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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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