Depressive Disorders

Depressive Disorders in DSM 5

From APA paper Highlights of Changes from DSM IV-TR to DSM 5:

DSM 5 contains several new depressive disorders, including

disruptive mood dysregulation disorder and

premenstrual dysphoric disorder.

To address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dys-control.

Depressive Disorders in DSM 5 Continued

Based on strong scientific evidence, premenstrual dysphoric disorder has been moved from DSM-IV Appendix B, "Criteria Sets and Axes Provided for Further Study," to the main body of DSM-5.

Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way.

What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder

Facts from Washington University School of Medicine

Of the estimated 17.5 million Americans who are affected by some form of depression, 9.2 million have major or clinical depression

Two-thirds of people suffering from depression do not seek necessary treatment

80% of all people with clinical depression who have received treatment significantly improve their lives

The economic cost of depression is estimated at $30.4 billion a year but the cost in human suffering cannot be estimated

Women experience depression about twice as often as men

By the year 2020, the World Health Organization (WHO) estimates that depression will be the number two cause of "lost years of healthy life" worldwide

Major Depression is 1.5-3.0 times more common among first-degree biological relatives of those with the disorder than among the general population

NIH Statistics

Depressive disorders NIH Statistics on Depressive Disorders

Often co-occur with anxiety disorders and substance abuse.

Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44 & affects approximately 14.8 million American adults

Signs of Depressive Illness

feeling worthless, helpless or hopeless,

sleeping more or less than usual,

eating more or less than usual,

having difficulty concentrating or making decisions,

loss of interest in taking part in activities

Facts about depression

Most widespread psychological disorder

25 to 30% of college students have symptoms of depression

Study showed 20 percent of all students surveyed thought about suicide,

9 percent had attempted suicide,

20 percent injured themselves.

Reinberg: September 10, 2018

Older persons

Between 1 and 2 percent of people over age 65 living in the community, i.e., not living in nursing homes or other institutions, suffer from major depression and about 2 percent have dysthymia (persistent depressive disorder in DSM 5-TR)

Depressive Symptoms

Disorders of

Mood or emotion

Thought or cognition

Motivation

Physical or somatic symptoms

Emotional symptoms

Sadness

Worse in morning

Anxiety

Anhedonia

Numbing

Flat affect

Dullness

Irritability

Cognitive Symptoms

Negative view of future

hopeless of future

future actions ineffective

belief that negative future is unable to be changed by action

low self-esteem

feelings of inferiority

distorted beliefs about achievement

self-blaming & guilt

Motivational Symptoms

Lack of response initiation

Psychomotor retardation

Inability to make decisions

Difficulty choosing alternatives

Somatic symptoms

Loss of appetite

Weight loss

moderate to severe depression

Sleep disturbance

normally in early morning awakening

Weakness & fatigue

Loss interest in sex

erectile difficulty

lack of arousal

Other Physical Complaints

Headache

Backaches

Gastrointestinal symptoms

Yeast infections

Upper respiratory infections

Shoulder aches

Accidents

Beck's Triad

DSM 5-TR: Depressive Disorders

Common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's ability to function. What differs is duration, timing, or presumed etiology.

DMDD was intended to

capture children with frequent temper tantrums and irritability, in part to prevent the overdiagnosis of bipolar disorder in youth with prepubertal onset of these symptoms. Often, such presentations result in a diagnosis of bipolar disorder or oppositional defiant disorder

Disruptive Mood Dysregulation Disorder 296.99 (F34.8)

The core feature is chronic, severe persistent irritability. The severe irritability has two features (a) frequent temper outbursts due to frustration, occurring three or more times per week for a year in two contexts, (b) chronic persistent irritable angry mood present between temper outbursts. The irritable mood must be characteristic of the child most of the day, every day, and noticed by those in the environment.

Disruptive Mood Dysregulation Disorder (F34.8) criteria

A. Severe temper outbursts verbally or behaviorally at least three times a week

B. Temper outbursts inconsistent with developmental level

C. Temper outbursts occur, on average, three or more times per week.

D. Mood between outbursts is persistently irritable and angry most of the day, nearly every day and observed by others.

E. Criteria A-D are present for 12 months and in that time individual not had 3 months without symptoms

F. Criteria A-D present in two of three settings and severe in one.

-G. Not made before six years old or after 18 years

-H. Symptoms begin before age ten

I. Never been period more than day when criteria not met

J. Do not occur exclusively with MDD or explained by other mental disorder

Cannot coexist with ODD, Intermittent Explosive Disorder, or Bipolar Disorder, but can with ADHD, MDD, CD and Substance Use Disorder

If DMDD, no ODD

Ever manic episode, no DMDD

Prevalence & Course-DMDD

Prevalence unclear, must have onset before age 10. Not be applied to children younger than 6 years.

Only use with clients 6-18 years.

Male predominance of condition.

Conversion from sever, non-episodic irritability to bipolar disorder are low.

Children diagnosed with DMDD more likely to develop unipolar depression and/or anxiety disorder.

Major Depressive Disorder

-Symptoms must be present every day to be considered present, with the exception of weight change and suicidal ideation with depressed mood most of day, every day

-At least one of these symptoms present (2 weeks)

depressed mood

loss of interest or pleasure

Major Depressive Episode

A. Five or more of following symptoms are present during the same 2-week period and represent a change in function— (Criteria A)

Five or more

Depressed mood most of day, nearly every day or observation

Children or adolescents may be irritable mood

Marked diminished pleasure in activities nearly every day

Significant weight loss or weight gain (5% month), decreased or increased appetite nearly every day

Children, failure to make expected weight gain

Insomnia or hypersomnia, nearly every day

Psychomotor agitation or retardation every day

Fatigue or loss of energy nearly every day

Feelings of worthlessness or excessive/inappropriate guilt

Diminished ability to concentrate, think or indecisive

Recurrent thoughts of death, suicidal ideation (no plan), or attempt or plan for suicide.

Symptoms cause clinically significant distress or impairment in social, occupational or other function (Criteria B)

Not attributable to effects of a substance or medical disorder (Criteria C)

E. There has never been a manic or hypomanic episode

Major Depressive Disorder- must rule out

Rule out Mixed Episode

Rule out Substance Disorder effects

Rule out General Medical Condition

Specifiers of MDD

Recurrent episode must have interval of 2 months

Mild

Few if any symptoms in excess of those required to make the diagnosis are present, intensity is distressing, but manageable, minor impairment in functioning

Single episode---(F32.0)

Recurrent--------(F33.0)

Moderate

In between mild and severe

Single episode--- (F32.1)

Recurrent---------(F33.1)

Severe

Symptoms in excess of what is required for diagnosis, intensity is seriously distressing, unmanageable, symptoms markedly interfere in function

Single episode----- (F32.2)

Recurrent---------- (F33.2)

Specify MDD by

With psychotic features

Mood congruent: inadequacy, guilt, disease, death

Mood incongruent: does not involve depressive themes

Single episode---(F32.3)

Recurrent--------(F33.3)

In partial remission

Symptoms present, but full criteria not met, or 2 months without sig. symptoms

Single episode---(F32.4)

Recurrent--------(F33.41)

In full remission

Past 2 months no signs or symptoms

Single Episode---(F32.5)

Recurrent---------(F33.42)

Unspecified

Features of MDD

MDD associated with high mortality, mostly by suicide.

Depressed individuals admitted to nursing homes die in first year.

Molecular studies indicate genetic variants (neurotrophic factors and pro-inflammatory cytokines).

Abnormalities in neural systems supporting emotional processing, reward seeking, and emotional regulation in adults occur in persons with MDD.

Prevalence- MDD

•12-month prevalence at 7% with differences by age group. (higher in 18-29 year olds)

•Higher prevalence in women, peaks in adolescence & stabilizes.

•More atypical symptoms in women than men & more often in non-Hispanic Whites.

•Peak onset in the 20s with variable course.

Persistent Depressive Disorder (F34.1)

This disorder represents a consolidation of DSM IV-TR defined chronic major depressive disorder and dysthymic disorder

Persistent Depressive Disorder (F34.1) Criteria

A. Depressed mood most of day for more days than not for at least 2 years.

Children or adolescents irritable mood and duration of one year

B. Presence depressed of

Poor appetite or overeating

Insomnia or hypersomnia

Low energy or fatigue

Low self-esteem

Poor concentration

Feelings of hopelessness

C. During the 2-year period never been without A and B symptoms for more than 2 months (1 year children)

D. Criteria for major depressive disorder may be continuously present for 2 years

E. No manic or hypomanic episodes

F. No cyclothymia, schizoaffective or other schizophrenia spectrum disorders

G. Not a substance or medical condition

H. Distress in social, occupational or other areas of functioning.

During the 2-year period never been without A and B symptoms for more than 2 months

Persistent Depressive Disorder (F34.1) specifiers

Partial remission (see MDD)

In Full remission (see MDD)

Early Onset (before 21)

Late onset (after 21)

Mild

Few if any symptoms in excess of those required to make the diagnosis are present, intensity is distressing, but manageable, minor impairment in functioning

Moderate

Between mild and severe

Severe

Symptoms in excess of what is required for diagnosis, intensity is seriously distressing, unmanageable, symptoms markedly interfere in function

Specify Persistent Depressive Disorder (F34.1) by

—Specify:

—With pure dysthymic syndrome

—Full criteria for major depressive episode have not been met in preceding 2 years

—With persistent major depressive episode

—Full criteria for major depressive episode have been met through out preceding 2 years

—With intermittent major depressive episode

—Full criteria for major depressive episode been met currently, but been periods of 8 weeks in the preceding 2 years with symptoms below threshold for major depressive episode

—With intermittent major depressive episodes, without current episode

—Full criteria for major depressive episode are not currently met, but one or more major depressive episode in preceding 2 years

Only specifiers for PDD

Anxious distress:

Two of following

Keyed up or tense

Unusually restless

Difficulty concentrating because of worry

Fear of something awful happening

Feeling loss of control

Specify level of severity

Mild: Two symptoms

Moderate: Three symptoms

Moderate-severe: Four to five symptoms

Severe: Four to five symptoms and motor agitation

Atypical features:

Mood reactivity

Mood brightens to positive events

Two following

Weight gain or increased appetite

Hypersomnia

Leaden paralysis

Heavy, leaden feelings in extremities

Reaction sensitivity

History of rejection sensitivity

Premenstrual Dysphoric Disorder (N94.3)

A. In majority of menstrual cycles, at least five symptoms present in final week before onset of menses, improve in a few days after onset of menses, minimal or absent in week post menses

B. One or more of following:

marked emotional liability

Marked irritability or anger or increased interpersonal conflicts

Marked depressed mood, feelings of hopelessness, self-deprecation

Marked anxiety, tension, feelings of being on edge or keyed up

C. One or more of following to reach a total of 5 symptoms when combined with above:

Decreased interest in usual activities

Subjective difficulty in concentration

Lethargy, fatigability, lack of energy

Marked change in appetite, overeating, or food cravings

Insomnia or hypersomnia

Overwhelmed or out of control feelings

Breast tenderness, swelling, joint/muscle pain, bloating, weight gain

Symptoms A-C must be met most menstrual cycles that occurred in preceding year

D. Symptoms of significant distress or interference in functioning

E. Not just exacerbation of another disorder

F. Criterion A should be confirmed by daily ratings during two cycles

G. Not substance abuse or medical condition

Substance/medication-induced Depressive Disorder

A. Persistent disturbance in mood

B. Evidence from history of the following

1. Evidence of symptoms developing after intoxication, withdrawal or exposure to medication

2.Medication can produce those symptoms

C. Not better explained by depressive disorder not substance induced

D. Does not occur in delirium

E. Causes clinically significant distress

Diagnosis made instead of diagnosis of substance intoxication or withdrawal only when symptoms predominate and are severe

Substances induce depressive disorders

Alcohol

Phencyclidine

Other hallucinogens

Inhalants

Opioids

Sedative, hypnotics, anxiolytics

Amphetamine

Cocaine

Other

Specify:

Mild

Moderate

Severe

Onset during intoxication

Onset during withdrawal

Depressive Disorder Due to another Medical Condition

Essential feature is prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all activities that is due to the direct physiological effects of another medical condition.

Depressive Disorder Due to another Medical Condition 293.83 criteria

Evidence from medical results depressive disorder is result of a medical condition

Not explained by another mental disorder

Not part of a delirium

Causes distress and impairment

Specify

With depressive features(F06.31)

With major depressive -like episode (F06.32)

With mixed features (F06.34)

Recurrent brief depression

Concurrent presence of depressed mood and four other symptoms of depression for 2-13 days one per month, not menstrual cycle for 12 months. No other criteria met

Short-duration depressive episode (4-13 days)

Depressed affect and 4 of the 8 other symptoms of major depressive episode, distress for more than 4 days, but not more than 14. No other criteria met

Depressive episode with insufficient symptoms

Depressed affect and one of the 8 symptoms for 2 weeks. No other criteria met

Specifiers for Depressive Disorders with anxious distress

Two of following

Keyed up or tense

Unusually restless

Difficulty concentrating because of worry

Fear of something awful happening

Feeling loss of control

Specify level of severity

Mild: Two symptoms

Moderate: Three symptoms

Moderate-severe: Four to five symptoms

Severe: Four to five symptoms and motor agitation

Specifies for Depressive Disorders with mixed features

At least three present nearly every day

Elevated, expansive mood

Inflated self-esteem or grandiosity

More talkative than usual or pressured speech

Flight of ideas or racing thoughts

Increased energy or goal directed activity

Increased involvement in activities with painful consequences

Decreased need for sleep, yet rested

Mixed symptoms observed by others

If meet criteria for mania or hypomania, bipolar disorder

Not substance or medical disorder

Specifiers Depressive Disorders with melancholic features

One of following:

Loss of pleasure

Lack of reactivity to pleasure

Three or more of following

distinct quality of depressed mood

depression worse in morning

early morning awakening

marked psychomotor retardation or agitation

significant anorexia

excessive or inappropriate guilt

Near complete absence of pleasure. Psychomotor changes and distinct quality of mood differs from non-melancholic depressive episode

Specifiers Depressive Disorders with atypical features

Mood reactivity

Mood brightens to positive events

Two following

Weight gain or increased appetite

Hypersomnia

Leaden paralysis

Heavy, leaden feelings in extremities

Reaction sensitivity

History of rejection sensitivity

Specifiers Depressive Disorders with psychotic features

Delusions and hallucinations present

Mood congruent psychotic features

Content of delusions/hallucination are consistent with the depressive themes or manic themes

Mood incongruent psychotic features

Content of delusions/hallucination are not consistent with the depressive themes or manic themes

Specifiers Depressive Disorders with seasonal pattern

Seasonal pattern of at least one type of episode

Time of the year and onset of mania, hypomania, depressive episode

Full remission when seasons change

Last 2 years, temporal relationship to remission

Seasonal mania or depression outnumber any other mania or depression

Specifiers depressive disorders with peripartum onset

Onset during pregnancy or postpartum

Present with or without psychotic features

Infanticide most often associated with postpartum psychotic episodes

Once woman has had postpartum episode with psychotic features recurrence at 30 to 50%

Childhood Mood Disorders

Seven to 14 percent of children will experience an episode of major depression before the age of 15. Twenty to 30 percent of adult bipolar patients report having their first episode before the age of 20.

Out of 100,000 adolescents, 2,000 to 3,000 will have a mood disorders, of which eight to 10 will commit suicide.

Research indicates that depression onset is occurring earlier in life today than in past decades. (NIH)

Early-onset depression often persists, recurs, and continues into adulthood. Depression in youth may also predict more severe illness in adulthood. (NIH)

Children in Depression

Somber, almost ill appearance.

Frequent complaints of physical problems for which no medical difficulties can be found.

Lack of bounce and enthusiasm characteristic of non-depressed peers.

Tearfulness for no little or no identifiable reason.

Depressed Children

Spontaneous irritability, not just when they do not get their way.

Frequent negative self-statements.

Self-injurious or self-destructive behaviors at times.

Anhedonia (i.e., experiencing little pleasure from things which most peers enjoy).

Elementary Child

Disruptive behavior.

Academic difficulties or declining school performance.

Frequent problems with peers.

Increased irritability and aggression compared to peers and to their own non-depressed state.

Suicidal threats & ideation

Anhedonia

Statements that they hate themselves and everything around them.

Sleeping too much.

Rapid, unpredictable emotional changes.

Physical complaints

Headaches

Stomach aches

Nausea

Vomiting

Adolescent Depression

About 20 percent of teens will experience teen depression before they reach adulthood.

Between 10 to 15 percent of teenagers have some symptoms of teen depression at any one time.

About 5 percent of teens are suffering from major depression at any one time

As many as 8.3 percent of teens suffer from depression for at least a year at a time,

Most teens with depression will suffer from more than one episode. 20 to 40 percent will have more than one episode within two years, and 70 percent will have more than one episode before adulthood. Episodes of teen depression generally last about 8 months.

Acting-out behavior (missing curfews, unusual defiance)

Appetite changes (usually a loss of appetite but sometimes an increase)

Criminal behavior (such as shoplifting)

Depressed or irritable mood

Difficulty concentrating

Difficulty making decisions

Episodes of memory loss

Adolescent depression continued

Excessive sleeping or daytime sleepiness

Excessively irresponsible behavior pattern

Excessive or inappropriate feelings of guilt

Failing relations with family and friends

Faltering school performance

Substance abuse or use

Temper (agitation)

Thoughts about suicide or obsessive fears or worries about death

Weight change

Loss of interest in activities

Persistent difficulty falling asleep or staying asleep

Plans to commit suicide or actual suicide attempt

Preoccupation with self

Reduced pleasure in daily activities

Adolescent Suicides

9 of 10 adolescents who suicide give warnings

Depression

Substance use & abuse

Withdrawal

Decreased activity & attention

Lack of concentration

Sleep & appetite change

Suicidal ideation

Verbal & written suicidal cues

Giving away possessions

Low feelings of self worth

Relationship breakup

Gender identity crises

Low grades

Drop in grades

Suicide in friends or relatives

Drugs most common implement of death

Guns most frequent method for completed suicide

Hanging second method

Differences in males & females

Males die 5X more often, women think about & attempt 3X more often

Older Adults with Depression

Recent NIMH studies show that 13 to 27 percent of older adults have subclinical depressions that do not meet the diagnostic criteria for major depression or dysthymia (persistent depressive disorder in DSM 5) but are associated with increased risk of major depression, physical disability, medical illness, and high use of health services.

Depression in Elderly (NAMI)

Depression in elderly people often goes untreated because many believe depression is a normal aging

Elderly people have challenges through loss, medical vulnerability and mortality of self and others.

Elderly people and families mistake symptoms of depression

Depression signs may be thought to be signs of:

dementia

Alzheimer's disease

arthritis

cancer

heart disease

Parkinson's disease

stroke

thyroid disorders

Depression in Elderly (NAMI) continued

Symptoms in older persons differ from symptoms in other populations.

Depression in older persons is at times characterized by:

memory problems

confusion

social withdrawal

loss of appetite

weight loss

vague complaints of pain

inability to sleep

irritability

delusions

hallucinations

-Older depressed individuals often have severe feelings of sadness, but these feelings frequently are not acknowledged or openly shown

-Sometimes, when asked if they are depressed, the answer is "no."

-Some general clues that someone may be experiencing depression are:

persistent and vague complaints

help-seeking

moving in a slower manner

demanding behavior

Suicide in Elderly

National Institute of Mental Health

Older Americans are disproportionately likely to die by suicide.

Of every 100,000 people ages 65 and older, 14.3 died by suicide in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population. 1

Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000

Suicide in Older Adults with Depression

Suicide is more common among the elderly than in any other age group. In studies of older adults who committed suicide, nearly all had major depression, typically a first episode, though very few had a substance abuse disorder.

Suicide among white males aged 85 and older was nearly six times the national U.S. rate (65 per 100,000 compared with 11 per 100,000) in 1996, the most recent year for which statistics are available.

American Association of Suicidology

The elderly made up 12.5% of the population; they accounted for almost 15.7% of all suicides.

The rate of suicide for the elderly for 2007 was 14.3 per 100,000.

There was one elderly suicide every 97 minutes. There were about 14.9 elderly suicides each day, resulting in 5,421 suicides in among those 65 and older.

Elderly white men were at the highest risk with a rate of approximately 31.1 suicides per 100,000 each year.

Suicide

From the Span USA website:

"More than 34,500 Americans die by suicide each year (CDC)

There is 1 suicide every 16 minutes and 89 suicides per day (CDC)

24% of the general population has considered suicide at some time in his/her life (Linehan et al., 1982)"

Suicide: A major public health problem

From the Span USA website

Suicide is the:- 11th leading cause of death overall in America (CDC)- 3rd leading cause of death for young Americans between the ages of 10-24 (CDC)- Each suicide produces at least six, and as many as hundreds of "survivors," or people left behind to grieve.