk factors for MDD
adverse childhood experiences (especially multiple experiences of diverse types)
stressful life events can be precipitants –> but presence or absence of adverse life events near the onset of episodes does NOT appear to provide a useful guide to prognosis or treatment selection
having a first degree family member with MDD increases risk for developing MDD by how much?
risk is 2-4x higher than general population
*relative risks appear to be higher for early onset and recurrent forms
what is the heritability of MDD
about 40%
the personality trait of neuroticism accounts for a substantial portion of this genetic liability
how do other psych conditions affect the risk of developing depression
essentially all major non-mood disorders increase the risk of developing depression
MDEs that develop against the background of another disorder often follow a more refractory course
what are some of the most commonly comorbid/precipitating psychiatric conditions with MDD
anxiety
borderline PD
substance use
how does medical illness affect risk and course of MDD
chronic or disabling medical conditions also increase risks for major depressive episodes
even common illnesses like diabetes, morbid obesity and CV disease are often complicated by depressive episodes
these episodes are more likely to become chronic that are depressive episodes in medically healthy individuals
among criterion A symptoms, which symptoms are most uniformly reported across cultures
insomnia and loss of energy
how does suicide risk in MDD differ by gender
risk of suicide attempt is higher in women but risk of completion is lower (compared to males)
what is the most consistently described risk factor for suicide in MDD
past history of suicide attempts or threats
*BUT most completed suicides are NOT preceded by unsuccessful attempts
list risk factors for increased risk for completed suicide
past history of suicide attempts or threats
male sex
being single or living alone
having prominent feelings of hopelessness
*presence of borderline PD also markedly increases risk for future suicide attempts *
what is the functional impact of MDD
varies widely
can range from very mild impairment to complete incapacity such that affected person cant attend to basic self care or is mute or catatonic
ddx MDD
manic episodes with irritable mood or mixed episodes
–> (MDE with irritable mood may be hard to distinguish from manic/hypomanic episodes with irritable mood or mixed episodes)
mood disorder due to another medical condition
sub/med induced depressive or bipolar disorder
ADHD
adjustment disorder with depressed mood
sadness
where do symptoms of ADHD and MDD Overlap
distractability and low frustration tolerance can be found in both
can diagnose both together
BUT–try not to overdiagnose MDD in kids with ADHD whose disturbance in mood is characterized by irritability rather than by sadness or loss of interest
how do you distinguish adjustment disorder with depressed mood from MDD
an MDE that occurs in response to a psychosocial stressor is distinguished from adjustment disorder with depressed mood by the fact that full criteria for MDE are NOT met in adjustment disorder
what is the annual prevalence of a depressive episode in canada
4.7%
what is the lifetime prevalence of a depressive episode in canada
11.3%
what are the hypothesis for why women have a 2-3x higher rate of being diagnosed with depression than males
hormonal differences
effects of childbirth
differing psychosocial stressors for men and women
increased seeking of clinical care in women
behavioural models of learned helplessness
what % of depressive episodes are brief and resolve within 3 months
about 50%
list risk factors for chronic depressive symptoms or recurrence
underlying anxiety, personality or substance use disorders
early age of onset
greater number of episodes
severity of initial episode
disruption of sleep-wake cycle
presence of comorbid psychopathylogy
family hx psych illness
presence of NEGATIVE COGNITIONS
higher NEUROTICISM
poor social support
stressful life events
MDD is asscociated with what chronic medical conditions
heart disease
arthritis
back pain
COPD
asthma
HTN
migraine
is there a correlation between depression and socioeconomic status
no
what is the estimated heritability of MDD
about 40%
why does atypical depression tend to result in more disability than melancholic depression
because individuals tend to have more interpersonal difficulties
are atypical depression, borderline PD, bipolar II and cyclothymic disorder overlapping conditions?
common feature in all is emotional dysregulation and mood reactivity
research “hints” that these disorders may all exist on a continuum
can be challenging clinically to distinguish between them
what are the geriatric giants
depression
dementia
delirium
define seasonal affective disorder (MDD with seasonal onset)
subtype of depression with annual onset between sept-nov and remission spontaneously in april-may
what medication has been shown to be preventative in SAD
buproprion–> if started prior to the winter season
list nonmodifiable risk factors for suicide
older men
past suicide attempt
hx of self harm behaviour
being a sexual minority
family history of suicide
history of legal problems
list modifiable risk factors for suicide with regard to symptoms and life events
active SI
hopelessness
psychotic symptoms
anxiety
impulsivity
stressful life events like financial stress and victimization
list modifiable risk factors for suicide related to comorbid conditions
SUDs–especially AUD
PTSD
comorbid personality disorders
chronic painful medical conditions
cancer
list common rating scales for depression
beck depression inventory (BDI)
–> measures severity of depression, for ages 13 and up
PHQ-9
–> primary care; screens for presence and severity of depression
hamilton rating scale for depression (HAM-D)
–> “should not be used as diagnostic instrument”
montgomery-asberg depression rating scale (MADRS)
–> severity of depressive episodes in patients with mood disorders
name two well replicated findings from neuroimaging in MDD
amygdala hyperactivity
volumetric changes
what blood work can be useful in assessing depression
CBC
iron studies
liver function tests
TSH
vitamin B12
vitamin D
serum zinc
calcium
magnesium
phosphate
what changes in sleep are associated with depression
decreased sleep efficiency
decreased slow wave sleep (decreased stage 3 and 4 sleep time)
shorter/decreased REM latency
increased REM intensity
how do you describe treatment approach to MDD?
DONT FORGET THIS PHRASE:
“MDD is a clinically heterogenous group of conditions that respond variably to a diverse group of interventions”
is there a one size fits all tx for depression
no
what treatment approaches may be considered when treating MDD
pharmacological
psychological
complementary and alternative medicine
neurostimulation
exercise treatments
what treatment should be offered to a patient with depression first, when possible?
psychotherapy
what is the recovery rate for those people treated with medication monotherapy
about 30%
what are two types of psychotherapy that provide strong protection from relapse following treatment discontinuation
IPT and CBT
why should psychotherapy be offered first whenever possible to patients with depression
both CBT and IPT provide stronger protection from relapse following tx discontinuation compared to medication
is depression placebo-sensitive
yes–> depression is a highly placebo sensitive condition
placebo response rates can be anywhere from 30-40%
what % of people have full remission of depressive symptoms within 12 months with NO treatment
about 50% of people
what is a book patients can buy to pursue psychotherapeutic principles on their own
mind over mood
is CBT effective in severe depression
can be as effective as meds in severe depression
(CBT is effective for mild, moderate and severe depression)
list the three first line psychotherapy treatment for acute depression
CBT
IPT
behavioural activation
what treatment is recommended for those with sub-threshold depression symptoms or mild depression
computerized CBT or guided self help
what should you do if your patient does not improve on antidepressant pharmacotherapy at the 2-4 week mark
dose should be optimized (instead of switching)
what should you do if your patient has poor response to initial antidepressant past the 4 week point
consider switching to another antidepressant if:
1. it is the first antidepressant trial
- if there are poorly tolerated side effects to the initial antidepressant
- if there is no response (less than 25% improvement) to the initial antidepressant
- there is more time to wait for a response (less severe, less functional impairment)
or
- if the patient prefers to switch
list 7 antidepressant medications that have been found to be more efficacious and better tolerated based on meta-analyses
escitalopram
venlafaxine
mirtazapine
paroxetine
vortioxetine
agomelatine + amitriptyline combo
how long should someone remain on antidepressant pharmacotherapy
for 6-9 months after remission of symptoms
how long should someone remain on antidepressant pharmacotherapy if they have risk factors for recurrence
2 years or more after achieveing remission of symptoms
list risk factors for recurrence of depression
frequent and/or recurrent episodes
severe episodes (i.e with psychosis, severe impairment, suicidality)
chronic episodes
presence of comorbid psych disorders or other medical conditions
presence of residual symptoms
difficult to treat episodes
how might availability of psychotherapeutic interventions affect length of antidepressant treatment
there is evidence to suggest that antidepressants can be successfully discontinued when concurrent preventative cognitive therapy (PCT) or mindfulness based cognitive therapy (MBCT) is offered
when should you consider switching completely to another antidepressant medication
consider switching to another antidepressant if:
1. it is the first antidepressant trial
- if there are poorly tolerated side effects to the initial antidepressant
- if there is no response (less than 25% improvement) to the initial antidepressant
- there is more time to wait for a response (less severe, less functional impairment)
or
- if the patient prefers to switch
when should you consider ADDING and adjunctive medication to antidepressant pharmacotherapy
- when there have been 2 or more antidepressant trials with poor response
- if the initial antidepressant is well tolerated
- if there is partial response (i.e more than 25% improvement to the initial med)
- if there are specific residual symptoms or side effects to the initial antidepressant that can be targeted
- if there is less time to wait for a response (i.e more severe, more functional impairment)
- or if the patient prefers to add on another med
in which cases of depression would you consider ECT
in cases of severe, treatment refractory depression
in cases where there are significant safety concerns
*ECT is a SAFE and RAPID treatment in these instances
when is light therapy considered an indication for depression treatment
indicated in depression with a seasonal affective subtype
can also be used for mild to moderate depression (even without seasonal subtype)
when is light therapy considered an indication for depression treatment
indicated in depression with a seasonal affective subtype
can also be used for mild to moderate depression (even without seasonal subtype)
is adding exercise to treatment for depression supported in the literature
yes
what type of diet is recommended in depression
healthy diet–> especially mediterranean diet
avoid pro-inflammatory diet
offers protection against depression in observational studies
