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4. Mood Disorders > Major Depressive Disorder > Flashcards

Major Depressive Disorder Flashcards

1
Q

criterion A of MDD

A

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

  1. 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
  2. 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)
  3. 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
  4. insomnia or hypersomnia nearly every day
  5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feeling of restlessness or being slowed down)
  6. fatigue or loss of energy nearly every day
  7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self reproach or guilt about being sick)
  8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
  9. 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
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2
Q

criterion B for MDD

A

the symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning

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3
Q

criterion C for MDD

A

the episode is not attributable to the physiological effects of a substance or another medical condition

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4
Q

what qualifies as a “major depressive episode”

A

criteria A-C in the DSM for MDD

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5
Q

criterion D for MDD

A

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

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6
Q

criterion E for MDD

A

there has never been a manic episode or hypomanic episode

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7
Q

what is considered a “significant weight loss”

A

change of more than 5% of body weight

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8
Q

list the possible specifiers with MDD

A

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

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9
Q

what is a common presenting complaint that ends up being MDD

A

insomnia or fatigue

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10
Q

what type of insomnia is most common with MDD

A

middle insomnia or terminal insomnia

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11
Q

how does being depressed affect an individuals mortality when entering a nursing home

A

depressed individuals admitted to nursing homes have a markedly increased likelihood of death in the first year

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12
Q

what neuroendocrinological correlate of depression has been the most extensively investigated abnormality?

A

hypothalamic-pituitary-adrenal axis hyperactivity

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13
Q

in the case of depression, HPA axis hyperactivity is associated with that features

A

melancholia

psychotic features

risks fo eventual suicide

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14
Q

fMRI studies of those with depression have provided evidence for functional abnormalities in what neural systems

A

those supporting emotion processing, reward seeking and emotion regulation

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15
Q

what is the 12 month prevalence of MDD in the USA

A

about 7%

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16
Q

how does prevalence of depression differ between younger cohorts and older cohorts

A

the prevalence in 18-29 year olds is 3x higher than in individuals over 60

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17
Q

what is the gender difference in terms of rates of depression

A

1.5-3x higher in females than males beginning in early adolescence

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18
Q

when does incidence of depression peak in the USA

A

in age 20s

(first onset late in life is not uncommon; can first appear at any age though likelihood increases markedly with puberty)

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19
Q

what is the course of MDD

A

quite variable

some people rarely, if ever, experience remission

others experience many years with few or no symptoms between discrete episodes

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20
Q

chronicity od depressive symptoms substantially increases likelihood of what?

A

underlying personality, anxiety and substance use disorders

*also decreases the likelihood that treatment will be followed by full symptom remission

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21
Q

what is considered “remission” in terms of depressive illness

A

a period of two or more months with no symptoms or only one of two symptoms to no more than a mild degree

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22
Q

when does recovery typically begin for most people with MDD

A

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

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23
Q

list features of MDD associated with lower recovery rates

A

current episode duration longer that a few months

psychotic features

prominent anxiety

personality disorders

symptoms severity

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24
Q

name a “powerful” predictor of recurrence of MDD according to the DSM

A

presence of even mild depressive symptoms during remission

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25
Q

list features that increase suspicion that the person will eventually go on to be diagnosed with bipolar illness rather than unipolar depressive illness

A

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

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26
Q

does gender seem to affect the phenomenology, course, or treatment response to MDD

A

no (despite the differences in prevalence between genders)

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27
Q

what symptoms of MDD are more common in younger people

A

hypersomnia and hyperphagia

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28
Q

what symptoms of MDD are more common in older individuals

A

melancholic features

particularly psychomotor disturbances

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29
Q

how does suicide risk in MDD change with age

A

likelihood of suicide attempt lessens in middle and late life, BUT risk of completed suicide does not

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30
Q

what is a temperamental risk factor for developing MDD

A

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

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31
Q

name environmental risk factors for MDD

A

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

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32
Q

having a first degree family member with MDD increases risk for developing MDD by how much?

A

risk is 2-4x higher than general population

*relative risks appear to be higher for early onset and recurrent forms

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33
Q

what is the heritability of MDD

A

about 40%

the personality trait of neuroticism accounts for a substantial portion of this genetic liability

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34
Q

how do other psych conditions affect the risk of developing depression

A

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

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35
Q

what are some of the most commonly comorbid/precipitating psychiatric conditions with MDD

A

anxiety

borderline PD

substance use

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36
Q

how does medical illness affect risk and course of MDD

A

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

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37
Q

among criterion A symptoms, which symptoms are most uniformly reported across cultures

A

insomnia and loss of energy

38
Q

how does suicide risk in MDD differ by gender

A

risk of suicide attempt is higher in women but risk of completion is lower (compared to males)

39
Q

what is the most consistently described risk factor for suicide in MDD

A

past history of suicide attempts or threats

*BUT most completed suicides are NOT preceded by unsuccessful attempts

40
Q

list risk factors for increased risk for completed suicide

A

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 *

41
Q

what is the functional impact of MDD

A

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

42
Q

ddx MDD

A

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

43
Q

where do symptoms of ADHD and MDD Overlap

A

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

44
Q

how do you distinguish adjustment disorder with depressed mood from MDD

A

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

45
Q

what is the annual prevalence of a depressive episode in canada

A

4.7%

46
Q

what is the lifetime prevalence of a depressive episode in canada

A

11.3%

47
Q

what are the hypothesis for why women have a 2-3x higher rate of being diagnosed with depression than males

A

hormonal differences

effects of childbirth

differing psychosocial stressors for men and women

increased seeking of clinical care in women

behavioural models of learned helplessness

48
Q

what % of depressive episodes are brief and resolve within 3 months

A

about 50%

49
Q

list risk factors for chronic depressive symptoms or recurrence

A

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

50
Q

MDD is asscociated with what chronic medical conditions

A

heart disease

arthritis

back pain

COPD

asthma

HTN

migraine

51
Q

is there a correlation between depression and socioeconomic status

A

no

52
Q

what is the estimated heritability of MDD

A

about 40%

53
Q

why does atypical depression tend to result in more disability than melancholic depression

A

because individuals tend to have more interpersonal difficulties

54
Q

are atypical depression, borderline PD, bipolar II and cyclothymic disorder overlapping conditions?

A

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

55
Q

what are the geriatric giants

A

depression

dementia

delirium

56
Q

define seasonal affective disorder (MDD with seasonal onset)

A

subtype of depression with annual onset between sept-nov and remission spontaneously in april-may

57
Q

what medication has been shown to be preventative in SAD

A

buproprion–> if started prior to the winter season

58
Q

list nonmodifiable risk factors for suicide

A

older men

past suicide attempt

hx of self harm behaviour

being a sexual minority

family history of suicide

history of legal problems

59
Q

list modifiable risk factors for suicide with regard to symptoms and life events

A

active SI

hopelessness

psychotic symptoms

anxiety

impulsivity

stressful life events like financial stress and victimization

60
Q

list modifiable risk factors for suicide related to comorbid conditions

A

SUDs–especially AUD

PTSD

comorbid personality disorders

chronic painful medical conditions

cancer

61
Q

list common rating scales for depression

A

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

62
Q

name two well replicated findings from neuroimaging in MDD

A

amygdala hyperactivity

volumetric changes

63
Q

what blood work can be useful in assessing depression

A

CBC

iron studies

liver function tests

TSH

vitamin B12

vitamin D

serum zinc

calcium

magnesium

phosphate

64
Q

what changes in sleep are associated with depression

A

decreased sleep efficiency

decreased slow wave sleep (decreased stage 3 and 4 sleep time)

shorter/decreased REM latency

increased REM intensity

65
Q

how do you describe treatment approach to MDD?

A

DONT FORGET THIS PHRASE:

“MDD is a clinically heterogenous group of conditions that respond variably to a diverse group of interventions”

66
Q

is there a one size fits all tx for depression

A

no

67
Q

what treatment approaches may be considered when treating MDD

A

pharmacological

psychological

complementary and alternative medicine

neurostimulation

exercise treatments

68
Q

what treatment should be offered to a patient with depression first, when possible?

A

psychotherapy

69
Q

what is the recovery rate for those people treated with medication monotherapy

A

about 30%

70
Q

what are two types of psychotherapy that provide strong protection from relapse following treatment discontinuation

A

IPT and CBT

71
Q

why should psychotherapy be offered first whenever possible to patients with depression

A

both CBT and IPT provide stronger protection from relapse following tx discontinuation compared to medication

72
Q

is depression placebo-sensitive

A

yes–> depression is a highly placebo sensitive condition

placebo response rates can be anywhere from 30-40%

73
Q

what % of people have full remission of depressive symptoms within 12 months with NO treatment

A

about 50% of people

74
Q

what is a book patients can buy to pursue psychotherapeutic principles on their own

A

mind over mood

75
Q

is CBT effective in severe depression

A

can be as effective as meds in severe depression

(CBT is effective for mild, moderate and severe depression)

76
Q

list the three first line psychotherapy treatment for acute depression

A

CBT

IPT

behavioural activation

77
Q

what treatment is recommended for those with sub-threshold depression symptoms or mild depression

A

computerized CBT or guided self help

78
Q

what should you do if your patient does not improve on antidepressant pharmacotherapy at the 2-4 week mark

A

dose should be optimized (instead of switching)

79
Q

what should you do if your patient has poor response to initial antidepressant past the 4 week point

A

consider switching to another antidepressant if:
1. it is the first antidepressant trial

  1. if there are poorly tolerated side effects to the initial antidepressant
  2. if there is no response (less than 25% improvement) to the initial antidepressant
  3. there is more time to wait for a response (less severe, less functional impairment)

or

  1. if the patient prefers to switch
80
Q

list 7 antidepressant medications that have been found to be more efficacious and better tolerated based on meta-analyses

A

escitalopram

venlafaxine

mirtazapine

paroxetine

vortioxetine

agomelatine + amitriptyline combo

81
Q

how long should someone remain on antidepressant pharmacotherapy

A

for 6-9 months after remission of symptoms

82
Q

how long should someone remain on antidepressant pharmacotherapy if they have risk factors for recurrence

A

2 years or more after achieveing remission of symptoms

83
Q

list risk factors for recurrence of depression

A

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

84
Q

how might availability of psychotherapeutic interventions affect length of antidepressant treatment

A

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

85
Q

when should you consider switching completely to another antidepressant medication

A

consider switching to another antidepressant if:
1. it is the first antidepressant trial

  1. if there are poorly tolerated side effects to the initial antidepressant
  2. if there is no response (less than 25% improvement) to the initial antidepressant
  3. there is more time to wait for a response (less severe, less functional impairment)

or

  1. if the patient prefers to switch
86
Q

when should you consider ADDING and adjunctive medication to antidepressant pharmacotherapy

A
  1. when there have been 2 or more antidepressant trials with poor response
  2. if the initial antidepressant is well tolerated
  3. if there is partial response (i.e more than 25% improvement to the initial med)
  4. if there are specific residual symptoms or side effects to the initial antidepressant that can be targeted
  5. if there is less time to wait for a response (i.e more severe, more functional impairment)
  6. or if the patient prefers to add on another med
87
Q

in which cases of depression would you consider ECT

A

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

88
Q

when is light therapy considered an indication for depression treatment

A

indicated in depression with a seasonal affective subtype

can also be used for mild to moderate depression (even without seasonal subtype)

88
Q

when is light therapy considered an indication for depression treatment

A

indicated in depression with a seasonal affective subtype

can also be used for mild to moderate depression (even without seasonal subtype)

89
Q

is adding exercise to treatment for depression supported in the literature

A

yes

90
Q

what type of diet is recommended in depression

A

healthy diet–> especially mediterranean diet

avoid pro-inflammatory diet

offers protection against depression in observational studies

4. Mood Disorders (17 decks)

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