Depressive Disorders

Boland, Robert; Verdiun, Marcia; Ruiz, Pedro. Kaplan & Sadock’s

Synopsis of Psychiatry (p. 379). Wolters Kluwer Health. Kindle Edition.
 Depressive Disorders

• Disruptive Mood Dysregulation Disorder

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• Major Depressive Disorder

• Persistent Depressive Disorder (Dysthymia)

• Premenstrual dysphoric disorder

• Substance/medication-induced depressive disorder

• Depressive disorder due to another medical condition,

• Other specified depressive disorder

Disruptive Mood Dysregulation Disorder
Diagnostic Criteria 296.99 (F34.8)
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal
rages) and/or behaviorally (e.g., physical aggression toward people or
property) that are grossly out of proportion in intensity or duration to
the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times per

week.
Disruptive Mood Dysregulation Disorder
Diagnostic Criteria 296.99 (F34.8)
D. The mood between temper outbursts is persistently irritable or
angry most of the day, nearly every day, and is observable by others
(e.g., parents, teachers, peers).

E. Criteria A-D have been present for 12 or more months. Throughout

that time, the individual has not had a period lasting 3 or more
consecutive months without all of the symptoms in Criteria A-D.
Disruptive Mood Dysregulation Disorder
Diagnostic Criteria 296.99 (F34.8)
F. Criteria A and D are present in at least two of three settings (i.e., at
home, at school, with peers) and are severe in at least one of these.

G. The diagnosis should not be made for the first time before age 6
years or after age 18 years.

H. By history or observation, the age at onset of Criteria A-E is before

10 years.
Disruptive Mood Dysregulation Disorder
Diagnostic Criteria 296.99 (F34.8)
I. There has never been a distinct period lasting more than 1 day during
which the full symptom criteria, except duration, for a manic or
hypomanic episode have been met.

J. The behaviors do not occur exclusively during an episode of major

depressive disorder and are not better explained by another mental
disorder

K. The symptoms are not attributable to the physiological effects of a

substance or to another medical or neurological condition.
Prevalence DMDD
• Among children and adolescents probably falls in the 2%-5% range.

• Rates are expected to be higher in males and school-age children than

in females and adolescents.
Development and Course DMDD
• Half of children have a presentation that continues to meet criteria for the
condition 1 year later.

• Rates of conversion to bipolar disorder are very low.

• They are at risk to develop unipolar depressive and/or anxiety disorders

in adulthood.

• Mood dysregulation disorder is more common than bipolar disorder prior

to adolescence, and symptoms of the condition generally become less
common as children transition into adulthood.
Development and Course DMDD
• Children with chronic irritability typically exhibit complicated
psychiatric histories.

• Dangerous behavior, suicidal ideation or suicide attempts, severe

aggression, and psychiatric hospitalization are common.

• Predominantly male vs bipolar disorder - an equal gender prevalence

Differential Diagnosis
• Bipolar disorders – irritation, longitudinal course vs episodic, elevated
or expansive mood and grandiosity

• Oppositional defiant disorder – ODD typically occur in DMDD, But in

ODD mood symptoms are rare.

• Attention-deficit/hyperactivity disorder, major depressive disorder,

anxiety disorders, and autism spectrum disorder.
Comorbidity

• Rates of comorbidity in disruptive mood dysregulation disorder are

extremely high.

• It is rare to find individuals whose symptoms meet criteria for

disruptive mood dysregulation disorder alone.

• Comorbidity between disruptive mood dysregulation disorder and

other DSM-defined syndromes appears higher than for many other
pediatrics mental illnesses;
Case (depression)
• Ms. A, a 34-year-old literature professor, presented to a mood clinic
with the following complaint: “I am in a daze, confused, disoriented,
staring. My thoughts do not flow, my mind is arrested.… I seem to lack
any sense of direction, purpose.… I have such an inertia, I cannot
assert myself. I cannot fight; I have no will.”
Key symptoms
• A depressed mood and a loss of interest or pleasure
• Patients may say that they feel blue, hopeless, in the dumps, or
worthless.
• For a patient, the depressed mood often has a distinct quality that
differentiates it from the normal emotion of sadness or grief. Patients
often describe the symptom of depression as one of agonizing
emotional pain.
• Alternately they perceive it as a physical illness in which they feel
exhausted and unmotivated. Others report feeling little, being unable
to cry, and finding it difficult to experience any pleasure.
Motor activity
• The classic presentation of a depressed patient is a person with a stooped
posture, decreased movement, and a downward averted gaze.

• In practice, there is a considerable range of behaviors ranging from

persons with no observable symptoms to the catatonically depressed
patient.

• Among observable signs of depression, generalized psychomotor

retardation is the most often described, in which patients show little
spontaneous movement. At times it may be so severe as to be challenging
to differentiate from catatonia.
Neurovegetative Symptoms of Depression
Common
Fatigue,
low energy
Inattention
Insomnia
early morning awakening
Poor appetite, associated weight loss

Sometimes
Decreased libido and sexual performance Menstrual irregularities
Worse depression in the AM
Psychotic symptoms
• Depressed patients customarily have negative views of the world and themselves.
Their thought content often includes nondelusional ruminations about loss, guilt,
suicide, and death.

• About 10 percent of all depressed patients have marked symptoms of a thought

disorder, usually thought blocking and profound poverty of content.

• Depressed patients may complain of either delusions or hallucinations associated

with their depressive episode: Mood-congruent and mood-incongruent delusions
or hallucinations
Risk of suicide
• About 2/3 of all depressed patients contemplate suicide

• 10 to 15 percent commit suicide

• Those recently hospitalized with a suicide attempt or suicidal ideation have a higher
lifetime risk of successful suicide than those never hospitalized for suicidal ideation.

• Depressed patients with psychotic features occasionally consider killing a person

• Patients with depressive disorders are at increased risk of suicide as they begin to
improve and regain the energy needed to plan and carry out suicide (paradoxical
suicide).
 Suicide risk

The top five risk factors for suicide from higher to lower risk are:
• (1) Serious prior suicide attempt.
• (2) Age older than 45 years.
• (3) Alcohol dependence.
• (4) History of rage and violent behavior.
• (5) Male sex.
Cognitive impairment
• About 50 to 75 percent of all depressed patients have some measure of
cognitive impairment.

• Cognitive symptoms include subjective reports of an inability to

concentrate (84 percent of patients in one study) and impairments in
thinking (67 percent of patients in another study).

• Most depressed patients are oriented, although some may not have
sufficient energy or interest to answer questions about these subjects
during an interview. Memory can be challenging to
Depression in Children and Adolescents.
• School phobia and excessive clinging to parents may be symptoms of
depression in children.

• Poor academic performance, substance abuse, antisocial behavior,

sexual promiscuity, truancy, and running away may be symptoms of
depression in adolescents.
Depression in Older People
• Prevalence rates in older persons ranging from 25 to almost 50 percent, although the
percentage of these cases that are caused by major depressive disorder is uncertain.

• Depression in older persons correlates with low socioeconomic status, the loss of a spouse, a
concurrent physical illness, and social isolation.

• Depression in older persons is underdiagnosed and undertreated, perhaps particularly by

general practitioners. The underrecognition of depression in older persons may occur because
the disorder appears more often with somatic complaints in older than in younger, age
groups.

• Further, ageism may influence and cause clinicians to accept depressive symptoms as usual in
older patients.
Major Depressive Disorder
A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning: at least one of the symptoms
• is either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by
either subjective report

2. Anhedonia - markedly diminished interest or pleasure in all, or

almost all, activities most of the day, nearly every day (as indicated by
either subjective account or observation).
 MDD
3. Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt

8. Diminished ability to think or concentrate

9. Recurrent thoughts of death

MDD
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a

substance or to another medical condition.

D. The occurrence of the major depressive episode is not better

explained by other mental disorders.

E. There has never been a manic episode or a hypomanie episode.

MDD Severity/course specifier
• Mild
• Moderate
• Severe
• With psychotic features**
• In partial remission
• In full remission
• Unspecified
Specify MDD:
• With anxious distress
• With mixed features
• With melancholic features
• With atypical features
• With mood-congruent psychotic features
• With mood-incongruent psychotic features
• With catatonia
• With péripartum onset
• With seasonal pattern (recurrent episode only)
Prevalence MDD

• Twelve-month prevalence of major depressive disorder in the United

States is approximately 7%, The National Comorbidity Study reported
a lifetime prevalence of nearly 17% for major depression.

• In 18- to 29-year-old individuals is threefold higher than the

prevalence in individuals age 60 years or older.

• Females experience 1.5- to 3-fold higher rates than males beginning

in early adolescence.
Risk and Prognostic Factors MDD

• Heritability is approximately 40%,

• Adverse childhood experiences,

• Personality traits - Neuroticism (negative affectivity)

• Substance use, anxiety, and borderline personality disorders

Specifiers for Depressive Disorders
Anxious distress is defined as the presence of at least two 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 that the individual might lose control of himself or herself.

 With mixed features

A. At least three of the following manic/hypomanic symptoms:

1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity
6. Increased or excessive involvement in risky activities
7. Decreased need for sleep
With Melancholic Features
• Melancholic depression is characterized by severe anhedonia, early
morning awakening, weight loss, and profound feelings of guilt
(often over trivial events).

• It is not uncommon for patients who are melancholic to have suicidal

ideation. Melancholia is associated with changes in the autonomic
nervous system and endocrine functions. For that reason, we
sometimes refer to melancholia as “endogenous depression” or
depression that arises in the absence of external life stressors or
precipitants.
 With melancholic features
B. Three (or more) of the following;
1. A distinct quality of depressed mood characterized by profound despair, or/and so-
called empty mood.

2. Depression that is regularly worse in the morning.

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

4. Marked psychomotor agitation or retardation.

5. Significant anorexia or weight loss.

6. Excessive or inappropriate guilt.

With Atypical Features
• Patients may, for example, overeat or oversleep.

• Patients with atypical features have a younger age of onset and more
severe psychomotor slowing.

• They are more likely to have comorbid disorders, including anxiety

disorders, substance use disorder, or somatic symptom disorder.

• Patients with atypical features may also have a long-term course, a

diagnosis of bipolar I disorder, or a seasonal pattern to their disorder.
 With atypical features
A. Mood reactivity (i.e., mood brightens in response to actual or
potential positive events)

B. Two (or more) of the following:

1. Significant weight gain or increase in appetite

2. Hypersomnia

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

4. A long-standing pattern of interpersonal rejection sensitivity that

results in significant social or occupational impairment.
Depression with seasonal pattern (DSP)

• DSP is a subtype of major depressive disorder associated with the

winter season and short days. While less common, it can also be
associated with the summer season and long days.

• DSP is characterized by atypical symptoms of depression (e.g.,

oversleeping and overeating and a heavy feeling in the limbs (“leaden
paralysis”)

• Patients with the short-day type of DSP may improve in response to

full-spectrum light exposure with or without antidepressant
medication.
 Persistent Depressive Disorder (Dysthymia)
A. Depressed mood for most of the day, for more days than not, as indicated by
either subjective account or observation by others, for at least 2 years (children
1 year).
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
 Persistent Depressive Disorder (Dysthymia)
C. During the 2-year period (1 year for children or adolescents) of the
disturbance, the individual has never been without the symptoms in
Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present

for 2 years.

E. There has never been a manic episode or a hypomanie episode, and

criteria have never been met for cyclothymic disorder.
Double Depression
• An estimated 40 percent of patients with major depressive disorder
also meet the criteria for dysthymia, a combination often referred to
as a double depression.

• Available data support the conclusion that patients with double

depression have poorer prognoses than patients with major
depressive disorder alone.
Premenstrual dysphoric disorder (PMDD)
A. In the majority of menstrual cycles, at least five symptoms must be
present in the final week before the onset of menses, start to improve
within a few days after the onset of menses, and become minimal or
absent in the week postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.
 Premenstrual dysphoric disorder (PMDD)
• C. One (or more) of the following symptoms must additionally be present, to reach a total
of five symptoms when combined with symptoms from Criterion B above.
1. Decreased interest in usual activities
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating; or specific food cravings.
5. Hypersomnia or insomnia.
6. A sense of being ovenwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, or weight
gain.
Biologic etiology
1. Altered neurotransmitter activity

2. A genetic component

3. Physical illness and related actors

4. Abnormalities of the limbic–hypothalamic–pituitary–adrenal axis

The psychosocial etiology
Depression and dysthymia:
• Loss of a parent in childhood.
• Loss of a spouse or child in adulthood.
• Loss of health.
• Low self-esteem and negative interpretation of life events.
• “Learned helplessness”

• Prevalence
• The 12-month prevalence - 0.5% for persistent depressive disorder and 1.5% for
chronic major depressive disorder.
Differential Diagnosis of Depression

• Schizophrenia (particularly after an acute psychotic episode)

• Adjustment disorder
• Anxiety disorder
• Normal reaction to a life loss, e.g., bereavement
• Somatic symptom disorder
• Eating disorder
• Drug and alcohol use (particularly use of sedatives and withdrawal
from stimulants)
• Prescription drug use (e.g., reserpine, steroids, antihypertensives,
antineoplastics)
Differential Diagnosis of Depression

• Cancer, particularly pancreatic and other gastrointestinal tumors

• Viral illness (e.g., pneumonia, influenza, acquired immune deficiency

syndrome [AIDS])

• Endocrinologic abnormality (e.g., hypothyroidism, diabetes, Cushing’s

syndrome)

• Neurologic illness (e.g., Parkinson’s disease, multiple sclerosis,

Huntington’s disease, dementia, stroke [particularly left frontal])

• Nutritional deficiency (e.g., folic acid, B12)

• Renal or cardiopulmonary disease

Management
• Depression is successfully managed in most patients

• Only about 25% of patients with depression seek and receive

treatment.

• Patients do not seek treatment in part because Americans often

believe that mental illness indicates personal failure or weakness.

• As in other illnesses, women are more likely than men to seek

treatment.
Pharmacologic management
• Treatment for depression and dysthymia includes antidepressant
agents
• Mood stabilizers - Lithium and anticonvulsants such as carbamazepine
and valproate
• Mood stabilizers in doses similar to those used to manage bipolar
disorder are the primary treatment or cyclothymic disorder.

• Atypical antipsychotics such as olanzapine and risperidone

• Sedative agents such as lorazepam are used to help manage acute

manic episodes
Psychological management

• Psychological management or depression and dysthymia includes

psychoanalytic, interpersonal, family, behavioral, and cognitive
therapies

• Psychological management in conjunction with medication is

more effective than either type of management alone.
Electroconvulsive therapy (ECT)
• The symptoms do not respond to antidepressant medications.

• Antidepressants are too dangerous or have intolerable side effects.

• ECT may be particularly useful for elderly patients.

• Rapid resolution of symptoms is necessary (e.g., the patient is acutely

suicidal or psychotic).
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