Week 5: Depressive Disorders

What is common among people who are depressed?

They say they are not depressed. Depression is an absence of feelings - misnomer

What can depression be?

A part of life, symptom of a disorder, a syndrome, a disorder, a misnomer, very culture bound and often other names - ataque de nervios, when it comes to diagnosis

What is a syndrome?

A set of concurrent things (such as emotions or actions) that usually form an identifiable pattern

How do we know depression when we see it?

Cognitive, affective, somatic

What are the depressive disorders?

Disruptive Mood Dysregulation Disorder 296.99 (F34.8), Major Depressive Disorder 296.2X (F33.X), Persistent Depressive Disorder (Dysthymia) 300.40 (F34.1), Premenstrual Dysphoric Disorder 625.4 (N94.3), Substance/Medication-Induced, Depressive Disorder 291.8X (F1X.X), Depressive Disorder Due to Another Medical Condition

What is Disruptive Mood Dysregulation Disorder 296.99 (F34.8)?

A relatively new diagnosis. Used with children and adolescents (Think about the word “disruptive.” We’re trying NOT to think about ODD, CD, BAD. Rule out ADHD and everything else. Refer to psych testing). These children are very likely to develop problems with depression or anxiety in adulthood.

What is the Disruptive Mood Dysregulation Disorder Prevailing pattern?

Relative uncommon in children. We would see the disorder in children who are going for services at a pediatric clinic. The overall 6-month to 1-year prevalence is between 2% and 5%.

What is the Disruptive Mood Dysregulation Disorder Differential Assessment?

The key characteristic is: (Chronic, severe, and persistent irritability in children older than 6. Between outbursts, the children show persistently irritable or angry moods, most of the day and nearly every day, that can be seen in various contexts by various people - not just parents and family). We would see: (Temper tantrums, Temper outbursts (3 or so times per week; often w/o the ability to be soothed), Persistently grouchy - All of which are out of proportion and go beyond the temper outbursts we would see among other children who do not have this, A sense of exaggerated self-esteem, Flight of ideas, Decreased need for sleep, Distractibility, Pressured speech). Not diagnosed before age 6 and after age 18

What is Major Depressive Disorder, 296.2X (F33.X)?

The big diagnosis! We would see: (“I feel like ____.” (affective) “I can’t concentrate at work.” (cognitive) “I can’t eat (somatic))).” The person’s reduced interest, energy, and motivation begin to adversely have an impact on their interpersonal life. The person often has difficulty making normal everyday decisions (should I shave or shower first? Should I clean or go get the mail?), loses interest in pleasurable activities, has difficulty sleeping, and/or shows decreased interest in sexual activities. The person is likely to be generally pessimistic and has little hope for themselves or their future. Self-care and hygiene may go unattended. Social isolation is common. The depressed mood is present most of the day and nearly every day. The individual reports feeling sad, empty, hopeless, helpless

What is important to bear in mind about depression?

Not all clients (especially children) can accurately describe how they feel. Presenting symptoms can vary greatly - (Some people may sleep all day long, others not sleep at all. Some people may lose weight, others may gain weight). Culture can play a large role in the expression of depression. Depression can occur as presenting features in a wide variety of other syndromes.

What is the Major Depressive Disorder Prevailing pattern?

Approximately 7% of the population over a 12-month period. The rates are for people between 18 and 29. Much higher (upwards to 3 times higher) in females than in males (women tend to internalize; males are more apt to self-medicate with drugs and alcohol, act out). The onset is often during adolescence and begins to worsen throughout the 20s.

What is the Major Depressive Disorder Differential assessment?

People with MDD don’t bounce back. Their experience of depression consumes their lives to the extent that nothing is interesting or fun. Although we would see the marked loss of ability to experience pleasure (anhedonia), we would likely see the presence of physical changes (vegetative features = somatic)!! - (These features are critical. They often serve as warning signals in the form of changes in sleep, energy, and appetite). We need to figure out if the individual has depression, or if the depression results from some other primary problem or related disorder. We may also see anxiety!!!

What is the Major Depressive Disorder Assessment?

The DSM tells us the person must have 5 or more of the following features for a period of 2 weeks and represent a change from the client’s earlier ways of coping: (Depressed mood most of the day, nearly every day. Markedly diminished or pleasure in most activities (anhedonia). Significant changes in weight (either gain or loss). Vegetative features such as insomnia or hypersomnia. Psychomotor agitation or retardation (hand wringing, restless pacing, slowness in activities such as walking or talking). Fatigue and/or loss of energy. Feelings of worthlessness or experiencing excessive guilt (perseverating on depression, feeling stuck). Inability to think or concentrate. Recurring thoughts of death or suicidal ideations).

What other things do we need to watch out for regarding depression and losing someone/something

Bereavement - Grief is healthy!! When we have a significant loss, we can experience depression. BUT!! we can tell the feelings of depression are a result of the loss – the feelings are not a result of something we can’t put our thumb on (with depression you don’t know what the cause is). Grief lasts as long as it lasts. The issue is if the person is moving forward. Is the person moving through grief stages?! Treat them with supportive counseling. If someone has depression in their 40s and it never showed up before, question that.

Why do we shy away from giving those who are grieving antidepressants?

They could cause a manic episode because bereavement is not depression.

How can we differentiate MDD from garden variety depression?

The depressed mood is not easily shaken off - (In severe cases, less than 35% of people with MDD recover. An average first episode of 4 to 9 months if not treated). Depression is severe enough to impair important areas of a person’s interpersonal functioning. Physical and cognitive symptoms!

What are MDD specifiers?

(9) With Anxious Distress, With Mixed Features, With Melancholic Features, With Atypical Features, With Psychotic Features, With Catatonia, With Peripartum Onset, With Seasonal Pattern, Remission

What is MDD With Anxious Distress?

at least 2 of the following 5 symptoms: Feeling tense, restless; unable to concentrate; Fearing something bad is going to happen; Feeling potentially out of control.

What is MDD With Mixed Features?

at least 3 of the following 7 symptoms: Elevated mood; inflated self-esteem or grandiosity; more talkative than usual; flight of ideas or fast-pace talking; increased energy; involvement in high-risk activities; decreased need for sleep. Looking a little bipolar.

What is MDD With Melancholic Features?

at least 1 of the following symptoms: Loss of pleasure or a lack of reactivity (the person doesn’t feel better even if something good happens to them); Then, 3 or more of the following 6 symptoms: depressed mood, depression that is usually worse in the morning; waking up early; agitation; weight loss; feeling excessively guilty

What is MDD With Atypical Features?

Mood reactivity or the person’s mood improves in response to positive events and 2 or more of the following 4 symptoms: significant weight gain or increase in appetite; hypersomnia or excessive daytime sleepiness; leaden paralysis or severe body exhaustion, particularly feeling that arms or legs are too heavy to move; and sensitivity to rejection.

What is MDD With Psychotic Features?

Delusions and/or hallucinations are present

What is MDD With Catatonia?

Applies if these features are present during most of the episode. Waxiness of the limbs.

What is MDD With Peripartum Onset?

Onset of mood symptoms occur during pregnancy or in the 4 weeks following delivery

What is MDD With Seasonal Pattern?

Dependent on the season of the year.

What is MDD Remission?

Seen as partial (symptoms of the previous MD episode are present, but full criteria are not met or the person has gone for less than 2 months without significant symptoms (or full remission (no symptoms present for at least 2 months).

In doing a MDD assessment, what are things we have to consider?

What are the individual’s particular symptoms? (Are the symptoms out of proportion to the precipitating event)? What is the duration and intensity of the depressive features? Is the individual’s mood “reactive” to changes in life? (Does the individual perk up when something good happens? - In MDD, this is unlikely to be the case). Is there a family history of MDD? In postpartum onset, pay particular attention because of the possible harm to the infant!

What is Persistent Depressive Disorder (Dysthymia) 300.40 (F34.1)?

Characterized by a relatively low-grade but chronic depression that often lasts for years. The symptoms are milder but remain relatively unchanged. (At times the symptoms are present for 20 to 30 years). Some have argued that the disorder is more of a personality disorder. (Was once called ‘depressive personality disorder’ and ‘depressive neurosis.’The chronic low mood is considered ‘normal).’

What is the Persistent Depressive Disorder Prevailing pattern?

The prevalence is somewhere around 0.5%

What is the Persistent Depressive Disorder Differential assessment?

Look for a depressed mood that lasts at least 2 years or longer (or in children/adolescents, presenting with an irritable mood for 1 year), it evident more days than not, and is not severe enough for MDD. The person reports never having been without symptoms and must exhibit at least 2 or more of the following: (Increased or decreased appetite, Increased or decreased sleep, Low energy, Low self-esteem, Poor concentration or decision-making ability, Hopelessness). Typically has an insidious onset beginning in childhood or adolescent years. Less common to find symptoms emerging in adulthood. Onset before age 21 is considered “early onset.” This can happen after bereavement.

What is the Persistent Depressive Disorder Differential assessment for AFFECTIVE?

Look for family history of MDD. Is there a history of childhood psychiatric illness? A person’s mood is characterized as Eeyore: (brooding, complaining, sorrowful, gloomy, somber, nihilistic (sense of one’s existence as senseless and useless)). Get in there to see if there is ego-syntonic stuff going on.

Persistent Depressive Disorder Differential assessment for SOMATIC?

Fatigue, Lack of energy, Problems eating and sleeping

Persistent Depressive Disorder Differential assessment for COGNITIVE?

Difficulty thinking. Inability “to get off the dime.” (‘Should I shave or shower first)?’

What is Premenstrual Dysphoric Disorder 625.4 (N94.3)?

Associated primarily with the latter phase of the menstrual cycle. We see the same types of symptoms: (Affective, Somatic, Cognitive). The symptoms follow a predictable, cyclic pattern and end shortly after menstruation begins. On average, the symptoms last 6 days with the most intense symptoms happening in the 2 days before and through the day of the start of blood flow. We would likely see a disruption in personal relationships with the main symptoms being affective lability, depressed mood, and marked anxiety.

How many symptoms must you have for Premenstrual Dysphoric Disorder?

Must have at least 5 or more of the following symptoms over the past year: (Decreased interest in daily activities and relationships, Trouble concentrating, Tiredness or low energy, Change in appetite, Trouble sleeping or sleeping all the time, Feeling out of control Physical symptoms such as: (Bloating, Breast tenderness, Headaches, Joint or muscle pain)).

What is Substance/Medication-Induced Depressive Disorder 291.8X (F1X.X)?

Depression that is induced by alcohol or drugs. Most people take drugs to feel better, yet it is those same drugs in substance/medication-induced depressive disorder that make them feel worse. Check to see the person’s depression was not there before the use of alcohol, drugs, or medications thought to be responsible. The diagnosis is not considered if the person has a history of depression without substance use, or if the symptoms continue for more than a month after the person becomes abstinent from alcohol, drugs, or medication. We would see a great deal of distress. You can have alcohol use disorder and MDD at the same time if the alcohol did not bring about the depression.

What is Depressive Disorder Due to Another Medical Condition 293.83 (F06.XX)?

Certain medical conditions can lead to depression. Parkinson's, Huntington’s, or traumatic brain injury. We would see the consequences of the medical condition leading to depression. We must establish that the mood disturbance is related to the medical condition - the medical condition ame first! We must establish that the mood disturbance is related to the medical condition.

What is Other Specified Depressive Disorder 311.00 (F32.8)

These diagnoses are reserved for use when the person shows symptoms characteristic of a depressive disorder but does not meet the full criteria for any specific diagnostic class. The practitioner may indicate the specific reason for the criteria not being met, such as: (a recurrent brief depression, a short-duration depressive episode (lasting 4 to 13 days), or a depressive episode with insufficient symptoms.

What is Unspecified Depressive disorder?

It is assigned when the practitioner chooses not to specify when the criteria are not met, such as when a client is seen in an emergency room.

What are Myths associated with MDD and suicide?

Discussing suicide will lead a client to attempt suicide. Clients who threaten suicide will actually not do it and the practitioner does not need to take them seriously. Suicide is an irrational act. Individuals who commit suicide are insane. Suicide is an act that is always impulsive. Suicide is an inherited tendency that tends to run in families. Once a person thinks about suicide the thought does not go away. When the individual has attempted suicide and moves through it without self-harm, the danger is over.One sign of recovery for the person who was suicidal is when he/she shows generosity and shares personal possessions. Suicide happens without warning.

What are Questions to ask when considering a person’s risk for suicidal behavior?

Is they anything in the client’s history that generates the suicidal thoughts/behaviors? (Family history & ACE). What precipitated the client’s current crisis and is it different from other life events? (Current health factors), What does the client feel during the crisis? (Hopelessness, helplessness, despair) How does the client think about suicide? (Frightened by the thought of self-harm or welcoming of the thought)? What active (or planned) suicidal behaviors have occurred or are occurring? (Timing, availability of method, setting)

What is a mnemonic for identifying the key warning signs for suicide?

IS PATH WARM

What is I in IS PATH WARM?

Ideation - The person will often express thoughts of suicide of threaten suicide before an attempt

What is S in IS PATH WARM?

Substance Abuse - Is the person suddenly increasing substance use?

What is P in IS PATH WARM?

Purposelessness - Does the person start talking having no purpose of meaning in life?

What is first A in IS PATH WARM?

Anxiety - The person may show signs of anxiety or agitation

What is T in IS PATH WARM?

Trapped - The person may feel like there is “not way out” of their situation

What is H in IS PATH WARM?

Hopelessness - The feelings and situations will never change

What is W in IS PATH WARM?

Withdrawal - Does the person withdraw from family, friends, and even society?

What is the second A in IS PATH WARM?

Anger - The person may show signs of rage, uncontrolled anger, and/or seek revenge

What is R in IS PATH WARM?

Recklessness - The person may engage in high-risk activities

What is M in IS PATH WARM?

Mood changes - Dramatic changes in the person’s personality, mood, or behavior.

All antidepressants have the potential of contributing to what?

suicidality by lifting a person out of depression

What are Medications commonly associated with depressive disorders?

The first 2 to 3 weeks are important to watch. Tricyclic antidepressants, Selective-serotonin reuptake inhibitors, Monoamine oxidase inhibitors

What are Tricyclic antidepressants?

Block the reuptake of certain neurotransmitters. They down-regulate norepinephrine. They can cause blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain, some sexual dysfunction

What are Selective-serotonin reuptake inhibitors?

First-line of choice. Inhibit the presynaptic reuptake of serotonin. Temporarily increases the levels of serotonin. Side effects: (Physical agitation, sexual dysfunction, low sexual desire, insomnia, and GI upset). Seem to be a little faster than the tricyclics

What are Monoamine oxidase inhibitors?

Blocking the enzyme MAO that breaks down neurotransmitters such as norepinephrine and serotonin. Can’t eat tyramine-rich foods leading to hypertension: certain cheese, sauerkraut, aged meat, sausages, cold cuts, chocolate, yogurt, sour cream, sardines. NO red wine or caffeinated beverages.