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Mood Disorders

(11-27-12)

“And Theo is probably right. I am depressed. And I almost like it. Depression is seductive: it offends and teases, frightens you and draws you in, tempting you with its promise of sweet oblivion, then overwhelms you with a nearly sexual power, squirming past your defenses, dissolving your will, invading the tired spirit so utterly that it becomes difficult to recall that you ever lived without it . . . or to imagine that you might live that way again. With all the guile of Satan himself, depression persuades you that its invasion was all your own idea, that you wanted it all along. It fogs the part of the brain that reasons, that knows right and wrong. It captures you with its warm, guilty, hateful pleasures, and, worst of all, it becomes familiar. All at once, you find yourself in thrall to the very thing that most terrifies you. Your work slides, your friendships slide, your marriage slides, but you scarcely notice; to be depressed is to be half in love with disaster.”

(Stephen Carter, 2002, The Emperor of Ocean Park)
  • Depression
  • Mania
  • Suicide
  • Specifiers for Mood Disorders:
    • severity/remission
    • interepisode course
    • atypical features

Depression

(10-2-06)

Modification of DSM-IV criteria for depressed preschool children: see Luby, Mrakotsky, Heffelfinger, Brown, Hessler, & Spitznagel, 2003.

Clinically Useful Depression Outcome Scale (CUDOS) (Zimmerman, Posternak, & CHelminski, 2004)

Depression

Emergence of gender differences in rates of depression by age 14 is robust finding across different countries, instruments, and conceptualization of depression (Wade, Cairney, & Pevalin, 2002).

Oquendo et al. (2004) failed to find evidence that the symptoms or subtypes of depression were stable from one episode to another in a group of inpatients with major depressive disorder: “there may be a single superfamily of mood disorder that is pleomorphic in its manifestations across episodes within indivdiual patients.” (p. 260).

Proposed diagnostic criteria for Minor Depressive Disorder (Judd, et al., 2004).

Major Depressive Disorder

  • Genetic influences:
    • May be influenced by different genes in males and females.
      • ZUBENKO GS, Maher BH, Hughes HB III, Zubenko WN, Stiffler JSS, Kaplan BB, Marazita ML:Genome-wide linkage survey for genetic loci that influence the development of depressive disorders in families with recurrent, early-onset, major depression. Am. J. Med. Genet (Neuropsychiatr. Genet.), in press, 2003. Online ISSN: 1096-8628. Available online July 2, 2003.
  • Precipitating events
    • The relationship between stressful life events and Major Depressive Disorder is strongest for the first episode and tends to decline with subsequent episodes. This observation is the basis of the “kindling hypothesis”: depressive episodes become more progressively more autonomous and less liked to environmental adversity. Kendler, Thornton, & Gardner (2001) found that the decline in association was strongest for those with weak genetic risk for depression, and weak or absent in those at high genetic risk. They concluded that, “Genetic risk factors for depression produce a ‘prekindling’ effect rather than increase the speed of kindling. The ‘kindled’ state, wherein depressive episodes occur with little provocation, may be reached by two pathways: many previous depressive episodes, perhaps driven by multiple adversities, and high genetic risk.” (Kendler, Thornton, & Gardner, 2001, p. 582).
    • Stability of symptoms across episodes of MDD: 2 recent studies appeared to reach contridictory findings regarding the consistency (or lack thereof) of symptoms experienced over successive episodes of MDD. Oquendo et al. (2004) found a lack of predictability regarding which symptoms of depression would occur over episodes of severe depression, and also found no consistency in the symptoms seen as characteristic of specific types of depression (atypical, melancholic, psychotic). Korszun et al. (2004) reported finding five groups of symptoms that clustered together, with the 2nd, 3rd, and 4th “dimensions” more highly correlated among siblings. The five groupings were:
    • – sadness, hopelessness, loss of pleasure & interest in life
    • – slow movements, lethargy, loss of energy, sexual interest, and initiative
    • – anxiety
    • – restlessness, agitation, irritabilty, guilt, and suicidal tendencies
    • – excessive sleep and appetite

Dysthymic Disorder

  • Course
    • In a report on a five-year follow up of 86 patients with early onset dysthymic disorder, Klein et al. (2000) found high chronicity, relapse, and eventual development of Major Depressive Disorder
    • Hayden & Klein (2001) found that comorbid anxiety disorder, cluster C and depressive personality features, and chronic stress were associated with a lower recovery rate at 5 year follow up; while a family history of bipolar disorder was associated with a higher recovery rate.
    • “Chronic stress was one of the strongest predictors of both failure to recover and depressive symptoms at 5-year follow-up.” (Hayden & Klein, 2001, p. 1868)
    • “almost all individuals with dysthymic disorder experience exacerbations that meet criteria for a major depressive episode, or ‘double depression’, at some point in their lives.” (Hayden & Klein, 2001, p. 1864)
  • Symptom Picture
    • Masi, et al., (2003) studied the symptom presentation of Dysthymic Disorder in children and adolescents: “Our findings on the entire sample of patients with DD showed that irritability, fatigue or loss of energy, low self-esteem, depressed mood, guilt, concentration difficulties, anhedonia, and hopelessness are present in more than 50% of subjects. Other studies have underscored that the predominant mood in early-onset depressive disorders is irritability and dysphoria rather than sadness or melancholia (24). Most reported symptoms pertain to emotional or cognitive, rather than somatic and vegetative domains.” (p. 102).
    • Masi, et al. (2003) suggest the alternative DSM-IV research diagnostic criteria for DD may be more appropriate for juvenile dysthymia.
    • Masi, et al. (2003) report that “pure DD” in children and adolescents is characterized primarily by emotional-cognitive manifestations–“the very symptoms reported by children and adolescents–not their parents.” (p. 104).

Criteria for Minor Depressive Disorder (all three are required)

  1. National Institute of Mental Health Diagnostic Interview Schedule (DIS), depression section
    • at least 2 weeks of depressed mood/dysphoria/sadness (DIS01 criterion)
    • and
    • Pervasive loss of interest/pleasure (DIS02 criteria)
    • and
    • One or more other depressive symptoms from DIS
    • OR
    • at least 2 weeks of depressed mood/dysphoria/sadness (DIS01 criterion)
    • and
    • Pervasive loss of interest/pleasure (DIS02 criteria) (but not both)
    • and
    • Two or more other depressive symptoms from DIS
  2. Global Assessment of Functioning Scale score less than or equal to 70
  3. Medical Outcomes Study 36-Item Short-Form Health Survey Social role function score less than or equal to 75 AND/OR Emotional role function score less than or equal to 67

(adapted from Judd, et al., 2004, p. 1870)

Mania

“DIGFAST”

  • Distractibility–Poorly focused, multitasking
  • Insomnia–Decreased need for sleep
  • Grandiosity–Inflated self-esteem
  • Flight of Ideas–Complaints of racing thoughts
  • Activities–Increased goal-directed activities
  • Speech–pressured or more talkative
  • Thoughtlessness–“Risk-taking” behaviors (sexual, financial, travel, driving)

(Ghaemi S.N. Primary Psychiatry. 2001;8:28-34)

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