Depression

(Mood – pervasive[means must last for longer duration] in nature

Affect - transient [for short duration]

Higher than baseline- Activities(high), called Elated, Before it was called Mania.

Most mood disorders are Episodic (6 to 8 months)

– Duration must be more than 6 months)

Depressive Disorders
Depressive disorders are a group of mental health conditions characterized by
persistent feelings of sadness, Inhedonia- loss of interest in previously enjoyed
activities, and various emotional and physical symptoms that significantly impair
daily functioning. These disorders can affect anyone, regardless of age or
background, and are often more prevalent among women.

 All mood disorders are formally called Affective Disorders.

 Some people with mood disorders experience only time periods or
episodes characterized by depressed moods. However, other people
experience manic episodes at certain time points and depressive episodes
at other time points.
 Normal mood states can occur between both types of episodes.
 Manic and depressive mood states are often conceived to be at opposite
ends of a mood continuum, with normal mood in the middle.
 In 2021, around 21 million adults in the U.S. experienced at least one major
depressive episode, representing 8.3% of the adult population.
 Approximately 56 million Indians are estimated to suffer from depression,
according to the World Health Organization (WHO).
Symptoms

Common symptoms across various depressive disorders include:

- Persistent sadness or low mood

- Loss of interest or pleasure in activities

- Changes in appetite (either increased or decreased)

- Sleep disturbances (insomnia or hypersomnia)

- Fatigue or loss of energy

- Feelings of worthlessness or excessive guilt

Difficulty concentrating or making decisions

- Thoughts of death or suicide.

Types-
• Two broad types:

– Involves only depressive symptoms

– Involves manic symptoms (bipolar disorders)

• DSM-IV-TR depressive disorders:

– Major depressive disorder

– Dysthymia(Persistent Depressive Disorder)

• DSM-5 adds three new depressive disorders:

– Mixed anxiety/depressive disorder

– Premenstrual dysphoric disorder

 – Disruptive mood dysregulation disorder

• DSM-IV-TR/DSM-5 Bipolar Disorders:

– Bipolar I disorder

– Bipolar II disorder

– Cyclothymia

Types of Depressive Disorders

(Bipolar Affective disorder (BPAD) means one episode of depression and other
episode of mania.

– If someone has mania, he had depression for sure, doesn’t matter for how
long it lasted)

1. Major Depressive Disorder (MDD): Also known as clinical depression, MDD is

marked by severe symptoms that interfere with daily life. To be diagnosed,
symptoms must persist for at least two weeks and include a depressed mood or
loss of interest in activities, along with additional symptoms such as changes in
appetite or sleep patterns, fatigue, feelings of worthlessness, and thoughts of
suicide.

2. Persistent Depressive Disorder (Dysthymia): This form involves chronic

depression lasting for at least two years but with less severe symptoms than
MDD. Individuals may experience a consistently low mood along with other
symptoms like low energy and poor self-esteem.

3. Perinatal Depression: This type occurs during pregnancy or after childbirth. It

includes both prenatal depression (during pregnancy) and postpartum depression
(after the baby is born) and can significantly affect new mothers.
4. Seasonal Affective Disorder (SAD): This type of depression is linked to seasonal
changes, typically occurring in the fall and winter months when daylight hours are
shorter.

5. Depressive Disorder Due to Another Medical Condition: Sometimes depression

can be secondary to other medical issues, such as chronic illness or hormonal
changes.

6. Substance-Induced Depressive Disorder: This occurs when depressive

symptoms arise due to substance use or withdrawal from drugs or alcohol.

Major Depression Disorder

Patients may appear miserable, with tearful eyes, furrowed brows, down-
turned corners of the mouth, slumped posture, poor eye contact, lack of
facial expression, little body movement, and speech changes (eg, soft
voice, lack of prosody[pattern of rhythm in speech], use of
monosyllabic words). Appearance may be confused with Parkinson disease. In
some patients, depressed mood is so deep that tears dry up; they report
that they are unable to experience usual emotions and feel that the world
has become colorless and lifeless.

Duration- Symptoms must be present for at least two weeks.

Median Age of MDD Onset by Generation

The diagnostic criteria for major depressive disorder (MDD; also known as “major
depression”) require that a person must be in a major depressive episode and
never have had a manic, hypomanic, or mixed episode.

• Sad mood OR loss of interest or pleasure (anhedonia)

– Symptoms are present nearly every day, most of the day, for at least
2 weeks

– Not due to normal bereavement (present in DSM-IV-TR but removed

in DSM-5)

• PLUS four of the following symptoms:

– Sleeping too much or too little

– Psychomotor retardation or agitation

– Poor appetite and weight loss, or increased appetite and weight gain
 – Loss of energy

– Feelings of worthlessness or excessive guilt

– Difficulty concentrating, thinking, or making decisions

– Recurrent thoughts of death or suicide

• Episodic

– Symptoms tend to dissipate over time

• Recurrent

– Once depression occurs, future episodes likely

• Average number of episodes is 4

• Subclinical depression

– Sadness plus 3 other symptoms for 10 days

– Significant impairments in functioning even though full diagnostic

criteria are not met

• Chronic depressive disorder

– Depressed mood for at least 2 years; 1 year for children/adolescents

– PLUS 2 other symptoms:

• Poor appetite or overeating

• Sleeping too much or too little

• Poor self-esteem

• Trouble concentrating or making decisions

• Feelings of hopelessness
Dysthymia

– DSM-IV-TR but not DSM-5 criteria specify that no major depressive

episode was present during the first 2 years of symptoms

• DSM-5 does not distinguish between chronic MDD and

dysthymia

• Chronicity of symptoms stronger predictor of negative

outcomes than number of symptoms

• In a 10-year study, 95% of patients with dysthymic disorder

developed MDD (Klein et al. 2006).

Disruptive Mood Dysregulation(DMDD)

Disruptive Mood Dysregulation Disorder (DMDD) is a mental health condition

primarily affecting children and adolescents, characterized by severe irritability
and frequent temper outbursts.

## Overview of Disruptive Mood Dysregulation Disorder

- Definition: DMDD is a mood disorder recognized in the DSM-5 that manifests as

persistent irritability and severe temper outbursts that are disproportionate to
the situation. It is specifically diagnosed in children and adolescents aged 6 to 18
years, with symptoms typically emerging before age 10.

Diagnostic Criteria (DSM-5)

To be diagnosed with DMDD, the following criteria must be met:

1. Severe Recurrent Outbursts: The child experiences severe temper outbursts
(either verbal or behavioral) that are grossly out of proportion in intensity or
duration to the provocation. These outbursts occur three or more times per week.

2. Inconsistent with Developmental Level: The temper outbursts are

inappropriate for the child's developmental level.

3. Persistent Mood: Between outbursts, the child exhibits a persistently irritable

or angry mood most of the day, nearly every day, observable by others.

4. Duration: The symptoms must be present for at least 12 months, with no

period lasting three or more consecutive months without all symptoms.

5. Impairment Across Settings: Symptoms must be present in at least two settings

(e.g., home, school, with peers) and cause significant impairment in functioning.

6. Onset before age 10.

Symptoms

Children with DMDD may exhibit:

- Frequent and intense temper tantrums.

- Chronic irritability or anger.

- Difficulty functioning in social settings, at home, or at school due to their mood

issues.

- Outbursts that are inappropriate for their age and context.

## Causes and Risk Factors

While the exact causes of DMDD are not fully understood, several factors may
contribute:

- Neurological Factors: Brain chemistry and neurological development may play a

role.

- Environmental Factors: Stressful life events such as trauma or family issues can
increase vulnerability.

- Family History: A family history of mood disorders may increase risk

Treatment Options

Treatment for DMDD typically involves:

- Psychotherapy: Individual therapy focusing on emotion regulation skills,

cognitive-behavioral therapy (CBT), and family therapy.

- Medication: In some cases, medications such as antidepressants or mood

stabilizers may be prescribed to manage symptoms.

Long-Term Outlook

Children diagnosed with DMDD are at a higher risk of developing anxiety and
depression later in life. Early intervention and appropriate management strategies
can help mitigate these risks and improve overall functioning.

Bipolar disorders-
• Three forms:

– Bipolar I, Bipolar II, and Cyclothymia

• Mania defining feature of each

• Differentiated by severity and duration of mania

– Usually involve episodes of depression alternating with mania

 • Depressive episode required for Bipolar II, but not Bipolar I

• Mania

– State of intense elation or irritability

– Hypomania (hypo = “under”; hyper = “above”)

• Symptoms of mania but less intense

• Does not involve significant impairment, mania does

• Bipolar I

– At least one episode or mania

• Bipolar II

– At least one major depressive episode with at least one episode of

hypomania

• Cyclothymic disorder (Cyclothymia)

– Milder, chronic form of bipolar disorder

• Lasts at least 2 years in adults, 1 year in children/adolescents

– Numerous periods with hypomanic and depressive symptoms

• Does not meet criteria for mania or major depressive episode

• Symptoms do not clear for more than 2 months at a time

Epidemiology
• Prevalence rates lower than MDD

– 1% in U. S.; 0.6% worldwide for Bipolar I

– 0.4% – 2% for Bipolar II

– 4% for Cyclothymia
 • Average age of onset in 20s

• No gender differences

– Women experience more depressive episodes

• Severe mental illness

– A third unemployed a year after hospitalization (Harrow et al., 1990)

– Suicide rates high (Angst et al., 2002)

Proposed DSM-5 Criteria for

Manic and Hypomanic Episodes
• Distinctly elevated or irritable mood for most of the day nearly every day

• Abnormally increased activity and energy

• At least three of the following are noticeably changed from baseline (four if
mood is irritable):

– Increase in goal-directed activity or psychomotor agitation

– Unusual talkativeness; rapid speech

– Flight of ideas or subjective impression that thoughts are racing

– Decreased need for sleep

– Increased self-esteem; belief that one has special talents, powers, or

abilities

– Distractibility; attention easily diverted

– Excessive involvement in activities that are likely to have undesirable

consequences, such as reckless spending, sexual behavior, or driving

• For a manic episode:

– Symptoms last for 1 week or require hospitalization

 – Symptoms cause significant distress or functional impairment

• For a hypomanic episode:

– Symptoms last at least 4 days

– Clear changes in functioning that are observable to others, but

impairment is not marked

– No psychotic symptoms are present

Psychological Treatment of Mood Disorders

• Interpersonal psychotherapy (IPT)

– Short-term psychodynamic therapy

– Focus on current relationships

• Cognitive therapy

– Monitor and identify automatic thoughts

• Replace negative thoughts with more neutral or positive

thoughts

• Mindfulness-based cognitive therapy (MBCT)

– Strategies, including meditation, to prevent relapse

• Behavioral activation (BA) therapy

– Increase participation in positively reinforcing activities to disrupt

spiral of depression, withdrawal, and avoidance

• Behavioral couples therapy

– Enhance communication and satisfaction