Depressive Disorder - PSR

Depressive Disorders and Bipolar Disorders

• DSM IV-TR combined the Depressive Disorders and Bipolar Disorders into one category, Mood Disorders assuming these disorders were on a Spectrum of Mood Disturbance.

• This is not true in DSM 5 or 5-TR.

• Mood disorder is no longer a DSM diagnosis.

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.

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

• 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

• decreased sex drive,

• avoiding other people,

• overwhelming feelings of sadness or grief,

• feeling unreasonably guilty,

• loss of energy, feeling very tired,

• thoughts of death or suicide.

Signs of 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.

Older persons and Depression

• 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 self 

  • low self-esteem

  • feelings of inferiority

  • distorted beliefs about achievement

  • self-blaming & guilt

• Negative view of future

  • hopeless of future

  • future actions ineffective

  • belief that negative future is unable to be changed by action

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 self

  • erectile difficulty

  • lack of arousal

Other Physical Complaints

• Headache

• Backaches

• Gastrointestinal symptoms

• Yeast infections

• Upper respiratory infections

• Shoulder aches

• Accidents

Beck’s Triad

The APA note that CBT is based on a number of beliefs, including the following:

• Unhelpful ways that people think can lead to psychological problems.

• If people learn unhelpful behavior, this, too, can lead to psychological issues.

• People can learn more beneficial ways of thinking and behaving.

• New habits can relieve symptoms of mental and physical conditions and allow people to act in better ways.

DSM 5: Depressive Disorders

• Disruptive Mood Dysregulation Disorder

• Major Depressive Disorder

• Persistent Depressive Disorder

• Premenstrual Dysphoric Disorder

• Substance/medication-induced Depressive Disorder

• Depressive Disorder due to another medical condition

• Other specified Depressive Disorder

• Unspecified Depressive Disorder

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 is 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 (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.

• 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.

  • Not made before six years old or after 18 years

  • 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

• Criteria

  • 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.

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

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

  • E. There has never been a manic or hypomanic episode

• Rule out Mixed Episode

• Rule out Substance Disorder effects

• Rule out General Medical Condition

• Specifiers

  • 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

  • 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.

MDD Prevalence

• 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

• 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

• 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:

  • 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

  • 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

  • Specify level of severity

    • Mild:  Two symptoms

    • Moderate: Three symptoms

    • Moderate-severe: Four to five symptoms

    • Severe: Four to five symptoms and motor agitation

Premenstrual Dysphoric Disorder (N94.3)

• Criteria

  • 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: Criteria B

    • 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: Criteria C

    • 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

• Specify

  • Mild

  • Moderate

  • Severe

  • Onset during intoxication

  • Onset during withdrawal

Substances that induce depressive disorders

• Alcohol

• Phencyclidine

• Other hallucinogens

• Inhalants

• Opioids

• Sedative, hypnotics, anxiolytics

• Amphetamine

• Cocaine

• Other

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.

• 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)

Other Specified Depressive Disorders & Unspecified Depressive Disorder

• Recurrent brief depression

• Short-duration depressive episode

• Depressive episode with insufficient symptoms

• (F32.8) & (F32.9)

• 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

• Specifiers

  • 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

  • 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

  • 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 for Depression

• 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

• 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

• 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

• 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%

• Specify if

  • Partial or full remission

  • Level of severity

    • Mild

    • Moderate

    • Severe

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.

• 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

• 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 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

• 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 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.

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. 

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

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 is the:

    • 11^th leading cause of death overall in America (CDC)

    • 3^rd 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. 

Suicide Rates by Age

• In 2016, the highest suicide rate (19.7) was among adults between 45 and 54 years of age.

• The second highest rate (19.0) occurred in those 85 years or older.

• Younger groups have had consistently lower suicide rates than middle-aged and older adults.

• In 2016, adolescents and young adults aged 15 to 24 had a suicide rate of 12.5.