Major Depressive Disorder
A Depressive Disorder
Depressive Disorders
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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=twhvtzd6
gXA
Symptoms of Depression
Cognitive
Physiological and
Behavioral
Emotional
Poor concentration,
indecisiveness, poor self-esteem,
hopelessness, suicidal thoughts,
delusions
Sleep or appetite disturbances,
psychomotor problems, catatonia,
fatigue, loss of memory
Sadness, 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
Criterion for Major Depressive Disorder
A. 5 (or more) of the following symptoms have been present during the same 2week 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 hypomaniclike episodes are substance-induced or are attributable to the physiological
effects of another medical condition. The symptoms are not better
accounted for by Bereavement
Need to Specify Severity and Course
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Mild
Moderate
Severe
With psychotic features
In partial remission
In full remission
Unspecified
*Recurrent
…as well as Specifiers without codes
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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 & Duration
Specific to Youth
• 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
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
MZF N = 106
DZF N = 100
DZOS N = 109
- 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
Accounting for Variance in Depression
• Environment
– Early Life Stress
– Lifetime traumas
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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
A few models explaining
Major Depressive Disorder
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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
Stress
Inherited
predisposition
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 selfcharacteristics
Hopelessness
Symptoms of
Hopelessness
Depression
Beck’s Theory
(1967)
Negative
Event
Negative
Cognitive
Style
Cognitive
Distortions
Negative Cognitive
Triad
Negative Automatic
Thoughts about Self,
World, Future
Symptoms of Depression
Therapy for Major Depressive
Disorder
Suicide Completion
Severity
Suicidal Ideation
Family history of
suicidal behavior
Internalizing
Age
Gender
Adversity
Childhood
Social
Support
(low)
SelfEsteem
Neuroticism
HPA-Axis
Childhood Sexual
Abuse
Immune System
Childhood
Parental Loss
Cognitive Substrates
Early-onset
anxiety
disorder
Structural
Enlarged anterior Pituitary
Adrenal Gland
Genetic Risk Factors
Externalizing
Neurobiological
Biology
Conduct
Disorder
ADHD
Early Adolescence
Substance
Misuse
Late Adolescence
Sleep
Disturbed Family
Environment
Educational Attainment
(low)
Lifetime Traumas
Adulthood
The Last Year
Past History of Major
Depression
Stressful Life
Events
independent of
respondent’s
own behavior
History of Divorce
Stressful Life Events
dependent on
respondent’s own
behavior
Difficulties
Marital
Problems
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