Depressive Disorders – Comprehensive Study Notes

Page 1 – Clinical Presentation

• Key defining symptoms: depressed mood (dysphoria) and loss of interest/pleasure (anhedonia).
• Patients’ descriptions – “blue,” “hopeless,” “worthless,” “agonizing emotional pain,” “physical illness,” exhaustion, emotional numbness.
• Classic observable picture: stooped posture, ↓ movement, downward gaze.
• Behavioral spectrum: completely asymptomatic ➜ catatonic depression.
• Common objective sign: generalized psychomotor retardation; may mimic catatonia.
• Case – Ms. A (34 y o literature professor): felt “in a daze,” mental arrest, inertia, loss of will.

Page 2 – Motor/Somatic Features & Terminology

• Psychomotor agitation variants: hand-wringing, hair-pulling.
• Speech: ↓ rate/volume, monosyllabic answers, latency in response.
• Absence of visible signs ≠ absence of disorder; some patients can appear bright/social.
• Neurovegetative symptoms (see Table 7-1):
– Energy: $97\%$ complain of ↓ energy.
– Sleep: $\approx80\%$ have insomnia, esp. early-morning awakening (terminal insomnia).
– Appetite/weight: most ↓, some ↑ (“reversed neurovegetative” or atypical).
• Terminology management:
– Dysphoria = umbrella term for depressed feelings.
– Anhedonia = absence of pleasure.
– Many deny “depression” label; clinicians use softer synonyms.
• Anxiety frequently co-occurs.

Page 3 – Subjective Illness Experience & Thought Content

• Depressive sadness experienced as abnormal; many first seek PCP for “feeling sick.”
• Cognitive content: pervasive negativity, guilt, loss, death, suicidal rumination.
• $10\%$ show thought-disorder signs (thought blocking, poverty of content).
• Case – 42 y o civil servant: felt actions controlled by malignant force; recovered on thymoleptics → psychotic depression ≠ schizophrenia.
• Psychotic features:
– Mood-congruent delusions/hallucinations (guilt, poverty, rotting body).
– Mood-incongruent delusions (grandiosity, power).

Page 4 – Table 7-1 & Risk Indicators

• Neurovegetative list (common): fatigue/low energy, inattention, insomnia, ↓ appetite/weight.
• Sometimes: ↓ libido, menstrual changes, diurnal worsening (AM).
• Suicidality: $\tfrac23$ contemplate, $10!–!15\%$ die by suicide.
– Paradoxical risk ↑ as energy returns.
• Cognitive impairment: $50!–!75\%$ report issues (concentration $84\%$ , thinking $67\%$ ).
• Some unaware of mood change yet socially withdraw; others exaggerate hopelessness.

Page 5 – Judgment, Interview Nuances & Special Populations

• Judge recent decisions/behaviour; advise postponing major life choices until euthymic.
• Patients may under- or over-report past treatment success; always seek collateral info.
• Functional-change questions often more revealing than emotion questions.
• Children: school phobia, clinging.
• Adolescents: poor grades, substance use, antisocial acts, truancy, runaway, promiscuity.
• Older adults: prevalence $25!–!50\%$ ; correlated with low SES, bereavement, illness, isolation; underrecognised due to somatic presentation & ageism.

Page 6 – Diagnostic Overview & Specifier Concepts

• “Classic” disorder = Major Depressive Disorder (MDD), but multiple depressive forms exist.
• MDD core: ≥1 Major Depressive Episode (MDE).
• Specifiers:
– Psychotic features (mood congruent vs incongruent) → severe, poor prognosis.
– Melancholic features: profound anhedonia, early AM awakening, weight loss, intense guilt, suicidality; historically “endogenous.”

Page 7 – Table 7-2 (DSM-5 vs ICD-10 – Criteria Snapshot)

• Duration: ≥ $2$ weeks.
• Essential symptoms (DSM-5):

Dysphoria.
Anhedonia.
• Plus any 3–7 of: appetite/weight change, sleep change, activity change, ↓ energy, guilt/worthlessness, ↓ concentration, suicidality.
• ICD-10 emphasises ↓ mood, ↓ energy, ↓ activity, anhedonia, worse AM, psychomotor changes.

Page 8 – Number, Consequences, Exclusions, Symptom Specifiers

• DSM-5: ≥ $5$ total symptoms, with ≥1 core.
• Must cause distress/functional impairment.
• Exclude: medical/substance causes, prior mania/hypomania, etc.
• Symptom specifiers:
– Anxious distress (≥2 anxiety sx).
– Mixed features (≥3 hypomanic sx).
– Melancholic, atypical, mood-congruent psychotic, mood-incongruent psychotic, catatonia, peripartum onset, seasonal pattern.

Page 9 – Atypical, Catatonic, Peripartum, Seasonal

• Atypical: mood reactivity + ≥2 (hyperphagia, hypersomnia, leaden paralysis, rejection sensitivity).
• Catatonic: stupor, blunted affect, negativism, extreme withdrawal.
• Peripartum: onset within $4$ weeks postpartum; often psychotic.
• Seasonal pattern (SAD): recurrent episodes in a specific season (commonly winter); light therapy effective.

Page 10 – Severity Specifiers (DSM)

• Mild: minimal sx, functional.
• Moderate: between.
• Severe: marked sx, dysfunction, suicidality.
• Severe w/ psychosis: add mood-congruent/incongruent psychotic sx.

Page 11 – Atypical Features Case Study (Kevin, 15 y o)

• Excess sleep (12–15 h), weight gain $+30\text{ lb}$ , anergia, loss of drive; initially worked-up for narcolepsy.
• Antidepressant improved sx but induced near-mania → highlights bipolar risk & younger onset link.
• Atypical profile: younger age, severe psychomotor slowing, comorbid anxiety/substance/somatic d/o, possible seasonal/bipolar trajectory.

Page 12 – Catatonia & Other Specifiers

• Catatonia across disorders; prognostic/treatment significance (e.g., ECT responsiveness).
• Postpartum specifier: high psychosis incidence; requires vigilance for infanticide/filicide risk.
• Seasonal pattern controversy: distinct entity vs MDD subtype.

Page 13 – Dysthymic Disorder (Persistent Depressive Disorder)

• Chronic, less severe but longer lasting than MDD (≥ $2$ yrs adult, ≥ $1$ yr children); symptom-free intervals ≤ $2$ months.
• Features: continuous depressed mood, feelings of inadequacy, guilt, irritability, social withdrawal, ↓ productivity.
• Term “dysthymia” = “ill-humored”; previously “neurotic depression.”
• Early-onset (<20 y o) common; patients say “always been depressed.”

Page 14 – Table 7-3 Highlights (DSM-5 vs ICD-10)

• DSM-5 name: Persistent Depressive Disorder.
• Core = depressed mood + ≥2 of appetite, sleep, energy, self-esteem, concentration, hopelessness.
• Specifiers mirror those of MDD (pure dysthymic, persistent MDE, intermittent MDE, anxious distress, mixed, melancholic, atypical, psychotic, peripartum).

Page 15 – Specifier Continuation

• Course specifiers track current/past presence of full MDE within the 2-year dysthymic period.
• Severity mirrors mild/moderate/severe gradations.

Page 16 – Dysthymia Case (27 y o Teacher)

• Lifelong gloom, anhedonia (even to orgasm), feelings of grotesque failure, passive suicidality (bought pistol but resisted for students’ sake).
• Illustrates chronicity, early onset, intact function yet profound subjective impairment.
• Late-onset dysthymia rarer; strong family loading for depressive & bipolar disorders.

Page 17 – Other Depressive Diagnoses & Rating Scales

• Minor Depressive Disorder: sub-threshold episodes; episodic; ICD-10 mild depressive episode; DSM-5 → “Other Specified Depressive Disorder.”
• Recurrent Brief Depressive Disorder: episodes < $2$ wk; severe symptoms; episodic. • Double Depression: MDD superimposed on dysthymia (≈ $40\%$ of MDD pts); poorer prognosis; treat both layers. • Objective Scales: – HAM-D (0–24 items): cut-offs $\le13$ mild, $14!–!17$ mild-moderate, $>17$ moderate-severe.
– Zung Self-Rating Depression Scale: normal ≤ $34$ ; depressed ≥ $50$ .
– Raskin Scale: clinician-rated 3–13; depressed ≥ $7$ .

Page 18 – Differential Diagnosis: Medical Mimics

• Always consider general medical causes; detailed history & labs vital.
• Test adolescents for mononucleosis; weight extremes → adrenal/thyroid panels; HIV & viral pneumonia in risk groups.
• Table 7-4 pharmacologic triggers: steroids, reserpine, methyldopa, interferon, cimetidine, antipsychotics, withdrawal states (alcohol, cocaine, amphetamine), heavy metals, chemotherapy agents.

Page 19 – Endocrine, Infectious, Collagen, Nutritional, Neurologic Lists

• Endocrine: hypo/hyper-thyroid, hyper-parathyroid, hypo-pituitary, Addison, Cushing, DM.
• Infectious: tertiary syphilis, influenza, HIV, mono, hepatitis, toxoplasmosis.
• Collagen: RA, SLE.
• Nutritional: pellagra, pernicious anemia.
• Neurologic: MS, Parkinson, head trauma, CPS, tumors, stroke.

Page 20 – Substance & Neurologic Considerations

• Any chronic medication could contribute; rule out substance-induced mood d/o.
• Parkinson disease: $50!–!75\%$ exhibit depressive sx independent of motor severity; responds to antidepressants/ECT.
• Temporal-lobe epilepsy (esp. right): interictal mood changes mimic depression.
• Post-stroke depression common (esp. anterior lesions).
• Diencephalic/temporal tumors linked to depressive presentations.

Page 21 – Dementia vs Depressive Pseudodementia

• Depressive cognitive impairment: sudden onset, diurnal variation, prominent self-reproach, improvable with encouragement; may refuse to answer vs confabulation in Alzheimer dementia.

Page 22 – Bipolar Differentiation (Table 7-5 Predictors)

• Indicators suggesting bipolar spectrum: early onset, psychotic depression < $25$ y o, postpartum psychosis, rapid cyclical short episodes (< $3$ mo), ≥ $5$ lifetime episodes, psychomotor retardation, atypical features, seasonality, strong family bipolar loading, mood lability, antidepressant-induced hypomania, mixed features.

Page 23 – Overlap with Other Mental Disorders

• Misdiagnosis as schizophrenia common; pitfalls (Table 7-6): cross-sectional focus, misinterpreting bizarreness, etc.
• Anxiety vs Depression profiles (Table 7-7):
– Anxiety: hypervigilant, tense, panic, perceived danger, phobic avoidance.
– Depression: psychomotor retardation, sadness, perceived loss, anhedonia, hopeless, suicidal.

Page 24 – Continued Anxiety–Depression Distinctions

• Anxiety: doubt/uncertainty, insecurity, performance anxiety.
• Depression: self-deprecation, libido loss, early-morning awakening, weight loss.

Page 25 – Bereavement vs Depression

• Uncomplicated grief not a disorder; $\approx\tfrac13$ bereaved spouses transiently meet MDD criteria.
• Case – 75 y o widow: prolonged inactivity, refusal of care, religious conflict with suicide; highlights risk points.

Page 26 – Table 7-8 Red Flags for Bereavement → Depressive Disorder

• Self-perception as “sick,” emotional non-reactivity, psychomotor retardation, guilt of commission, mood-congruent delusions, active suicidality, pathological behaviours (mummification), severe anniversary reactions.
• Mixed Anxiety-Depressive Disorder recognised; pathophysiology debated.

Page 27 – Substance Use Comorbidity

• Alcohol use disorder frequently co-occurs; stronger depression link in women.
• Men may exhibit independent dual diagnoses with distinct genetics.
• Stimulant use (cocaine, amphetamines) common self-medication; dysthymia prone to polysubstance coping.
• Chronic substance use can mimic dysthymia → diagnostic challenge.

Page 28 – Course of Illness

• MDD: $50\%$ show prodromal sx pre-first episode; first episode < $40$ y o in $50\%$ .
• Untreated episode lasts $6!–!13$ mo; treated ≈ $3$ mo (maintain meds ≥ $3$ mo to prevent relapse).
• Mean lifetime MDD episodes = $5!–!6$ across $20$ yrs; frequency ↑ and inter-episode interval ↓ with progression.
• Dysthymia: insidious onset, often untreated for ≈ $10$ yrs; $20\%$ convert to MDD, $15\%$ to bipolar II, < $5\%$ to bipolar I.

Page 29 – Prognosis & Treatment Principles

• MDD chronicity: $50\%$ first-admission pts recover in 1 yr; recurrence: $25\%$ within 6 mo, $30!–!50\%$ in next 2 yrs, $50!–!75\%$ within 5 yrs.
• Relapse risk ↓ with maintenance pharmacotherapy & fewer prior episodes.
• Prognostic indicators (Table 7-9):
– Favourable: mild first episode, absence of psychosis, good support, no comorbidity, late onset.
– Unfavourable: psychosis, catatonia, early onset, multiple prior episodes, dysthymic overlay, comorbid anxiety/substance, poor support.
• Treatment approach:

Ensure safety (suicide risk, psychosis, catatonia).
Comprehensive diagnostic assessment.
Acute, continuation, maintenance phases (Table 7-10):
• Acute – symptom remission.
• Continuation – prevent relapse (6–9 mo).
• Maintenance – prevent recurrence (> $12$ mo; consider lifelong for recurrent/severe cases).
• Combine pharmacotherapy, evidence-based psychotherapy, and stressor reduction.
• Dysthymia responds to same modalities; modern practice avoids “no treatment” stance.