Transcript Depressive Disorders

Mood
Disorders
M
Anne Washington Derry (1927)
Oil on canvas
by Laura Wheeler Waring(1887 - 1948)
Mood Disorders
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Depressive Disorders
Bipolar Spectrum Disorder
Cyclothymiacs Disorder
Mood Disorder duo to GMC
Substance induced mood disorder.
Depressive Disorders
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Major Depressive Disorder (single, recurrent)
[Major Depressive Disorder: Postpartum onset]**
Dysthymic Disorder
Double Depression
**Postpartum depression will also be a specifier
for bipolar disorder.
Major Depressive Disorder:
Diagnostic Criteria
5 of following symptoms, must include one of
first two, occurred almost every day for two
weeks lead to dysfunction
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Depressed mood
Pleasure or interest/ Loss
Appetite
Sleep disturbance, too much or too little
Agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Difficulty concentrating or deciding
Recurrent thoughts of death or suicidal thought
Depressive Symptoms Mnemonic:
“Space Drags”
S leep disturbance
D epressed mood
P leasure/interest (lack of)
R etardation movement
A gitation
A ppetite disturbance
C oncentration
G uilt, worthless, useless
E nergy (lack of)/fatigue
S uicidal thought
Mental Status Exam
• Psychomotor retardation or agitation
• Depress mood & affect
• Non spontaneous speech , Low tone
speech
• Hallucinations, commanding
• Thought of death, Suicidal thought(60%)
& plan & attempt (15%), Negative thought
Delusion (appropriate with mood)
• Cognitive problem : Distractibility ,memory
impairment , Concrete thinking
Age & Presentation
• Child hood: Somatic complaint, Agitation,
Hallucination, Phobia,…
• Adolescent : Antisocial behavior ,Truancy
Substance abuse , Promiscuity,….
• Geriatrics :Apathy ,Distractibility ,
Psoudodemance.
Other Classification
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Melancholic
Atypical
Chronic(more than 2 yr)
With seasonal pattern.
Post partum onset
With Catatonia
Double depression
Sub clinical depression(Minor depression)
With psychotic feature
Dysthymic Disorder: Symptoms
A. Depressed/irritable mood
B. Presence of two of the following:
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Appetite disturbance
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Sleep disturbance
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Low energy/fatigue
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Poor concentration of difficulties making decision
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Feelings of hopelessness
C. Present for two year period (one year in children and adolescents)
D. No evidence of a Major Depressive Epidsode during the first two
years (one year for children)
E. No manic or hypomanic episode
F. No chronic psychotic disorder
G. Not related to organic factors
Dysthymic Disorder
• Early Onset: before 21 year old
• Late Onset : after 21 year old
• With or Withought Atypical feature.
“Double Depression”
• Not a diagnosis
• Meet diagnostic criteria for both MDD and
Dysthymic Disorder
Manic Episode: Diagnostic Criteria
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C.
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A distinct period of abnormally and persistently elevated,
expansive, or irritable mood
Mood disturbance plus three of the following symptoms (four if the
mood is only irritable):
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas, or racing thoughts
Distractibility
Increase in goal directed activity
Excessive involvement in pleasurable activities
Marked impairment
No psychosis
Not organic
Hypomania: Diagnostic Criteria
• All the criteria of a Manic episode except
criterion C (marked impairment)
Bipolar Disorder
Bipolar I
• Alternation of full
manic and depressive
episodes
• Average onset is 18
years
• Tends to be chronic
• High risk for suicide
Bipolar II
• Alternation of Major
Depression with
hypomania
• Average onset is 22
years
• Tends to be chronic
• 10% progess to full
biploar I disorder
Cyclothymia
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For at least two years (one year for children and
adolescents) presence of numerous hypomanic
episodes and numerous periods with depressed mood
or loss of interest or pleasure that did not meet
criterion A (5 symptoms) of Major Depression
During a two-year period (1 year in children and teens)
of disturbance, never without hypomanic or depressive
symptoms for more than tow months at a time
No evidence of MDD or Manic episode during the first
two years of disturbance
No psychotic disorder
No organic cause
Mood Disorders: Summary
Depressive Disorders
• Major Depressive
Disorder (single,
recurrent)
• [Major Depressive
Disorder: Postpartum
onset]**
• Dysthymic Disorder
Bipolar Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
Mood Disorders: Prevalence
Life Time
Disorders
Major Depression
Dysthymia
Bipolar I
Bipolar II
Prevalence
male: 5 – 12 %
Female : 10 -25 %
6%
0.8%- 1.6%
0.5%
MDD (Postpartum)
13%
Epidemiology
• Life time prevalence : High(10-25%)
• Gender: Female more than Male(2, times)
Differential Diagnosis
• Mood Disorder due to GMC
(Hypothyroidism)
• Substance Induced Mood Disorder
(Amphetamine , Steroids ,…)
• Schizophrenia
• Grief
• Personality Disorder
• Adjustment Disorder
Prognosis
• 50% attempt Suicide
• Un treated depression get 10 mo or more
to recover
• 75% have recurrence.
• 5 Episode occurs long life
• 50% full recovery.
• 30% partial remission.
• 20% tend to be Chronic
• 20%-30% of Dystymic Disorder go to MDD
Major Depressive Disorder:
Etiological Theories
• Biological (genetic, brain structures,
neurotransmitters)
• Behavior and cognition
• Emotion
• Social and cultural factors
• Developmental factors
Major Depression: Genetics
Family studies:
• Relatives of those with a mood disorder are two
to three times more likely to have a mood
disorder (usually major depression)
Twin studies:
If one identical twin has a mood disorder the othe
twin is 3 times more likely than a fraternal twin to
have a mood disorder (particulrly for bipolar
disorder)
Major Depression: Genetics
• Severe mood disorders may have stronger
genetic contribution than less severe
disorders
• Heritability rates are higer for females
Major Depression:
Neurotransmitters
• Low levels of serotonin deregulates the
activity of other neurotransmitters such as
Dopamine & NE.
• Imbalance in cortisole & TSH
Major Depression: Cognition
• Learned helplessness (Seligman)
• Negative cognitive styles (Beck)
Learned Helplessness
• Attribution of lack of control over stress
leads to anxiety and depression
• Depressive attributional style is internal,
stable, and global
Negative Cognitive Styles
Aaron Beck
Depression is the result of negative interpretations
(wearing gray instead of rose colored glasses,
e.g. Eyore in Winnie the Pooh)
Key Components of Negative Interpretations
• Maladaptive attitudes (negative schema)
• Automatic thoughts
• Cognitive triad
• Errors in thinking
Seligman and Beck
Seligman
Attributions are:
• Internal
• Stable
• Global
Beck
Negative interpretations about:
• Themselves
• Immediate world (their place)
• Future (their place)
I am inadequate (internal) at
everything (global) and I
always will be (stable).
I am not good at school (self). I
hate this campus (world).
Things are not going to go well
in college (future).
“Dark glasses about why things
are bad”
“Dark glasses about what is going
on”
Interpretation (theory)
Description
Major Depression: Social and
Cultural Factors
• Stressful life events
• Social support (marital relationship) (see
chart)
• Gender
• Culture (see chart)
Marital Status and MDD
Percentage w/MDD
7
6.3
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Married
Widowed
Never M.
M/D/W
4
2.8
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2.1
2.1
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Married
Widowed
Never M.
M/D/W
Ethnicity and Prevalence of MDD
Percentage by Ethnicity
6
5.1
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4.9
4.4
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3
Af. Am
Latina
White
Average
3.1
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Af. Am
Latina
White
Average
Treatment Major Depression:
Overview
Biological Treatments
• Medication
• ECT
• Special note about antidepressants and children
Psychological Treatments
• Cognitive Therapies
• Interpersonal Psychotherapy (IPT)
NIMH Collaborative Treatment Study
Biological Treatment
Medications
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Tricyclic antidepressants
Monoamine oxidase (MAO) inhibitors
Selective serotonin uptake inhibitors
St. John’s Wort
ECT (will cover in discussion section)
Antidepressant Medication with
Children
• The effectiveness of antidepressant medication
with children is questionable.
• December 2003 British drug regulators told
physicians to stop writing perscriptions for all but
one of the newer generation of antideressant
drugs to treat children under 18.
• Benefit did not outweigh the risks (including
suicidal thoughts and behavior and agression)
• Prozac was exempted.
Controversy
Pro Medication
• Cost of untreated
depression is high
• Depression itself is lethal
(particularly in teens)
• Indisputable proof that it
works in their own clients
• Questioned the adequacy
of the studies
Anti Medication
• Review of 11 studies of
effects of medication in
children revealed that the
risks outweigh the
benefits
• Evidence based practice
is guided by the results of
research not clinician’s
opinions
Psychological Treatments
• Cognitive-Behavioral Treatment
• Interpersonal Therapy
Which treatment is best?
Depression Collaborative Research Program
Treatment
Groups
Cognitive
Therapy
Interpersonal
Psychotherapy
Medication
Imiprimine
Placebo & Clinical
Management
Outcome Measures
Depressive Symptoms
Overall symptomotology and life functioning
Functioning in treatment specific domains
Procedures
T16 weeks of treatment
Extensive Assessment:
Results
Results:
Follow-up-18 months
Post-Treatment
•Equivalent success in three
active treatments over
placebo
•Medication was faster
•IPT better than CBT for more
severely depressed patients
•Particular treatments effected
change in expected domains
•Equivalent success in three active treatments
•Only 20 to 30% of recovered patients were still
well
•Patients in IPT report more satisfaction with
treatment
•IPT and CBT patients more likely to report that
treatment affected capacity to establish and
maintain relationships and to understand source
of their depression
Many Controversial Issues
Special Topic 1
Childhood Onset Depression
Childhood Onset Depression:
Historical Aspects
Initial View
• Psychoanalytic: developmentally children could
not experience depression
• Sadness results from loss of valued
object/person
• Sadness results in hostility and aggression
• Depression is result of inward hostility
• Children lack superego development to direct
aggression toward self
Childhood Onset Depression:
Historical Aspects
Initial View:
Clinical findings of Rene Spitz
Childhood Onset Depression:
Historical Aspects
Early View:
• Masked Depression
Later rejected:
• Difficult to verify
• Depressive symptoms were evident
Current Childhood Onset
Depressive Disorders
• Adjustment Disorder with Depressed
Mood
• Dysthymic Disorder
• Major Depression
• Bipolar Disorder
Adjustment Disorder with
Depressed Mood
• Short-term
• Emotional or behavioral problems
• Reaction to identified stressor
Special Topic 2
Suicide
Suicide
• 8th leading cause of death in the U.S.
• Overwhelmingly white phenomena
• Suicide rates also quite high in Native
American
• Rate of suicide is increasing in
adolescents and elderly
• Males are more likely to commit suicide
• Females are more likely to attempt suicide
(except China)
Suicide: A Sociological Typology
Emile Durkeim
Formalized or altruistic
suicide
Sanctioned suicide
Egoistic suicide
Disintegration of social
support
Anomic suicides
Major disruption
Fatalistic suicide
Loss of control of one’s
destiny (mass suicide’s)
5 Myths and Facts About
Suicide
Myth #1:
Fact:
• People who talk about • Most people who
killing themselves
commit suicide have
rarely commit suicide.
given some verbal
clues or warnings of
their intentions
5 Myths and Facts About
Suicide
Myth #2:
• The suicidal person
wants to die and feels
there is no turning
back.
Fact:
• Suicidal people are
usually ambivalent
about dying; they may
desperately want to
live but can not see
alternatives to
problems.
5 Myths and Facts About
Suicide
Myth # 3:
• If you ask someone
about their suicidal
intentions, you will
only encourage them
to kill themselves.
Fact:
• The opposite is true.
Asking lowers their
anxiety and helps
deter suicidal
behavior. Discussion
of suicidal feelings
allow for accurate risk
assessment.
5 Myths and Facts About
Suicide
Myth # 4:
• All suicidal people are
deeply depressed.
Fact:
• Although depression is
usually associated with
depression, not all
suicidal people are
obviously depressed.
Once they make the
decision, they may
appear happier/carefree.
5 Myths and Facts About
Suicide
Myths # 5:
• Suicidal people rarely
seek medical
attention.
Fact:
• 75% of suicidal
individuals will visit a
physician within the
month before they kill
themselves.
Sociodemographic Risk Factors
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Male
> 60 years
Widowed or Divorced
White or Native American
Living alone (social isolation)
Unemployed (financial difficulties)
Recent adverse life events
Chronic Illness
Clinical Risk Factors
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Previous Attempts
Clinical depression or schizophrenia
Substance Abuse
Feelings of hopelessness
Severe anxiety, particularly with depression
Severe loss of interest in usual activities
Impaired thought process
Impulsivity
Assessing Risk and Planning
Intervention
Risk
Level
Specific
Plan
Risk
Factors
Severity Interven.
Intent
Low
No
Few
None
Safety Plan
Mod.
Vague
Plan/low
lethal
Increased
None
Safety Plan
Severe
Specific
lethal plan
Increased
None
Safety Plan
Remove
Lethal Items
Extreme
Specific lethal
plan
Increased
Intent to die
Safety Plan
Remove
Lethal Items
Hospitalize
Clinical Considerations of
Suicide Assessment
For those who are reluctant to assess
suicide:
• Asking questions may feel intrusive but not
asking has dangerous consequences
• A calm and genuinely concerned approach
is effective
Suicide:Treatment
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Problem-solving
Cognitive behavioral therapy
Coping skills
Stress reduction
Postpartum Depression
Special Topic # 3
• See separate Power Point presentation