Major Depressive Disorder

Common Thread of Depressive Disorders

-sad, empty, or irritable mood, accompanied by somatic and cognitive changes

Prevalence of MDD in ADULTS

(Gender, Age, Race)

- Gender --> Highest in adults females, 2x more common (10.3%)

-Age --> highest in ages 18-25 (18.6%)

-Race --> highest in adults reporting 2 or more races (13.9%)

Prevalence of MDD in ADOLESCENTS 12-17 yrs old

(Gender, , Race, suicide)

- Gender --> Highest in adolescents females (29.2%)

-Race --> highest in adolescent reporting 2 or more races (27.2%)

-Suicide -->8% of adolescents diagnosed with MMD have completed suicide by young adulthood

(making suicide the 2nd leading cause of death amount the age group)

Prevalence of MDD in the U.S

Prevalence of MDD was 10% and

the life time prevalence was 21%

(Not taking age into account)

Avg onset age of MDD

30 years old

How does the prevalence of depressive disorders change in community-dwelling seniors (aged >65)

The prevalence decreases of MDD unless they have comorbidities

Prevalence of Depression in children aged 3-17 yrs (Overall and Gender)

-Prevalence is 4.4% overall

-Before puberty depression is 60% higher in boys than girls

Least depressed and Most depressed states

-Least --> Hawaii

-Most --> West Virginia

Causes of Lack of Treatment of depressive disorders (5)

1. Negative Bias (ex: family)

2. Lack of access to care

3. Cost of treatment and medication w/o insurance

4. Black box warning for adolescents (increases suicide)

5. Many don't know where to go to seek care

How does depression affect suicide death rate and medical illness

- In ppl with affective disorders suicide death rate can >15-20%

-Ex: MI, successful treatment of the depressive episode improves outcomes

Pathophysiology of depressive disorders

-suggests ↓ CNS serotonin as important factor (supported by efficacy of SSRIs)

- NE, dopamine also implicated

Genetic contributors of depressive disorders (4)

1. Family history

2. Twin concordance (increases risk by 37%)

3. First degree relatives (increases risk by 3x)

4.Neuroticism

Physical and social contributors of depressive disorders (4)

1.Chronic pain

2.Increased disability,

3.Decreased independence

4.disrupts social networks

Diseases associated with depressive disorders (2)

1.Left CVAs

2. Anterior strokes (left sided stroke)

- Association because of the involvement of limbic system (mood), basal ganglia (motor movement) and hypothalamus (appetites..ect)

Beck's Triad

-Cognitive contributors of depressive disorders

-Depressed people think irrationally and pessimistically and biased toward negative interpretation

-they will automatically and unconsciously overlook their positive attributes

Characteristics of Beck's Triad (5)

1.Lack of motivation

2."paralysis of will" - expect efforts to end in failure

3.Ruminative thinking

(tendency to think repetitively about the causes, situational factors, and consequences of one's negative emotional experience)

4. Passive ppl

5. Helplessness, hopelessness, overwhelmed, or inadequate

Psychological contributors of depressive disorders (2)

1. Stressors (big in MDD)

2.Interpersonal losses

Causes of depressive disorders in pediatrics (10)

1.Low birth weight

2.Family Hx of depression/anxiety (including post-partum depression)

3.Family dysfunction or caregiver-child conflict

4.Early adversity (i.e., abuse, neglect, early loss - i.e., loss of parent at age <10 years)

5.Low paternal involvement

6. Divorce

7. Stressors (i.e., peer problems, bullying, academic difficulties, gender dysphoria/homosexuality (++ if bullied)

8.Low socioeconomic status (i.e., homelessness),

9. "screen time"

10. COVID-19

Risks for depressive disorders in ADULTS (14)

1.Loss of status or employment

2.Impaired social support

3. Divorce, separation,

4.Widow

5.Caregiver burden

6.Negative life events (<1 year)

7.Low socioeconomic status

8.Lower income

9.Lack of education

10.Substance abuse

11. Medical or psychiatric illness

12.Lack of community

13.Low self-esteem

14.Bereavement

Current trends that affect risk of depressive disorders (6)

1. Social Media

2. School shootings

3. Student loan debt

4. Less recess and loss of play for children

5. Cyberbullying

6. COVID

Implications of COVID for mental health and substance abuse

1. Symptoms of anxiety and depression increased during the pandemic

2. Deaths due to drug overdose increased sharply across the total population coinciding with the pandemic

3.Alcohol-induced death rates increased substantially during the pandemic

4.After briefly decreasing, suicide deaths are on the rise again as of 2021

5. Many changes have been made in the delivery of mental health and substance use services since the

onset of the pandemic (ex: telehealth and 988 crisis line)

US Preventative Task Force recommendations

-Screening for depression in :

Adult population --> including older adults, pregnant and postpartum women in clinical practices that can assure proper management

-Clinical practices include: Pediatrics, Internal medicine, and ER with proper referral

T/F: Are you depressed is a good screening question

FALSE

-Bad question because ppl have different definitions of depression (may say "Im numb but not depressed)

Most common questionnaire used for depression screening

-The Patient Health Questionnaire (PHQ)-2 and PHQ-9

Criteria for Major Depressive Disorder (MDD) (3)

A.

5 or more of the following most/nearly every day, during same 2-week period, representing a change from previous functioning

-At least 1 of the symptoms is depressed mood or anhedonia

-On and off discrete episodes lasting 2 weeks or more

B.

Causes clinically significant distress or impairment in social, occupational, or other important areas of function

C.

NOT due to substance abuse, general medical condition, bereavement, mixed episode

❖ Never had a manic or hypomanic episode

Specifiers of MDD (10)

1. Single vs. recurrent episode

2. Severity

3. Catatonia

4. Anxious distress

5. Mixed features

6. Melancholic features

7. Atypical features

8. Psychotic features

9. Peripartum onset

10. Seasonal pattern

MDD criteria A symptoms (9)

A.

5 or more for most/nearly every day, during same 2-week period,

-At least 1 of the symptoms is depressed mood or anhedonia

1. Depressed mood (subjective or observed)

(In children and adolescents irritable)

2. Anhedonia

3. Significant weight loss/↓ appetite most days (typical sx) or weight gain (atypical sx)

5% different in body weight within a month

4. Insomnia (typical sx) or hypersomnia (atypical sx)

5. Psychomotor agitation or retardation (must be observed)

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive or inappropriate guilt

8. Impaired concentration or indecisiveness (subjective or observed)

9. Recurrent thoughts of death, recurrent suicidal ideation (+/- specific plan) or attempts

SIGECAPS of Depression

-Sleep

-Interest

-Guilt

-Energy

-Concentration

-Appetite

-Psychomotor retardation

-Suicide

More common sx seen in Asians with MDD (3)

1. Fatigue

2. Malaise

3. Loss of energy

- More somatic sx instead of depressed complaint

More common sx seen in Elderly with MDD

-Atypical features

-More somatic/cognitive sx (ex: confusion, general decline in function)

Pseudodementia

- Term used to describe MDD in elderly

- Due to memory loss

Mild to moderate MDD ( Definition and score on PHQ-9)

-No suicidal or homicidal ideation or behavior, no psychotic features, no aggressiveness

- intact judgement – patient/others are not at imminent risk of being harmed

- Score less than 20 points on PHQ-9

- Generally treated outpatient

Moderately severe MDD score on PHQ-9

- Score 15 to 19

- Need urgent attention

- Treated in a partial hospital program or inpatient

Severe unipolar MDD

- Score 20 points or more on PHQ-9

- Often reports suicidal ideation and behavior,

- Typically demonstrates obvious impairment of functioning

- More likely to develop complications such as psychotic features

-Treated in patient and referred to psychiatry for management

MDD specifier: Catatonia definition

-disrupts a person's awareness of the world

- impaired communication

-unusual movements or lack of movement

- behavior abnormalities

Catatonia DSM-V criteria (12)

Presence of 3 or more of the following:

1. Catalepsy (the individual maintains a fixed/frozen posture)

2. Waxy flexibility (slight, even resistance to bodily manipulation)

3. Stupor (no conscious mental activity is witnessed within the person’s environment)

4. Agitation

5. Mutism

6. Negativism (bodily manipulations are resisted during examination)

7. Posturing (the individual maintains bodily or facial postures for long periods of time)

8. Mannerisms (exaggerated or repetitive gestures or expressions)

9. Stereotypy (patients display repetitive motor or verbal behavior)

10. Grimacing

11. Echolalia (mimics another’s speech)

12. Echopraxia (mimics another’s movements)

MDD specifier: With anxious distress criteria (5)

-Common (40-60%)

-Presence of >2 of the following:

1. Feeling keyed up or tense

2. Feeling unusually restless

3. Difficulty concentrating because of worry

4. Fear that something awful may happen

5. Feeling of potential loss of control

❖ High anxiety associated with higher suicide risk, longer duration of illness and greater likelihood of nonresponse to treatment

MDD specifier: With mixed features criteria

-MDD episode + 3 or more manic symptoms

-Manic symptoms happen within same 2 weeks of MDD symptoms

MDD specifier: With melancholic features criteria

-Presence of more than 1 of Criteria A and more than 3 of Criteria B

-Criteria A:

1. Anhedonia

2. Lack of reactivity to pleasurable stimuli

Criteria B:

1. Depressed mood characterized by profound despondency

3. Despair, and/or moroseness or empty mood

4. Depression that is regularly worse in the morning

5. Early-morning awakening (i.e., at least 2 hours before usual)

6. Observable psychomotor retardation or agitation

7. Significant weight loss or anorexia

8. Excessive or inappropriate guilt

Melancholic features of MDD are more common in and less common in?

-MC in inpatients

- More likely to be comorbid with psychotic features

-Less likely to occur with mild MDD episodes

When are melancholic features of MDD applied?

-‘Melancholic features’ only applied when there is near-complete absence of the capacity for pleasure (it's not just lessened)

MDD specifier: With atypical features criteria

A. Mood reactivity (i.e., mood brightens in response to positive events)

B. Presence of more than 2 of the following:

1. Increased appetite or significant weight gain

2. Hypersomnia

3. Leaden paralysis (i.e., heavy, leaden feelings in arms/legs),

4. Long-standing pattern of interpersonal rejection sensitivity

Physical appearance of pt with MDD (4)

1. Most have normal appearance (but may have decline in grooming, flattened/diminished affect, change in weight)

2. Psychomotor changes

3. Poor memory or concentration (but no significant deficits on cognitive exam)

4. Low, monotone, speech or lacking in spontaneity and content

History to look for in Psychosis (4)

1. Bipolar disorder

2. Schizophrenia or schizoaffective disorder

3. Substance abuse

4. Organic brain syndrome.

Seasonal Affective Disorder (SAD) (definition and prevalence)

-Major Depressive Disorder with seasonal pattern

-SAD is more in women than in men

- More common in those living farther north (shorter daylight hours in the winter)

SAD Criteria (Double check)

A. Depression that begins and ends during a specific season every year (with full remittance during other seasons) for at least two years

B.Having more seasons of depression than seasons without depression over a lifetime

*Seasonal pattern disorders occur most frequently in winter although they can also occur in summer.

Treatment for SAD (4)

1. Broad spectrum light therapy

2. Psychotherapy

3. Antidepressants

4. Vitamin D

Bereavement (define)

-Response to a significant loss (not just of a person)

-Person faces Survivors guilt, social withdrawal, traumatic distress

**Exercise clinical judgment based on individual’s history, cultural norms for expression of distress, context of loss

Grief

-Predominant affect/mood is emptiness/dysphoria

-Focus on the loss

- Closeness of others is usually comforting

-Decreases in intensity over days to weeks and occurs in waves 'pangs of grief' (ex: Birthdays or holidays)

-Pain accompanied by positive emotions and humor

(Able to feel wide-range of emotions)

-May express guilt (Ex: should've called or seen deceased more)

-Self-esteem usually preserved after the loss

-Thoughts of death (no of suicide)

MDD compared to Grief

In MDD:

1. Person focuses one self

2. Inability to feel pleasure

3. Prolonged/marked impairment

4. Isolation

5. Limited feelings

6. Generalized guilt

7. Thoughts of death (suicide)

Prolonged Grief Disorder Criteria (4)

A. Death of someone close at least 1 year ago

(In children/adolescents – 6 months)

B. Since the death, the development 1 or more of following symptoms for most days to a clinical significant degree nearly every day for at least the last month:

1. Intense yearning/longing for the deceased

2. Preoccupation with thoughts or memories of the deceased (in children/adolescents – preoccupation

on the circumstances of death)

C. 3 or more of the following symptoms present most days to a clinically significant degree and nearly every day for the past month or more: *see next card

D. Causes clinically significant distress/impairment in social, occupational/important areas of functioning

E. Duration and severity of the bereavement reaction clearly exceed expected social, cultural, or religious norms for the individual's culture and context

Prolong Grief disorder Criteria C Symptoms (8)

C.

3 or more of the following symptoms for past month or more

1. Identify disruption (i.e., part of oneself has died)

2. Marked sense of disbelief about the death

3. Avoidance of reminders that the person is dead

4.Intense emotional pain related to the death(i.e., anger, bitterness, sorrow)

5. Difficulty reintegrating into one’s relationships and activities after the death

6. Emotional numbness

7. Feelings that life is meaningless

8. Intense loneliness

When is Prolonged Grief Disorder more common ?

-After losing a child or partner

-After sudden or violent death

Persistent Depressive Diroder (Dysthymia) Criteria (5)

A. Depressed mood (subjective or observed) for most of the day, for more days than not for 2 years

B. Presence while depressed of 2 or more of the following symptoms *next card

C.Never been without symptoms for 2 moths or more at a time for 2-years

D. Criteria for a major depressive disorder may be continuously present for 2 years (if so, dual diagnosis)

E. Cause clinically significant distress or impairment in social, occupational, or other important areas of function

Persisten Depressive Disorder Criteria B symptoms (6)

B.

2 or more of the following symptoms

1. Poor appetite or over-eating

2. Insomnia or hypersomnia

3. Fatigue or loss of energy

4. Low self-esteem

5. Decreased concentration or indecisiveness

6. Feelings of hopelessness

Risk of which comorbidity increases with Persistent Depressive disorder

Psychotic comorbidity

Persistent Depressive Disorder (Dysthymia) (prevalence, onset)

- Prevalence 2%

-Usually early, gradual onset (in childhood) and chronic course

**Consolidation of DSM-IV’s chronic major depressive disorder and dysthymic disorder

Persistent Depressive Disorder (Dysthymia) compared to MDD

- In comparison to MDD, these PTs are at higher risk for:

1. Psychiatric co-morbidity

2. Anxiety disorders

3. Substance abuse disorders

Question to ask pt with depressive Disorders before treating

-when was the last time you were entirely symptom free for 2 months?

-This helps distinguish individuals who present for treatment during exacerbation of chronic depressive illness vs. symptoms recently developed

(chronic MC have underlying personality, anxiety, and substance abuse disorders; ↓likelihood that Tx will be followed by full symptom resolution)

Peripartum

-MDD specifier

-Most recent episode occurs during pregnancy or up to four weeks following delivery

-85% of pregnant ppl develop mood disturbances in the postpartum period due to hormones and life change

-Causes negative impact on pregnancy and parenthood

Types of peripartum mood disturbances (3)

1. Baby blues

2. Postpartum Depression

3. Postpartum Psychosis

Baby Blues Criteria onset

-Symptoms peak within 5 days after delivery

-Symptoms resolve spontaneously by 2 weeks

-Symptoms do not interfere with the care of the baby

(tearful, mood changes, irritability, insomnia, anxiety, and “mild” depression);

Postpartum Depression onset and prevalence

-Usually develops gradually over first 3 months up to 12 months

- Affects mothers 50% before delivery, and 20% one year after birth

-Affect 10-15% of fathers

Symptoms interfere with mother’s ability to function, risk of self-harm or harm to infant

APA guidelines for postpartum depression tx (2)

1. Psychotherapy (first line for mild depression)

2. SSRIs or antianxiety meds for 1 year

Risks for Postpartum depression (9)

1. Personal Hx of MDD/anxiety

2. Young maternal age

3. Lack of support

4. Lower SES

5. Unintended pregnancy,

6. Family Hx of postpartum depression

7. Birth complications

8. Breastfeeding problems

9. NICU stay

Significance of Postpartum Depression (5)

1. Impaired bonding

2. Decreased rate of feeding

3. Missed appointments

4. Psychiatric Dx in child

5. Abuse/neglect

Postpartum Psychosis prevalence and onset

- rare 0. 1-0.2% of new mothers

- Begins within the first 6 months after delivery

When is Postpartum Psychosis most common and does it cause?

1. Hx of psychosis or bipolar

2. Severe insomnia

3. Agitation and restlessness,

-Causes:

1. Hallucinations

2. Paranoia

3. Bizarre behavior

4. Delusions

All above focused on baby and on one's role as a mother

5. homicidal and suicidal thoughts

Postpartum Psychosis Treatment

- Postpartum psychosis is a medical emergency and mothers should me hospitalized

-Treatment --> ECT which is rapidly effective and tx for all psychosis

Postpartum psychosis in 2nd pregnancy

There is a 30-50 % recurrence rates with 2nd pregnancy

LGBTQI+ and postpartum Depression

They are at increased risk because of increased prevalence of mental illness

Suicide Statistics

(age groups with 1st and 2nd greatest increase, and avg suicide day)

-Greatest increase in Adults aged 65+ (8.1%)

-2nd greatest increase in Adults 45-64 (6.6%)

-On avg there are 123 suicides a day (every 12 min)

Risk factors for long time to recovery from MDD

1. Lonnger episode duration at baseline (recentness of onset is a strong determinant of likelihood of recovery)

2. Greater baseline symptom severity

3 Psychotic features

4. Higher level anxiety or neuroticism

5. Pre-existing comorbid disorders (including personality)

6. Poorer psychosocial function

7. Childhood maltreatment

Prognosis for PTs with late-onset (geriatric) depression

-Prognosis is poorer in geriatric than younger patients;

-Associated with:

1. Physical disability

2. Chronic medical conditions or illness

3. Lack of social support

4. Increased risk of death by suicide (particularly among elderly men)

Suicide (define)

-Act of a person willingly, perhaps ambivalently, taking his or her own life

-Completed suicide if person dies

Suicidal Ideation (definition and prevalence)

-Thoughts or plan to kill oneself

-In the US, the annual prevalence of suicidal ideation is 4%

(low because it's self-reported

-More than 50% of ppl with suicide ideation don't get treatment

Suicide attempt (definition and prevalence)

-Non fatal self-injury behavior intended to kill oneself

-Suicide attempt survivors have long-term health effects (i.e., fractures, organ, and brain damage)

-For every suicide there are 10-40 attempts

Suicide Threat (definition)

-Verbalized thoughts of engaging in self-injury behavior intended to lead others to think one wants to die

- No intention of dying

Suicide Gesture (definition)

-Non fatal self-injury behavior intended to lead others to think that one wants to die (ex: superficial wrist cutting)

-No intention to die

-Cry for help or attention

Suicide Equivalent (definition)

-Behavior that will get a similar reaction to what a suicide would have caused

-Common in Children

-Indirect cry for help

Ex: running way from home

What 2 countries account for 50% of all suicide?

China and India

Suicide prevalence by gender and age

-Males commit suicide more commonly than women

-White males accounted for 69.67% of suicides in 2017

(in particular white middle aged men, highest in 45-54 yrs then >85 yrs old)

-In 2017, men died by suicide 3.54x more often than women

Risk factors of suicide (16)

-several demographic or categorical factors

1. Prior hx of attempted suicide (greatest predictor of trying again)

2.Single, divorced, widowed (2x the risk vs married)

3. Childhood adversity (2-4x the risk if abused or neglected)

4. Alternative sub-cultures (emo, punk, both)

5. LGBTQ ( increased risk in bisexual and transgender)

6. Profession (police, physician, dentist)

7. Family hx of suicide (30-50% heritable)

8. Western states and rural areas

9. Losses

10. Middle school

11. Religion

12. Death by cop

14. Incarceration

15. Veterans

16. Level of education ( 2x more in highssool education vs. college)

Reason why middle school suicide doubled in US (2004-2014) (4)

1. Social media for cyberbullying,

2. Increased academic pressure

3. Popular media/Internet ("how-to-guides" "copycat suicides", "suicide contagion")

4. Celebrities (increases risk by 13% using same method)

"Werther effect" Vs. "Papageno effect"

-Media affecting suicide risk in both

- "Werther effect" increased suicides

- "Papageno effect" decreases suicide

(focuses on support and resources)

"Year-end holiday spike"

-Myth

-November through January show decreased rates of suicide

-Most common in spring - May has the highest rate of suicide

*Tree pollen may increase risk of suicide attempt

Characteristic of Suicide (6)

1. Preoccupation with death

2. Isolation and withdrawal

3. Few friends or family

4. Emotional distance from others

5. Lack of humor

6. Dwell on past (loss, defeat; anticipates no future)

How mental illness affects risk of suicide

-Greater than 90% of patients who attempt and

95% of people who complete suicide have a psychiatric disorder

Mental illnesses that increase risk of suicide (11)

1. MDD

2. Bipolar disorder

3. Substance abuse (alcohol is factor for at least 30% of suicides)

4. Schizophrenia

5. Personality disorders

6. Anxiety disorders (panic)

7. PTSD

8. Eating disorders (highest in anorexia)

9. Impulsivity

10. Delirium,

11. Dementia

- The severity of illness correlates with risk of suicide

Medical illness at risk of suicide

-Prolonged, painful, progressive medical increases risk:

1. End stage renal disease

2. COPD

3. Cancer

4. HIV/AIDS

5. Traumatic brain injury

6. Quadriplegia

7. Multiple sclerosis

8. Severe whole-body burns

9. Congestive heart failure

10. Intractable pain

*All share loss of dependence

Suicide risk and psychodynamic formulations

-Common in children

-Pt deflects anger inward to hurt themself when they want to strike out at others

Suicide Protective factors (3)

1. Social support and family connectedness

2. Pregnancy and parenthood (particularly for mothers)

3. Religion

Suicide and visiting PCP

-Significant number of ppl will visit their PCP shortly before suicide attempt

-Common sx: fatigue and tiredness

12 Red-Flags for Real Suicide Potential

1. Have a definitive plan

2. Systematic pattern of behavior/activities that indicate

they are leaving life (saying goodbye to friends, making

a will, writing a suicide note, developing a funeral plan)

3. Strong family history of suicide, especially at anniversary or holiday

4. The presence of a gun, especially a handgun

5. Influence of drug or alcohol

6. Presence of a severe, immediate, unexpected loss (suddenly fired or left by spouse)

7. PT is isolated and alone

8. Hx of Depression or severe medical illness

9. Command hallucinations

10. Discharge from psychiatric hospitals

11. Unbearable anxiety

12. Clinician's feelings (6th sense or clinical intuition)

Info for assessment of suicide (3)

1. suicidal ideation (active vs. passive)

2. method/plan and intent

3. Homicidal ideation

Other source of info: interviews with family, friends or coworkers, EMS, suicide note

Treatment for suicide (4)

-Medical or surgical stabilization

1. Psychotherapy, CBT (correcting disturbed view of self)

2. Psychodynamic therapy (changing maladaptive behavior)

3. Medication (alone can relieve sx in adults not in children or adolescents )

4. Combined approach meds + therapy (preferred. quickest, most sustained response)

Methods for reducing risk for recent Suicidal ideation

- 1:1 observation in safe room

- Involuntary hospitalization (must still consent for

treatment; only can be given meds necessary for behavioral stabilization during crisis)

*Signing out of involuntary hospitalization requires the signature of 2 psychiatrists

"Contracting for safety"

- PT promises clinician will try not to harm and when pt has suicidal ideation they will get help

-Outpatient care:

1. involves family

2. Restrict access to lethal means

3. CBT

4. Safety plan for recurrent suicidal ideation

-For MDD or bipolar – lithium has anti-suicide effect

(avoid TCA/MAOI – lethal in OD)

World Suicide Prevention day

-September 10th

- Prevention is possible bc 90-95% of ppl have a treatable mental illness

Need for psychiatric consult depends on (7)

1. Your comfort level

2. Severity of symptoms

3. Intensity of care needed

4. Presence of suicidal ideation

5. Psychosis (should be in patient with psych referral)

6. Mania

7. The need for psychotherapy