Major Depressive Disorder

A Depressive Disorder

Depressive Disorders

• Disruptive Mood Dysregulation Disorder • 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 • Unspecified Depressive Disorder

Depressive Disorders

• Similarities • Differences

History of Major Depressive Disorder in the DSM

• Introduced DSM-III, 1980• Additional Information in DSM-IV• DSM-5 changes in subtypes

Major Depressive Disorder DSM-IV to DSM-5

• Not included in the DSM-5 are the following Diagnostic Criteria – B. The symptoms do not meet criteria for a Mixed

Episode• Coexistence within a major depressive episode of at

least 3 manic symptoms (not sufficient to meet for manic episode) is now a specifier

– E. The symptoms are not better accounted for by Bereavement• Allow people to grieve without a label

Quick Portrayal of Major Depressive Disorder

• https://www.youtube.com/watch?v=twhvtzd6gXA

Symptoms of Depression

CognitivePoor concentration, indecisiveness, poor self-esteem, hopelessness, suicidal thoughts, delusions

Physiological and Behavioral

Sleep or appetite disturbances, psychomotor problems, catatonia, fatigue, loss of memory

EmotionalSadness, depressed mood, anhedonia (loos of interest or pleasure in usual activities, irritability

Major Depressive Disorder: DSM-5 A. 5 (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.

Note: do not include symptoms that are clearly attributable to another medical condition (1) Depressed mood most of the day, nearly every day (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day,

nearly every day (3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of

body weight in a month), or decrease or increase in appetite nearly every day. (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 nearly every day (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a

specific plan, or a suicide attempt or a specific plan for committing suicide 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 another medical

condition E. There has never been a manic episode or a hypomanic episode Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are

substance-induced or are attributable to the physiological effects of another medical condition. The symptoms are not better accounted for by Bereavement

A. 5 (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.

Note: do not include symptoms that are clearly attributable to another medical condition (1) Depressed mood most of the day, nearly every day (2) Markedly diminished interest or pleasure in all, or almost all, activities most

of the day, nearly every day (3) Significant weight loss when not dieting or weight gain (e.g., a change of

more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

(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 nearly every day (8) Diminished ability to think or concentrate, or indecisiveness, nearly every

day (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal

ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Criterion for Major Depressive Disorder

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 another medical condition

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

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. The symptoms are not better accounted for by Bereavement

Criterion for Major Depressive Disorder

Need to Specify Severity and Course

• Mild• Moderate • Severe • With psychotic features• In partial remission• In full remission • Unspecified• *Recurrent

…as well as Specifiers without codes

• 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 Peripartum Onset• With Seasonal Pattern

Specific Notes about Children and Adolescents

• Must also experience at least 4 additional symptoms drawn from a list that includes– Changes in appetite or weight, sleep, and

psychomotor activity – Decreased energy– Feelings of worthlessness or guilt– Difficulty thinking, concentrating, or making

decisions– Recurrent thoughts of death or suicidal ideation or

suicide plans or attempts

Specific Notes about Children and Adolescents

• What does depression in children look like?– Mood • Irritable

– This pattern needs to be differentiated from a pattern of irritability when frustrated

• Cranky

– At School – Physical problems

Examples of Symptoms in Children and Adolescents

• Social withdrawal or neglect of pleasurable activities

• Appetite changes

Onset, Course, Duration

• Beginning in adolescence (12-16yo)(5-19yo)• Mean age at onset 30yo • Mean age start of treatment 33.5yo – Reflects amount of time depression often goes

undiagnosed or untreated• Elderly onset – At risk for downward spiral

• Course is Variable • Duration Remits or Variable– Lasts 6-13 months

• Course – Recurrence 1 to 2 years after remission = 20-60%– Recurrence 5 years after remission = 70%

• Duration – Median Clinically referred sample = 8 months– Median Community referred sample 1-2 months

Course & Duration Specific to Youth

Prevalence in Children and Adolescence

• Lifetime Prevalence of 13 to 18 year olds

• The difficulty with the numbers

Prevalence in Children and Adolescence

• Demographics(for lifetime prevalence)Sex and Age

FIGURE 1 Cumulative lifetime prevalence of major classes of DSM-IV disorders among adolescents (N=10,123).

Comorbidity and Differential Diagnosis

• Highly comorbid with other psychiatric disorders– Anxiety– Dementia– Schizophrenia– Substance Abuse

• Medical conditions– General – Neurological

• Medications

Accounting for Variance in Depression• Age and Genetics (phenotype expression)– The Sample MZM N = 106

DZM N = 100

DZOS N = 109

MZF N = 106DZF N = 100

- Children 8-11 years, N = 252- Adolescents 12-16 years, N = 244

Additive Genetic

Shared Environment

Non-shared Environment

Accounting for Variance in Depression

• Neurobiological: HPA axis

• Environment– Early Life Stress– Lifetime traumas

• Sexual abuse• Physical assault • Unexpected death • Abortion • Parental Loss

– Sleep– Family

• Parental bonding• Emotional tone of the home

– Education– Substance “misuse” – Social Support

Accounting for Variance in Depression

• Personality– Neuroticism– Self-Esteem– Early-onset anxiety disorder– Conduct Disorder– Cognition

Accounting for Variance in Depression

A few models explaining Major Depressive Disorder

• Biopsychosocial Model• Interpersonal Theory• Diathesis-Stress Model• Cognitive Vulnerability-Stress Model• Hopelessness Theory• Beck’s Theory• Maddie Marks’ Model

Biopsychosocial Model

Depression

Interpersonal Theory

Diathesis-Stress Model

Depression

Diathesis

Inherited predisposition

Stress

Loss of loved one

Cognitive Vulnerability-Stress Models of Depression

• Hopelessness Theory• Beck’s Theory

Hopelessness Theory Abramson et al., 1989

Negative Event

Negative Cognitive Style

Event-Specific Inferences

1. Stable-global causes

2. Negative consequences

3. Negative self-characteristics

Hopelessness

Symptoms of Hopelessness

Depression

Beck’s Theory(1967)

Cognitive Distortions

Negative Cognitive Triad

Negative Automatic Thoughts about Self,

World, Future

Symptoms of Depression

Negative Cognitive

Style

Negative Event

Therapy for Major Depressive Disorder

Family history of suicidal behavior

Suicidal Ideation

Educational Attainment(low)

Lifetime Traumas

History of DivorcePast History of Major Depression

Biology

Age Gender

Conduct Disorder

ADHD

Substance Misuse

Neuroticism

Self-EsteemEarly-onset

anxiety disorder

Neurobiological

StructuralEnlarged anterior Pituitary Adrenal Gland

HPA-Axis

Marital Problems

DifficultiesStressful Life Events

dependent on respondent’s own

behavior

Stressful Life Events

independent of respondent’s own behavior

Immune System

Sleep

Internalizing Externalizing Adversity

Genetic Risk Factors

Childhood

The Last Year

Late Adolescence

Early Adolescence

Adulthood

Disturbed Family Environment

Childhood Sexual Abuse

Childhood Parental LossCognitive Substrates

Social Support

(low)

Suicide Completion Severity

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