DEPRESSIVE DISORDERS

MOOD DISORDERS DSM-IV-TR

1. Major Depressive Disorder
2. Dysthymic Disorder  Persistent Depressive Disorder

3. Bipolar I Disorder
4. Bipolar II Disorder
5. Cyclothymic Disorder

6. Mood Disorder due to a Gen. Med. Condn.

7. Substance-Induced Mood Disorder
 DSM-IV-TR  DSM-5
Mood Disorders  2 categories:

 Depressive Disorders
 Bipolar and Related Disorders
 DEPRESSIVE DISORDERS
DSM-5 CLASSIFICATION
1. Disruptive Mood Dysregulation Disorder
2. Major Depressive Disorder (MDD)
3. Persistent Depressive Disorder (Dysthymia)
4. Premenstrual Dysphoric Disorder

5. Substance/Medication-Induced Depressive Disorder

6. Depressive Disorder due to Another Medical Condition
7. Other Specified Depressive Disorder
8. Unspecified Depressive Disorder
Outline
• History
 Epidemiology (risk factors)
• Etiology
 Diagnosis (criteria and classification)
 Clinical features
 Differential Diagnosis
• Course and Prognosis
• Treatment
MAJOR DEPRESSIVE DISORDER
Epidemiology
Lifetime prevalence : 5-17% (highest of all)
25-50% in elderly
1.5-3X more common in females (hormones,
childbirth, learned helplessness)

Age of onset: (mean) 40 years (20-50 years)

Incidence : 10-15% (may be increasing among

people below 20 years)
Epidemiology
 Persons w/o close interpersonal relationships
 Divorced or separated
• No correlation with socio-economic status
• More common in rural areas ? (US stats)
 Childhood trauma (risk factor)
Etiology
• Biologic amines : norepinephrine and serotonin
• Neuroendocrine regulation
• Neuroanatomical abnormalities
• Psychodynamic factors
– Cognitive theory (Aaron Beck)
– Learned helplessness
• Psychosocial factors
– Losing a parent before age 11 (childhood trauma)
– Loss of a spouse
– Unemployment
– Personality type
Diagnostic features
• Feelings of sadness
– Agonizing emotional pain; inability to cry
• Loss of interest pleasure  withdrawal/neglect
• Somatic complaints (headache, constipation)
• Increased irritability
– Persistent anger
– Respond with angry outburst /blaming others
– Exaggerated frustration over minor matters
 GRIEF vs MDD
 Feeling of emptiness  Depressed mood
 Dysphoria decreases or
 Persistent dysphoria, not
occurs in waves
tied to specific thoughts
 May have positive
emotions/ humor
 Thoughts of deceased  Self-critical / pessimistic

 Intact self-esteem  Worthlessness

 Thoughts of death of  Thoughts of ending
deceased / “joining”
one’s worthless life
Clinical features
• Suicidal ideation in 60-70% (10-15% commit)
• Reduced energy in 97%
• Trouble sleeping (terminal insomnia) in 80%
• Decreased appetite* and weight loss*
 aggravate coexisting medical illness
• Anxiety symptoms in 90%
• Inability to concentrate (84%)
• Impairments in thinking (67%)

Diurnal variation of symptoms in 50%

Mental Status Examination
 Generalized psychomotor retardation
• Veraguth’s fold
• Depression is key symptom but may be absent in (or
denied by) 50% of patients
• Decreased rate / volume of speech
• Delayed response to questions
• Mood-congruent perceptual disturbances
• Negative thoughts (cognitive triad)
• Depressive pseudodementia (50-75%)
Mental Status Examination
• Impulse control : risk of suicide
• Judgment /insight : overemphasize their
problems  misinform on their sx/meds

• Rating Scales:
– Hamilton Rating Scale for Depression (HAM-D)
– Zung Self-Rating Depression Scale
– Raskin Depression Scale
– Beck Depression Inventory (BDI)
 Clinical age-related features
Children: school phobia and excessive clinging

Adolescents: poor academic performance,

substance use, sexual promiscuity, antisocial behavior,
truancy, running away

Elderly : may be correlated with SE status, loss of a

spouse, physical illness, and social isolation
- somatic complaints  underdiagnosed
 MAJOR DEPRESSIVE DISORDER
A. At least 5 of the ff symptoms* in the same 2-wk
period ; at least 1 is either (1) or (2)
B. Clinically significant distress/functional impairment
C. Not due to substance/medication or AMC

D. Not better explained by any Schizophrenia

spectrum disorder
E. Absence of manic/hypomanic episode
 Depressive symptoms
1. Depressed mood (subjective/objective)
2. Diminished interest or pleasure in all activities

3. Fatigue / loss of energy

4. Feelings of worthlessness / excessive guilt
5. Recurrent thoughts of death / suicidal ideation*
6. Psychomotor retardation/agitation

7. Weight loss/gain * or increase/decrease appetite

8. Insomnia or hypersomnia

9. Diminished ability to think / concentrate or indecisiveness

Differential Diagnosis
• Substance use – rule: any drug the depressed patient is
taking should be considered a potential factor in the mood
disorder

• Neurological conditions : Parkinson’s , dementias,

epilepsy, cerebrovascular diseases, tumors

• Medical conditions
Take good Hx, PE, neurological exam, routine blood and
urine tests, to include tests for thyroid and adrenal functions
Differential Diagnosis
• Mental disorders w/ depressive features:
Adjustment disorder
Anxiety disorders
Alcohol use disorders
Eating disorders
Schizophrenia
Schizophreniform disorder
Somatoform disorders
Course and Prognosis
• 50 % have onset before age 40
• Later onset for those w/o a family hx, those
with antisocial PD, and alcohol abuse
• Episodes last 6-13 months (w/Tx: 3 mos)
• Mean of 5-6 episodes over period of 20 yrs
• 5-10% will have manic episode in 6-10yrs
• First episode hospitalization : 50% recovery
• Recurrence: in 6 mos.(25%) , in 5 yrs (50-75%)
 Prognostic factors
Good prognostic indicators:
- mild episodes
- absence of psychotic symptoms
- short hospital stay
- solid friendships during adolescence
- stable family functioning
- sound premorbid social functioning
- absence of psychiatric comorbidity
- advanced age of onset
 Treatment
• Treatment goals:
– Patient’s safety
– Complete diagnostic evaluation
– Relief from immediate symptoms ; address
patient’s prospective well-being

Pharmacotherapy
- goal is symptom remission
- takes 3-4 wks to exert significant effect
 Pharmacotherapy
• Early drugs:
– Monoamine Oxidase Inhibitors (MAOIs)
– Tricyclic Antidepressants (TCAs)
• Recent drugs:
– NE reuptake inhibitors
– 5-HT reuptake inhibitors (Fluoxetine or Prozac)
– NE and 5-HT reuptake inhibitors (Amitriptyline)
– Pre- and Post –synaptic Active Agents
– Dopamine Reuptake inhibitor (Bupropion)
– Mixed action agents (Clomipramine or Anafranil)
 Persistent Depressive Disorder
(Dysthymia)
A. Depressed mood for at least 2 years
B. Presence, while depressed, of at least 2 of the ff
C. Never asymptomatic for > 2 months
D. Criteria for MDD may be continuously present

E. No manic / hypomanic episode

F. Not better explained by Schizophrenia
G. Not due to substance /AMC
H. Distress / functional impairment
 Persistent Depressive Disorder

Symptoms
1. Poor appetite / overeating
2. Insomnia / hypersomnia
3. Low energy/ fatigue
4. Low self-esteem
5. Poor concentration or indecisiveness
6. Feelings of hopelessness
 Persistent Depressive Disorder

• Prevalence is 0.5%
• Early, insidious onset; chronic course
• Risk factors : parental loss/separation;
presence of anxiety / conduct disorder
• Higher risk for psychiatric co-morbidity
(anxiety disorder and substance use)
• Early onset strongly associated with Personality
Disorders
 Premenstrual Dysphoric Disorder
DSM-5 DIAGNOSTIC CRITERIA

A. In the majority of menstrual cycles,

at least 5 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 post menses
 Premenstrual Dysphoric Disorder
DSM-5 DIAGNOSTIC CRITERIA

A. …
B. One or more of the ff
1. marked affective lability (mood swings)
2. marked irritability or increased conflicts
3. marked depressed mood
4. marked anxiety, tension
 Premenstrual Dysphoric Disorder
DSM-5 DIAGNOSTIC CRITERIA

C. One or more of the ff to reach total of 5

1. decreased interest in usual activities
2. subjective difficulty in concentration
3. lethargy, easy fatigability, lack of energy
4. marked change in appetite; cravings
5. hypersomnia / insomnia
6. sense of being overwhelmed / out of control
7. physical symptoms (breast tenderness, joint or
muscle pain, sensation of bloating or weight gain)
 Premenstrual Dysphoric Disorder
DSM-5 DIAGNOSTIC CRITERIA

A. …
B. …
C. …
D. Clinically significant distress / interference
E. Not merely an exacerbation of another disorder
(MDD, PDD, panic disorder, or PD)
F. Criterion A should be confirmed by prospective
daily ratings during at least 2 symptomatic cycles
G. Not due to substance / AMC
 PMDD diagnostic features
• Mood lability, irritability, dysphoria, anxiety sx
occur repeatedly during premenstrual phase*
• May be accompanied by behavioral/physical sx
• Occurred in most of the cycles the past year
• Sx have adverse effect on work/social fxning
• Sx are of comparable severity (but not duration) to
those of another mental disorder
• Delusions and hallucinations are rare
*risk for suicide
 Premenstrual Dysphoric Disorder
 Prevalence :
 1.8% – 5.8% of menstruating women
 Onset can occur at any time after menarche.
 Symptoms worsen with approach of menopause.

 Risk factors:
stress interpersonal trauma
seasonal changesociocultural aspects
(women on OCP may have fewer
premenstrual sx)
 Premenstrual Dysphoric Disorder

 Dx : 2 months of prospective symptom ratings

(Premenstrual Tension Syndrome Rating Scale)

 Diffl Dx :
Premenstrual Syndrome
Depressive and Bipolar disorders
Use of hormonal treatment
 Substance/Medication-Induced Depressive Disorder

A. Prominent/persistent disturbance in mood

B. There is evidence from the history, PE, lab exams
that…
C. Disturbance is not better explained by a depressive
disorder that is not substance/medication-induced
(timing)
D. There is no delirium
E. There is significant distress/functional impairment
Substance/Medication-Induced Depressive Disorder
 Prevalence is 0.26 %
 Symptoms should not persist beyond 1 month of
cessation of substance/medication

 Substances
 Anti-viral agents
 Cardiovascular agents
 Retinoic acid derivatives
 Antidepressants and antipsychotics
 Anti migraine and anti-convulsants
 Hormonal agents (OCPs)
 Smoking cessation agents
 Immunological agents (interferon)
 Substance/Medication-Induced Depressive Disorder

 Diagnostic work-up : lab assays of substance

 Risk of 0.01 % of treatment emergent suicidal ideation

 Comorbidity :
 alcohol use disorder
 histrionic PD
 paranoid PD.
 Depressive Disorder due to AMC
 Studies point to clear associations between depression and
 Stroke
 Huntington’s disease
 Parkinson’s disease
 Traumatic brain injury
 Multiple sclerosis

 Onset is very acute in stroke patients (w/in 1 day or few days)

 Differential Diagnosis:
 Adjustment Disorder w/ depressed mood
 Other Specified Depressive Disorder

2 SUBTYPES:
1. RECURRENT Depressive episode
- lasts between 2-13 days, at least once/mo
2. SHORT-DURATION Depressive episode
- lasts from 4-14 days w/o recurrence
Thank you