Depressive
Disorders
Ariana Budri
Jordan Constantine
Table of Contents
1.
2.
3.
Mood Disorders vs
Mood Episodes
Suicide Risk
Assessment
Depressive
Disorders
4.
5.
Major Depressive
Disorder
Persistent
Depressive
Disorder
Table of Contents (cont’d.)
6.
7.
Premenstrual
Dysphoric Disorder
Substance/Medication
Induced Depressive
Disorder
8.
Depressive Disorder
due to Another Medical
Condition
MOOD DISORDERS
1.
vs MOOD EPISODES
WHAT IS A MOOD?
●
Mood is a pervasive and sustained feeling tone that is experienced
internally and that influences a person’s behavior and perception of the
world
●
Affect is the external expression of mood
●
Mood can be normal, elevated, or depressed
●
Healthy persons experience a wide range of moods and have an equally
large repertoire of affective expressions; they feel in control of their moods
and affects
●
Patients with mood disorders experience an abnormal range of moods and
lose some level of control over them
●
Distress may be caused by the severity of their moods and the resulting
impairment in social and occupational functioning
Mood Disorders vs
Mood Episodes
Mood Disorders
defined by their patterns of
mood episodes. They
include Major Depressive
Disorder (MDD) and
Persistent Depressive
Disorder etc
Mood Episodes
distinct periods of time in
which some abnormal
mood is present. Such as
major depressive episode,
mania, and hypomania.
TYPES OF MOOD EPISODES
Major
depressive
●
●
Characterized by a
depressed mood and
anhedonia for at least a
2-week period
A persistent inability to feel
positive emotions
Mania
●
●
●
A distinct period of
abnormally and persistently ●
elevated, mood, and
abnormally and persistently
increased goal-directed
activity or energy.
Lasting at least 1 week
●
May have psychotic
●
features
Hypomania
Unlike in mania, the episode
is not severe enough to
cause marked impairment
in functioning or require
hospitalization.
Lasts at least 4 days
No psychotic features
MAJOR DEPRESSIVE EPISODE (DSM-5 CRITERIA)
M SIG E CAPS
Interest
Mood
Sleep
Depressed mood
most of the time
Insomnia or
hypersomnia
Anhedonia
Guilt
Feelings of worthlessness
or excessive guilt
Energy
Concentration
Appetite
Psychomotor
Fatigue or loss of
energy
Diminished
concentration
Change in appetite or
weight (↑ or ↓)
restlessness or
slowness)
Suicidal
ideation
Recurrent thoughts
of death or suicide
Must have at least five of the following symptoms including depressed mood or anhedonia
for at least a 2-week period
MANIC EPISODE (DSM-5 CRITERIA)
DIGFAST
D - DISTRACTIBILITY
I - IRRESPONSIBILITY
G - GRANDIOSITY
F - FLIGHT OF IDEAS
A - ACTIVITY/ AGITATION
S - SLEEP DEFICIT
T - TALKATIVENESS
Must have at least three of the following (four if mood is only irritable) lasting at
least 1 week
2. SUICIDE RISK
ASSESSMENT
SUICIDE RISK ASSESSMENT
WHAT IS SUICIDE?
SUICIDE
death caused by
injuring oneself with
the intent to die
SUICIDAL
BEHAVIOUR
Encompasses a spectrum
from suicide attempts and
preparatory behaviours to
completed suicide
SUICIDE
ATTEMPT
when someone harms
themselves with any intent
to end their life, but they do
not die as a result of their
actions
SUICIDAL
IDEATION
thoughts about self-harm,
with deliberate consideration
or planning of possible
techniques of causing one's
own death
RISK FACTORS
●
Previous suicide attempt (most important risk factor)
●
Psychiatric disorders
●
Schizophrenia
●
Major depressive disorder
●
Bipolar disorder
●
Alcohol or substance use disorder
●
Recent psychiatric hospitalization
●
History of aggressive behavior
●
Male sex: ↑ risk of completed suicide
●
Family member that died by suicide
●
possession of firearms: ↑ risk of completed suicide
The Modified SAD PERSONS Scale
5 or less are considered
low level of risk (may be
safe to discharge)
6-8 are intermediate level
of risk (may require
psychiatric consultation)
9-11 are high level of risk
(may require hospital
admissions)
12 or more are very high
level of risk
3. DEPRESSIVE
DISORDERS
TYPES OF DEPRESSIVE DISORDERS
●
Major Depressive Disorder
●
Persistent Depressive Disorder
●
Premenstrual Dysphoric Disorder
●
Substance/Medication Induced Depressive Disorder
●
Depressive Disorder due to Another Medical Condition
COMMON FEATURES
sad, empty, or irritable mood
related changes that significantly
affect the individual’s capacity to
function
●
●
DIFFERENCES
●
●
●
Duration
Timing
presumed aetiology
4. MAJOR DEPRESSIVE
DISORDER
Major Depressive Disorder
Major depressive disorder is defined by the presence of at least one major
depressive episode occurring in the absence of a history of manic or hypomanic
episodes.
Essential feature - period lasting at least 2 weeks during which there is either
depressed mood or the loss of interest or pleasure in all or nearly all activities for most
of the day nearly every day (Criterion A)
EPIDEMIOLOGY
●
●
●
●
●
12 month prevalence of MDD in USA ~7%
prevalence 18- to 29 yrs is 3x > 60+ yrs
++ prevalence in females - peaks in adolescence then stabilizes
2:1 rates in women:men, notably between menarche and menopause
Women → more atypical symptoms e.g. hypersomnia, increased appetite, and
leaden paralysis compared with men
CLINICAL FEATURES
● Duration: 2 weeks
● Changes in:
- appetite and/or weight
- sleep
- psychomotor activity
● decreased energy
● feelings of worthlessness or guilt
● difficulty thinking, concentrating, or making decisions
● thoughts of death, suicidal ideation, a suicide attempt, or a specific
plan for suicidal behaviour
DEVELOPMENT AND COURSE
●
●
●
●
●
●
●
●
Can appear at any age - likelihood of onset ↑ puberty - peaks in 20s in USA;
first onset in late life not uncommon
Variable course - some rarely experience remission vs some go years with
few/no symptoms between episodes
Recovery begins within 3 months of onset for 40% of individuals with major
depression and within 1 year for 80% of individuals
Recency of onset, psychotic features, prominent anxiety, personality disorders
and symptom severity determine recovery rates
Risk of recurrence decreases as duration of remission ↑
Risk higher with severe preceding episodes and in younger individuals
Bipolar illnesses can begin with one or more depressive episodes - more likely
in cases of adolescent onset, those with psychotic features, and those with a
family history of bipolar illness
MDD with psychotic features may also transition into schizophrenia
ETIOLOGY
Biological
factors
Psychological
factors
Genetic
factors
Comorbidities
DIFFERENTIAL DIAGNOSIS
●
Manic episodes with irritable mood or with
mixed features
●
Bipolar I disorder, bipolar II disorder, or other
specified bipolar and related disorder
●
Depressive disorder due to another medical
condition
●
Substance/medication-induced depressive
disorder
●
Major depressive episodes
superimposed on schizophrenia,
delusional disorder, schizophreniform
disorder, or other specified or
unspecified schizophrenia spectrum
and other psychotic disorder
●
Schizoaffective disorder
●
Attention-deficit/hyperactivity disorder
●
Adjustment disorder with depressed
mood
●
Persistent depressive disorder
●
Premenstrual dysphoric disorder
●
Bereavement
●
Disruptive mood dysregulation disorder
●
Sadness
PHARMACOTHERAPY
PSYCHOTHERAPY
Cognitive-behavioral
Behavioral
Psychodynamic
therapy (CBT)
activation
psychotherapy
Interpersonal
Supportive
1
3
5
psychotherapy
psychotherapy
relies on both
behavioral
modifications
and cognitive
restructuring
2
Focuses on
identifying
and analyzing
problematic
interpersonal
relationships
focuses on
facilitating
change by
raising
patients'
awareness of
behavioral
patterns that
influence their
mood
4
Focuses on
empathizing and
providing
encouragement
and coping
techniques to
improve
self-esteem and
functioning
uncovers
unconscious
patterns of
childhood
experiences
and past
conflicts, to
improve
functioning
NEUROMODULATION
●
Indicated in patients with inadequate response to medications and
psychotherapy, if patient can’t tolerate pharmacotherapy (pregnancy), or
if rapid reduction of symptoms is desired (e.g., immediate suicide risk,
refusal to eat/drink, catatonia)
●
Can involve a magnetic field (rTMS), an electric current
(electroconvulsive therapy), or a drug instilled directly in the subdural
space (intrathecal drug delivery)
PERSISTENT
5. DEPRESSIVE
DISORDER
Persistent Depressive Disorder
dysthymia. mild, chronic form of depression that lasts at least 2 years, during
which, on most days, the individual experiences depressed mood for most of the
day and at least two other symptoms of depression (Adapted from Kaplan & Saddock’s
Book of Clinical Psychiatry)
EPIDEMIOLOGY
●
●
●
●
●
●
More common and chronic in women than in men F:M= 2:1
Prevalence- 2-3% “pure dysthymia”
Can occur more often in those with a history of long-term stress or sudden losses or
with other psychiatric disorders
Symptoms tend to be worse later in the day
Onset generally between ages of 20 and 35
More common among first-degree relatives with major depressive disorder
CLINICAL FEATURES
●
●
●
●
●
●
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
MNEMONIC: HE'S 2 SAD: Hopelessness, Energy loss or fatigue, Self-esteem is low, 2 years
minimum of depressed mood, Sleep is increased or decreased (insomnia or hypersomnia), Appetite is
increased or decreased, Decision-making and/or concentration is impaired. (2 years+ at least 2)
DEVELOPMENT
● Persistent depressive disorder often has an early
and insidious onset
● Early onset (before the age of 21)
● Associated with a higher likelihood of comorbid
personality disorders and substance use disorders
ETIOLOGY
Temperamental:- higher levels of neuroticism (negative affectivity),
greater symptom severity, poorer global functioning and presence of
anxiety disorders or conduct disorder
Environmental:- Childhood risk factors include parental loss or
separation
Genetic and physiological:- Individuals with persistent depressive
disorder will have a higher proportion of first-degree relatives with
persistent depressive disorder than individuals with major depressive
disorder
DIFFERENTIAL DIAGNOSIS
Major
Depressive
Disorder
Depressive or
Substance/
bipolar and related
medication-induced
disorder due to
depressive or
another medical
bipolar disorder
condition
Personality
disorders
TREATMENT
PROGNOSIS
● Impact on both morbidity and mortality and it is a common
cause of global disease burden and disability worldwide
● Represents a disorder of chronic depression and outcomes
and prognosis can be similar to or worse than major
depressive disorder
● Independently associated with greater severity of
depression, anxiety and somatic symptoms in comparison
to major depressive disorder
6. PREMENSTRUAL
DYSPHORIC
DISORDER
PREMENSTRUAL DYSPHORIC
DISORDER
Premenstrual dysphoric disorder occurs about 1 week before the menses and is
characterized by irritability, emotional lability, headache and anxiety or depression
that remits after the menstrual cycle is over (Adapted from Kaplan & Saddock’s Book of
Clinical Psychiatry)
EPIDEMIOLOGY
●
●
●
The twelve-month prevalence of premenstrual dysphoric disorder is between 1.8% and
5.8% of menstruating women
Onset of premenstrual dysphoric disorder can occur at any point after menarche
Incidence of new cases over a 40-month follow-up period is 2.5%
CLINICAL FEATURES
●
●
●
●
●
●
●
●
●
mood lability
irritability
depressed mood
hopelessness
poor concentration
fatigue
changes in appetite
changes in sleep pattern and physical symptoms
(breast tenderness, swelling, and bloating)
anxiety symptoms
ETIOLOGY
Environmental:- Factors associated with expression of premenstrual
dysphoric disorder (stress, history of interpersonal trauma, seasonal
changes and sociocultural aspects of female sexual behavior and female
gender role
Genetic and physiological:- Heritability of premenstrual dysphoric
disorder is unknown
Course modifiers:- Women using oral contraceptives may have fewer
premenstrual complaints than women who do not use oral
contraceptives.
DIFFERENTIAL DIAGNOSIS
Premenstrual
syndrome
Dysmenorrhea
Major
depressive
disorder
Bipolar
disorder
Persistent
depressive
disorder
TREATMENT
● SSRIs are first-line treatment, either as daily
therapy or luteal phase-only treatment (starting
on cycle day 14 and stopping upon menses or
shortly thereafter)
● Diet- consuming less caffeine, sugar or alcohol,
and eating smaller, more frequent meals
● Aerobic exercise
● Supplements:- Vitamin B6, calcium, magnesium
supplementsand herbal remedies
https://www.health.harvard.edu/womens-health/treating-prem
enstrual-dysphoric-disorder
7.
SUBSTANCE/MEDICATION
INDUCED DEPRESSIVE
DISORDER
The name of the substance/medication-induced depressive disorder begins
with the specific substance that is presumed to be causing the depressive
symptoms. E.g. dexamethasone-induced depressive disorder
The essential feature of substance/medication-induced depressive disorder is a
prominent and persistent disturbance in mood that predominates in the clinical
picture and is characterized by depressed mood or markedly diminished interest or
pleasure in all, or almost all, activities that is due to the direct physiological effects
of a substance.
EPIDEMIOLOGY
●
●
●
lifetime rate of alcohol- and stimulant-induced depressive episodes ~40% in
individuals with relevant substance use disorders
lifetime prevalence of substance/medication-induced depressive disorder in
absence of a lifetime history of non-substance- induced depressive disorder
0.26%
DEVELOPMENT AND COURSE
● onset must be during active usage of the substance
or during withdrawal
● the depressive disorder usually has onset within the
first few weeks or 1 month of heavy use
● Once substance is stopped, symptoms usually remit
within days to several weeks
● If symptoms persist >4 weeks beyond the expected
time course of withdrawal, other etiologies should be
considered
TYPES OF
SUBSTANCES/MEDICATIONS
stimulants
depressants
Medications associated with substance/medication induced depressive
disorder:
● Steroids
● Antihypertensives
● Antibiotics
● Antiviral agents
● Psychiatric drugs
● Hormonal and chemotherapeutic drugs
RISK FACTORS AND PROGNOSIS
Histories of:
●
●
●
●
●
●
antisocial personality disorder
Schizophrenia
bipolar disorder
stressful life events in past 12 months
prior drug-induced depressions
family history of substance use disorders
neurochemical changes associated with alcohol and other drugs of
abuse → depressive and anxiety symptoms during withdrawal that
subsequently influence ongoing substance use and reduce the
likelihood of remission of substance use disorders
DIFFERENTIAL DIAGNOSIS
Substance
intoxication
and
withdrawal
Independent
depressive
disorder
Depressive disorder
due to another
medical condition
TREATMENT
Pharmacotherapy
●
Discontinue drug
●
Lower dose
●
Consider an alternative
●
Antidepressants
Psychotherapy
●
Cognitive behaviour therapy
●
Interpersonal therapy
8.
DEPRESSIVE DISORDER
DUE TO ANOTHER
MEDICAL CONDITION
Depressive Disorder due to
Another Medical Condition
This condition is a state of depression secondary to a medical disorder, for
example, hypothyroidism, Cushing’s syndrome (Adapted from Kaplan & Saddock’s
Book of Clinical Psychiatry)
EPIDEMIOLOGY
●
●
Rates of depression in primary care patients are between 5% and 10 %,
Rates of depression in patients with diabetes and coronary heart disease
(CHD) have been estimated to be 12% to 18% and 15% to 23%
respectively
Katon W. J. (2011). Epidemiology and treatment of depression in patients with chronic medical illness.
Dialogues in clinical neuroscience, 13(1), 7–23. https://doi.org/10.31887/DCNS.2011.13.1/wkaton
CLINICAL FEATURES
●
●
●
●
●
●
●
●
●
Being irritable
Having trouble falling asleep, waking up very early or
sleeping more than usual
Noticing changes in your appetite and weight
Having low energy
Losing interest in sexual activity
Feeling worthless and guilty
Not being able to concentrate or remember things
Feeling hopeless or just not caring about anything
Worrying that you will never feel better
ETIOLOGY
The exact cause of this disorder is unknown
Many medical problems upset the balance of chemicals in your body,
such as:
●
●
●
●
●
Heart disease or a stroke
Brain problems such as Parkinson’s disease or Huntington’s disease
Hormone problems such as thyroid problems or adrenal gland
changes
Infections such as mononucleosis, hepatitis or pneumonia
Cancer
Certain medicines can also cause or worsen depression
RISK AND PROGNOSTIC FACTORS
● The risk of acute onset of a major depressive disorder
following a CVA (within 1 day to a week of the event) appears
to be strongly correlated with lesion location
● Gender-Related - CVA is more common in middle-aged males
compared to females
● Diagnostic markers
● Suicidal Risk
DIFFERENTIAL DIAGNOSIS
Depressive
disorders not due
to another
medical condition
Medicationinduced depressive
disorder
Adjustment
disorders
TREATMENT
Treatment specific to the condition
Psychotherapy
- Cognitive behaviour therapy
- Interpersonal therapy
Pharmacological
- Selective Serotonin Reuptake Inhibitors-Sertraline,
fluoxetine
- Tricyclic antidepressants- Amitriptyline, Clomipramine,
Doxepin, Nortriptyline
- Monoamine oxidase inhibitors- Phenelzine
References
●
Sadock et.al. (2015). Kaplan & Sadock’s Synopsis of
Psychiatry Behavioural Sciences/Clinical Psychiatry.
United States: Wolters Kluwer
●
The Diagnostic and Statistical Manual of Mental Disorders
(5th ed.; DSM–5; American Psychiatric Association, 2013)
●
A John Rush. Unipolar major depression in adults: Choosing
initial treatment. Post TW, ed. UpToDate. Waltham, MA:
UpToDate Inc. http://www.uptodate.com. (Accessed on
March 22, 2023.)
Thanks for
listening!
CREDITS: This presentation template was
created by Slidesgo, including icons by Flaticon
and infographics & images by Freepik