Day # 22: Intro to Depressive Disorders

Now that we have finished our first theme (psychotic disorders) we can jump right into our next theme in the curriculum which is depressive disorders. These disorders include Major depressive disorder (MDD), persistent depressive disorder (PDD), disruptive mood dysregulation disorder (DMDD), premenstrual dysphoric disorder (PMDD), substance/medication induced depressive disorders, and depressive disorder due to another medical condition. Over the next few weeks we will cover this topic in depth, but today will be an introduction to the clinical features and diagnostic criteria of depressive disorders.


Today's Content Level: Beginner; Intermediate (Review)



General Clinical Features


Common to all depressive disorders include patient reports of experiencing:

  • Mood changes to include sad, empty, or irritable.

  • Physical/Somatic changes that limit function.

  • Cognitive changes that limit function.

Like every DSM-V diagnosis, symptoms must cause significant distress or impairment and not be caused by another substance or medical condition.



Diagnostic Criteria of Depressive Disorders


MAJOR DEPRESSIVE DISORDER (MDD)


•Duration: "episodes" of depression lasting ≥2 weeks. Disorder marked by recurrent episodes.

•Must have ≥5 of the 9 symptoms below.

•At least one of the symptoms is either depressed mood or loss of interest or pleasure (anhedonia).


Full criteria can be remembered by the very popular mnemonic: SIG-E-CAPS.

  • Depressed mood: Subjective (feels sad, empty, hopeless) or observation.

  • Sleep: Insomnia or hypersomnia nearly every day.

  • Interest: Markedly diminished interest in all or almost all activities. Aka Anhedonia.

  • Guilt: Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

  • Energy: Fatigue or loss of energy nearly every day.

  • Concentration: Diminished ability to think or concentrate.

  • Appetite: Increase or decrease. Significant weight loss or weight gain.

  • Psychomotor: Agitation or retardation nearly every day (observable by others).

  • Suicidality: Recurrent thoughts of death, suicidal ideation, with or without plan.


PERSISTENT DEPRESSIVE DISORDER (PDD)


•Duration: symptoms must persist for 2 years.

•For child/adolescent timeline is ≥1 year and mood can be irritable.

Never been symptom free for longer than 2 months.

•Must have 2 of the 6 symptoms below for most of the day and more days than not.


Criteria can be remembered by a little known mnemonic: CHASES.

  • Concentration: poor, or difficulty making decisions

  • Hopelessness

  • Appetite: poor or overeating

  • Sleep: insomnia or hypersomnia

  • Energy: low, fatigue

  • Self-esteem: low


•May also have major depressive episode(s) or meet criteria for major depression continuously. PDD + MDD is sometimes called "double depression".



DISRUPTIVE MOOD DYSREGULATION DISORDER


•Severe recurrent verbal and/or physical outbursts out of proportion to the situation.

•Outbursts occur ≥3x per week and inconsistent with developmental level.

•Mood between outbursts is persistently angry/irritable most of the day nearly every day and is observed by others.

•Symptoms for ≥1 year in at least 2 settings. Not symptom free for ≥3 months.

•Started before age 10, but diagnosis can be made from ages 6-18.

•Diagnosis cannot coexist with oppositional defiant disorder (ODD), intermittent explosive disorder (IED), or bipolar disorder.


PREMENSTRUAL DYSPHORIC DISORDER


•Mood lability, irritability, dysphoria, and anxiety that occur repeatedly during the premenstrual phase of the cycle.

•Must occur in the majority of menstrual cycles.

•Symptoms must be present in the final week before onset of menses, start to improve within a few days after the onset of menses, and become minimal/absent in the week postmenses.

•Must have ≥5 symptoms:

  • At least one: affective lability (mood swings), irritability/anger, depressed mood, anxiety/tension.

  • At least one: anhedonia, problems concentrating, fatigue, appetite changes/food cravings, hypersomnia/insomnia, feeling overwhelmed/out of control, physical symptoms (e.g., breast tenderness/swelling, joint/muscle pain, bloating, weight gain).


•Premenstrual dysphoric syndrome should be confirmed by daily ratings / symptom diary for at least 2 menstrual cycles.



SUBSTANCE/MEDICATION INDUCED DEPRESSIVE DISORDER


•Prominent and persistent mood disturbance (depression or anhedonia) that develops during or soon after substance/medication is started or during intoxication or withdrawal. The symptoms is not better explained by a depressive disorder. Also be sure to rule out delirium (hypoactive), as the disturbance must not occur exclusively during the course of delirium.


DEPRESSIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION


•Prominent and persistent mood disturbance (depression or anhedonia) that develops in the setting of evidence for a medical cause. Evidence can be from the history, physical examination, laboratory, or radiological findings that the disturbance is a direct consequence of the medical condition.



Specifiers


Commonalities between all depressive disorders include depressed mood and decreased interest in activities. Aside from this each patient with depression can present very differently. For example, one patient may have depressed mood, hypersomnia, fatigue, increased appetite with weight gain, and have slowed movements. Another patient may have decreased interest, insomnia, poor appetite, weight loss, and constantly be agitated. We would, unfortunately, call both of these people depressed even though their clinical symptoms are very different. To help somewhat with this we have a further way to classify these disorders. They are called specifiers.


Some specifiers include:


•With anxious distress: feeling keyed up, tense, restless, difficulty concentrating, fearful that something awful may happen, feel they might lose control.


•With mixed features: "mixed" depression and mania. Must include ≥3 manic/hypomanic symptoms. We will cover these criteria in the bipolar theme.


•With melancholic features: loss of interest or reactivity to usually pleasurable activities, despair/emptiness, worse in the morning, early-morning awakenings, decreased appetite or weight loss, excessive guilt.


•With atypical features: mood reactivity (mood brightens in response to positive events), increase appetite or weight gain, hypersomnia, heavy feelings in arms/legs, long pattern of interpersonal rejection sensitivity.


•With mood-congruent psychotic features: content of delusions/hallucinations consistent with depressive themes (inadequacy, guilt, disease, death, punishment).


•With mood-incongruent psychotic features: content of delusions/hallucinations not consistent with depressive themes.


•With catatonia: catatonic features are present during most of the episode. More on catatonia in a later theme.


•With peripartum onset: onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. "Postpartum depression".


•With seasonal pattern: in the last 2 years, two major depressive episodes have occurred that demonstrate a relationship to a certain season (usually winter). Seasonal episodes must substantially outnumber the nonseasonal episodes. "Seasonal affective disorder (SAD)".



Conclusion


There is a lot of information in this post. For beginners (medical students and trainees in other fields) I recommend reading this article again tomorrow or making notecards of the criteria. This was, hopefully, a review for more experienced learners. As a reminder, due to reader feedback, we will now be transitioning to a Mon-Wed-Fri curriculum schedule as opposed to daily. In a few days we will cover the epidemiology, known risk factors, and pathogenesis of depressive disorders.


Resources used today include Pocket Psychiatry and Pocket DSM-V (I use the pocket version on a daily basis as a desk reference).



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