Depressive Disorders

Question 1

DSM 5 changes

Answer 1

New Depressive Dx’s

1. premenstrual dysphoric dx: moved from the appendix to an actual dx, as a way to reconceptualize chronic forms of depression.
2. disruptive mood dysregulation disorder: children up to age 18, who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol (replaces bipolar dx in children).

Question 2

Major Depressive Disorder

(MDD)

Answer 2

consistent with DSM iv, but better definition of

Mixed Features: coexistence w/in a major depressive episode of at least 3 manic symptoms (insufficient to satisfy criteria for a manic episode).

presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum BUT if they never met criteria for a manic or hypomanic episode, then MDD is retained.

Question 3

MDD continued.

Answer 3

Major Depressive Dx: one or more MDD episodes w/o history of manic, hypomanic, or mixed episodes.

1. Postpartum Onset: onset is w/in 4 weeks postpartum.
   
   1. anxiety and preoccupation with infant’s well-being and/or delusional thoughts about baby.
   2. 10-20% of women dx, but only .5%-.1 develop depressive psychosis.
   3. NOT baby blues: transitory mood symptoms that impact up to 70% of women during the 10 days postpartum.
2. **Seasonal Affective Dx (SAD): **common for Northern Hemisphere in winter.
   
   1. hypersomnia, increased appetite, weight gain, craving for carbs.
   2. caused by: dark-light cycle increases melatonin levels, phase-delay in circadian rhythms, serotonergic dysfunction.
   3. Phototherapy is effective treatment.
3. specifier of Severe with Psychotic Features applied to MDD or BP if delusional or hallucinations during a current mood episode.

Question 4

MDD

prevalence

course

Answer 4

Major Depressive Disorder

1. sleep abnormalities in 40-60% outpatients and 90% inpatients.
2. sleep continuity distrubances, reduced stage 3 and 4 (slow-wave) sleep, decreased REM latency (earlier onset of REM) and increased duration of REM sleep early in night.
3. prior to puberty: male/female rates equal, but in adolescence rate of females is twice that to males.
4. Life time risk: females 10-25%, males 5-12%.
5. Average range for onset: mid 20’s.
6. Untreated: symptoms may last for 6 or more months, then remit with full return to premorbid functioning.
7. 60% have more than 1 episode and 5-10% will then have a Manic Episode.
8. Major Depressive Episodes: especially the first one may be precipitated by a severe psychosocial stressor such as death of family/divorce.
9. KINDLING model: as the nyumber of previous depressive episodes increases, the risk for subsequent episodes is related more to the number of prior episodes than to the occurrence of a life stressor.

Question 5

MDD

age/culture

etiology

Treatment

Answer 5

Age:

1. Children: somatic complaints, irritability and social withdrawal are common.
2. Preadolescents: aggressiveness and destructiveness esp. boys.
3. Older Adults: memory loss, distractibilityy, disorientation, other cognitive symptoms present which make it hard to distinguish depression (pseudodementia) from Dementia.

Culture: Latinos may say nerves and headaches are common. Asians: weakness, tiredness and ‘imbalance’.

ETIOLOGY

• Strong genetic component
• .50 for identical twins and .20 for fraternal.
• 1.5 to 3 times more common among the first-degree bio relatives of individuals with the dx.
• BUT, similar risk increases with offsping but similar weather one or both bio parents have MDD.
• Catecholamine Hypothesis: deficiency of norepinephrine
• Indolamine Hypothesis: low levels of serotonin
• Elevated Levels of Cortisol: stress hormone secreted by the adrenal cortex.
• Lack of new cell growth: left subgenual prefrontal cortex (positive emotions) and Hippocampus!
  
  • Hippocamus is smaller than normal and some antidepressants increase neurogenesis in the hippocampus and elsewhere!

Question 6

MDD

Behavioral and CBT approaches

Answer 6

1. Behavioral Theory of Depression (Lewinsohn): operant conditioning:
2. low rate of response-contingent reinforcement for social and other behaviors (as the result of death of partner/change in social env), which results in extinction of those behaviors as well as in pessimism, low-self-esteem, social isolation, and other features of depression that tend to reduce the likelihood of positive reinforcement in the future.
3. Learned Helpless Model (Seligman): result of prior exposure to uncontrollable negative events coupled with a tendency to attribute those events to internal, stable, and global factors.
4. current model places less emphasis on attributions and more on sense of hopelessness.
5. Self-Control Model (Rehm): result of a combination of problems related to self-monitoring, self-evaluation, and self-reinforcement.
6. those who are depressed attend most to negative events and immediate outcomes, fail to make accurate internal attributions and set strigent criteria for self-evaluation, have low rates of self-reinforcement and high rates of self-punishment.
7. **Cognitive Theory of Depression (Beck): **being result of negative, illogical self-statements about oneself, the world, and the future (depressive cognitive triade).
8. some studies agree with Beck, but others say: negative beliefs may actually reflect a more accurate awareness of reality!
9. depressed people are actually more accurate about heir self-evaluations than non-depressed (overly optimistic!).

Question 7

MDD

Treatment

Answer 7

Combination of antidepressants and psychotherapy.

1. Tricyclics (TCA): best for classic depressions that involve vegetative (bodily) symptoms, worsening of symptoms in the morning, acute onset and short duration of symptoms, symptoms of moderate severity.
2. SSRI: better for melancholic depressions and are associated with fewer side effects than TCAs.
3. MAOI: if TCA and/or SSRI don’t work, atypical depressions like phobic features, panic attacks, increased appetite, hypersomnia, mood worsening late in the day.
4. Venlafaxine (Effexor) and Mirtazapine (Remeron): increase levels of both norepinephrine and serotonin. pretty good results.

NIMH Study

compared cognitive therapy, interpersonal therapy (IPT), and TCA (imipramine) treatment.

• all 3 treatments effective, but imipramine was better for severe symptoms.
• follow up study results were disappointing.
• only 20-30% were symptom free 18 months later for any of the treatments.
• Combining CBT and Meds is somewhat better than either alone.
• CBT has lower risk of relapse than Meds alone.
• ECT (electroconvulsive therapy): effective for very severe cases of endogenous depression w/ delusions or SI that do not respond to Meds.
  
  • side effects of temporary anterograde/retrograde amnesia, confusion, disorientation reduced by giving only to right hemisphere.

Question 8

Dysthymic disorder

Answer 8

1. chronically depressed mood that is present most of the time for at least 2 years in adults or 1 year with children/adolescents (depressed or irritable).
2. depressive symptoms must not be severe enough to meet criteria for MDD during the first 2 years of illness and never have a period of more than 2 months symptom-free.
3. Meds (ssri) and CBT/IPT.

Question 9

Bereavement Exclusion

DSM 5

Answer 9

Exclusion Criteria removed: depressive symptoms lasting less than 2 months following the death of a loved one **(bereavement exclusion has been removed). **

1. bereavement lasts longer than 2 months (1-2 years).
2. bereavement is a severe psychosocial stressor that can precipitate a MDepisode.
   
   1. MDD with bereavement adds risks of: suffering, worthlessness, SI, poor somatic health, worse social and work functioning, increased risk for persistent complex bereavement disorder.
3. genetically influenced, i.e. past personal and family histories of MDD.
4. bereavement-related depression respond to same psychosocial and medications as non-bereavement-related depressions.
5. evidence supports the inclusion of ‘loss of a loved one with other stressors in terms of likelihood of precipitating a MDD”.

Question 10

Specifiers for Depressive Disorders

DSM 5

Answer 10

1. Suicidality
2. Mixed Symptoms: for BP and MDD allows for the possibility of manic features in people with a diagnosis of unipolar depression.
3. Anxiety: anxious distress specifier gives an opportunity to rate the severity of anxious distress for those with BP and Depressive Dx.