Depressive Disorders: Diagnosis & Treatment

Objective 1: read Townsend (2014) page 379 (historical perspective) before listening to the recording for this handout. This handout will inform you about how the DSM-5 presents this weeks assigned psychiatric disorders. Assigned questions 2/student are noted on this handout. We will apply the NP in class on Friday, February 7, 2014. NP content is in Townsend (2014) pages 392-403. My apology for the page numbers from DSM-5 (2013) just ignore those; any important page numbers for Townsend have been added to this handout. The depressive disorders these depressive disorder diagnoses relate to Objective 3, Townsend (2014) page 378 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 DSM-IV-TR -> DSM-5 Unlike in DSM-IV depressive disorders is separated from bipolar disorders. Depressive disorders in DSM-5 differ by : duration, timing, or presumed etiology The common feature of all depressive disorders in DSM-5 is the presence of : sad, empty, or irritable mood accompanied by somatic changes and cognitive changes that significantly affect capacity to function

Disruptive Mood Dysregulation Disorder 296.99 Coding numbers associated with each diagnosis are used to receive reimbursement for services related to the particular psychiatric diagnosis; we will discuss related nursing diagnoses in class. There is a very helpful Table 16-5 in Townsend (2014) pages 395-396) This section relates to Objective 6, Townsend (2014) page 378 (symptomatology): A. Severe recurrent temper outbursts manifested verbally &/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts re inconsistent with developmental level. C. The temper outbursts occur, on average, three or more times per week. D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others. E. Criteria A-D present for 12 or more months with no period lasting 3 or more consecutive months without A-D. F. Criteria A & D present in at least 2 of 3 settings & severe in at least 1 setting. G. The diagnosis should not be made for the first time before age 6y or after age 18y. H. By history or observations, the age of onset of Criteria A-E is before 10y. I. There has never been a distinct period lasting >1d during which the full symptoms criteria, except during, for a manic or hypomanic episode have been met. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder. K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition. Diagnostic Features Core feature is chronic, severe persistent irritability with 2 prominent manifestations: frequent temper outbursts & chronic, persistently irritable or angry mood present between severe temper outbursts
2

Prevalence this relates to Objective 2, Townsend (2014) page 378 (epidemiology) Disruptive mood dysregulation disorder is common among children presenting to pediatric mental health clinics Prevalence estimates of the disorder in the community are unclear but probably fall in the 2-5% range Rates are expected to be higher in males & school-age children than in females & adolescents Development & Course this relates to Objective 5, Townsend (2014) page 378 Onset must be before age 10y The diagnosis should not be used for children < 6y Approximately 50% of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1y later Rates of conversion to bipolar disorder are very low & these children tend to develop unipolar depressive &/or anxiety disorders as adults Risk & Prognostic Factors Tempermental Children typically exhibit complicated psychiatric histories Pre-diagnostic presentations of chronic irritability may meet the diagnostic criteria for oppositional defiant disorder Children may also meet the diagnostic criteria for ADHD and an anxiety disorder from a relatively early age For some children diagnostic criteria for major depressive disorder may also be met Genetic & physiological This disorder tends to be associated with familial anxiety disorders, mood disorders, and substance abuse Gender-Related Diagnostic Issues Children presenting to clinics with features of disruptive mood dysregulation disorder are predominately male A male preponderance also appears to be supported in the community This is a difference when compared to bipolar disorder, in which there is an equal gender prevalence
3

Suicide Risk In general, evidence documenting suicide behavior and aggression, as well as other severe functional consequences, in disruptive mood dysregulation disorder should be noted when evaluating children with chronic irritability Functional Consequences Marked disruption in a child s: family relationships peer relationships - trouble initiating & sustaining friendships school performance Common to both DMDD and pediatric bipolar disorder are: dangerous behavior Suicidal ideation or attempts severe aggression psychiatric hospitalization Differential Diagnosis Bipolar disorders Oppositional defiant disorder ADHD Major depressive disorder Anxiety disorders Autism spectrum disorder Intermittent explosive disorder Co-morbidity Rates of comorbidity in DMDD are extremely high It is rare to find persons whose symptoms meet criteria for DMDD alone Also, the range of comorbid illnesses appears particularly diverse However, children with DMDD should not have symptoms that meet criteria for bipolar disorder If symptoms meet criteria for ODD or IED & DMDD, only the diagnosis of DMDD should be assigned Also, DMDD should not be assigned if the symptoms occur only in an anxietyprovoking context (ex. ASD, OCD, MDD)
4

Major Depressive Disorder This section relates to Objective 6, Townsend (2014) page 378 (symptomatology for MDD) A. Five or > present during the same 2w period representing a change from previous functions with at least one symptom either depressed moor or loss of interest/pleasure: Depressed mood, diminished interest, change in >5% of weight/m with change in appetite, sleep changes, psychomotor retardation or agitation, fatigue, feelings of worthlessness/guilt, difficulty concentrating, and thoughts of death B. Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning C. Episode not attributable to the physiological effects of a substance or to another medical condition Occurrence of MDE is not better explained by: Schizoaffective disorder Schizophrenia Schizophreniform disorder Delusional disorder or Other specified & unspecified schizophrenia spectrum & other psychotic disorders E. There has never been a manic or hypomanic episode Diagnostic Features Symptoms of MDD must be present nearly every day with the exception of weight change and SI Depressed mood must also be present for most of the day in addition to being present nearly every day Caution: insomnia or fatigue is often the presenting complaint Psychomotor disturbance much < common but indicative of greater overall severity, as is delusional or near-delusional guilt Anhedonia is nearly always present to some degree Appetite & sleep disturbances considered hallmarks Distractible, difficulty thinking may be mistaken for dementia (pseudodementia)

Thoughts of death, SI, suicide attempts may range from passive to transient but recurrent to putting affairs in order, acquiring means, and choosing a location and time. Associated Features MDD is associated with high mortality mostly suicide but other examples include greatly increased likelihood of death in the first year after being admitted to a nursing home Often present: tearful irritable brooding obsessively ruminating phobic excessively worrying about physical health complaints of pain in children separation anxiety Prevalence -this relates to Objective 2, Townsend (2014) page 378 (epidemiology) 12m prevalence of MDD in US is ~7% with marked differences by age and gender: Age: 18-29y 3x > persons 60y Gender: females 1.5-3x > males beginning in early adolescence Development & Course May first appear at any age Likelihood of onset increases markedly with puberty U.S. incidence appears to peak in 20 s However, first onset in late life is not uncommon Course is: Variable Chronicity > underlying personality, anxiety and substance use disorders Recovery typical within 3m of onset for 40% & within 1y for 80% Risk of recurrence becomes progressively lower as duration of remission increases Risk & Prognostic Factors this relates to predisposing factors in Townsend (2014) Temperamental - Neuroticism (negative affectivity)
6

Environmental -Adverse childhood experiences & stressful life events Genetic & physiological - First-degree family members with MDD increases risk 2-4X > than the general population (or ~40% heritability) Course modifiers: Substance abuse Anxiety BPD Chronic, disabling medical conditions Culture-Related Diagnostic Issues Clinicians should be aware that in most countries the majority of cases of depression go unrecognized in primary care settings In many cultures, somatic symptoms are very likely to constitute the presenting complaint insomnia and loss of energy most commonly reported Gender-Related Diagnostic Issues Aside from prevalence of MDD there are no clear differences between genders observed in: Symptoms Course Treatment response Functional consequences Suicide attempt > in females; completion > in males but disparity in suicide rate by gender is not as great with depressive disorders as it is in the general population Most consistently described risk is past history of suicide attempts or threats (BPD markedly increases risk for future attempts) However, most completed suicides are not preceded by unsuccessful attempts Other risk factors include: Male Single or living alone Prominent feelings of hopelessness
7

Suicide Risk

Functional Consequences Impairment may be mild such that persons who interact with the depressed person are unaware of his/her depressed symptoms Impairment may range to complete incapacity with the person unable to attend to basic self-care needs or is mute or catatonic In general medical settings persons experiencing MDD have > pain and physical illness Differential Diagnosis Manic episodes with irritable mood or mixed episodes Mood disorder due to another medical condition Substance/medication-induced depressive or bipolar disorder ADHD Adjustment disorder with depressed mood Sadness Co-morbidity Substance-related disorders Panic disorder OCD Anorexia nervosa Bulimia nervosa BPD 300.4 Persistent Depressive Disorder - This section relates to Objective 6, Townsend (2014) page 378 (symptomatology) A. Depressed mood most of day, > days than not, subjective or objective, for at least 2y B. While depressed 2 or > of appetite changes, sleep changes, fatigue, low selfesteem, poor concentration, feelings of hopelessness C. During the 2y period (1y for C&A) person never without criteria A & B > 2m at a time
8

D. Criteria continually present for 2y E. Never a manic or hypomanic episode nor cyclothymia F. Not better explained by persistent schizophrenia spectrum or psychotic disorder G. Not attributable to physiological effects of a substance or another medical condition H. Symptoms cause significant distress or functional impairment See specifiers, DSM-5 (2013) page 169 Diagnostic Features Essential feature of dysthymia is depressed mood for most of day, > days than not for at least 2y (1y for C&A) Consolidates DSM-IV chronic MDD & dysthymic disorder Prevalence 12m U.S. prevalence ~0.5% for persistent depressive disorder and ~1.5% for chronic major depressive disorder Development & Course - this relates to Objective 5, Townsend (2014) page 378 Onset is often early & insidious Early onset associated with a higher likelihood of co-morbid Personality disorders & Substance use disorders By definition the course is chronic Risk &Prognostic Factors Temperamental Factors predictive of poorer long-term outcome include: higher levels of negative affectivity Greater symptom severity Poorer global functioning Presence of anxiety disorder or Presence of conduct disorder Environmental Parental loss Parental separation Persons with dysthymia will have a higher proportion of first-degree relatives with dysthymia
9

Genetic & physiological

Functional Consequences

A number of brain regions have been implicated in dysthymia Possible polysomnographic abnormalities exist as well

The degree to which dysthymia impacts functioning likely varies widely, but effects can be as great or > than with MDD Differential Diagnosis MDD Psychotic disorders Depressive or bipolar & related disorder due to another medical condition Substance/medication-induced depressive or bipolar disorder Personality disorders Co-morbidity Higher risk for psychiatric comorbidity in general & particularly anxiety disorders and substance use disorders than persons with MDD Early-onset dysthymia strongly associated with DSM-IV personality disorders in cluster B (antisocial, borderline, histrionic, narcissistic) & cluster C (avoidant, dependent, OCD) 625.4 Premenstrual Dysphoric Disorder -This section relates to Objective 6, Townsend (2014) page 378 (symptomatology) A. In the majority of menstrual cycles, at least 5 symptoms present the final week before onset of menses B. One or > marked affective lability, irritability, depressed mood, anxiety C. One or > must also be present to total 5: Decreased interest in usual activities Subjective difficulty concentrating Easy fatigability Appetite changes Sleep changes Sense of being overwhelmed or out of control Physical symptoms such as breast tenderness, joint or muscle pain, bloating, weight gain D. Clinically significant distress or functional impairment
10

E. Not just an exacerbation of another disorders but may co-occur F. Provisional diagnosis made until at least 2 symptomatic cycles are confirmed G. Not attributable to a substance or another medical condition Recording Procedures If symptoms have not been confirmed by prospective daily ratings of a least two symptomatic cycles, then provisional should be noted after the name of the diagnosis: Premenstrual dysphoric disorder, provisional Diagnostic Features Mood lability Irritability Dysphoria Anxiety There must be a symptom-free period in the follicular phase after the menstrual period begins Associated Features Delusions & hallucinations have been described in the late luteal phase of the menstrual cycle but are rare The premenstrual phase has been considered by some to be a risk period for suicide Prevalence 12m prevalence 1.8 5.8% in menstruating women Best estimate is 1.3% meeting current criteria with functional impairment and without co-occurring symptoms from another mental disorder Development & Course - this relates to Objective 5, Townsend (2014) page 378 Any time after menarche Symptoms cease after menopause Cyclical hormone replacement can trigger the re-expression of symptoms Risk & Prognostic Factors Environmental
11

Stress History of interpersonal trauma Seasonal changes Sociocultural factors related to: Female sexual behavior Female gender role Genetic & physiologic - Unknown Course modifiers - Fewer premenstrual complaints are associated with use of oral contraceptives Culture-Related Diagnostic Issues Not a culture-bound syndrome Unclear whether rates differ by race Help-seeking patterns may be significantly influenced by cultural factors Diagnostic Markers Daily Rating of Severity of Problems Visual Analogue Scales for Premenstrual Mood Symptoms Premenstrual Tension Syndrome Rating Scale Functional Consequences Symptoms must be associated with clinically meaningful distress or functional impairment in the week prior to menses Chronic interpersonal problems should not be confused with the dysfunction that occurs only in association with premenstrual dysphoric disorder. Differential Diagnosis Premenstrual syndrome Dysmenorrhea Bipolar disorder Major depressive disorder Persistent depressive disorder (dysthymia) Use of hormonal treatments

12

Co-morbidity A wide range of medical and mental disorders may worsen in the premenstrual phase: Migraine Asthma Allergies SZ depressive disorder Bipolar disorder Anxiety disorders Bulimia nervosa Substance use disorders Substance/Medication-Induced Depressive Disorder (DSM-5, 2013) ICD-9-CM Recording Procedures Naming the substance/medication-induced depressive disorder begins with: The specific substance presumed to be causing the depressive symptoms Followed by specification of onset - Onset during intoxication or onset during withdrawal Example: 292.84 cocaine-induced depressive disorder, with onset during withdrawal Diagnostic Features The depressive symptoms are associated with the ingestion, injection or inhalation of a substance and symptoms persist beyond the expected length of the physiological effects, intoxication or withdrawal period Prevalence In a nationally representative U. S. adult population, the lifetime prevalence of substance/medication-induced depressive disorder is 0.26% Development & Course this relates to Objective 5, Townsend (2014) page 378 Onset must occur while the person is using the substance OR during withdrawal Most often onset is within the first few weeks or 1m use of the substance Once the substance is D/C d symptoms usually remit within days to several weeks (depending upon half-life)
13

A history of certain identified substances may help increase diagnostic certainty Risk &Prognostic Factors Temperamental - Pertain to the specific type of drug Environmental - Pertain to the specific type of medication Course modifiers - more likely to be: Male Black Have at most a high school education Lack insurance Lower family income Stressful life events in past 12m Higher family history of: substance abuse and/or APD

Diagnostic Markers diagnosis Suicide Risk

Laboratory assays of the suspected substance in blood or urine to corroborate the

FDA meta-analyses reveal an absolute risk of suicide in patients taking investigational antidepressants of 0.01% (this evidence indicates that suicide is an extremely rate treatment-emergent phenomenon) FDA Black Box Warning (2007) carefully monitor treatment-emergent SI in patients receiving antidepressants Differential Diagnosis Substance intoxication and withdrawal Primary depressive disorder Depressive disorder due to another medical condition Co-morbidity Any DSM-IV mental disorder Pathological gambling Paranoid personality disorder Histrionic personality disorder APD
14

Alcohol use disorder Depressive Disorder Due to Another Medical Disorder This section relates to Objective 6, Townsend (2014) page 378 (symptomatology) A. A prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all, or almost all, activities that predominates the clinical picture B. Evidence from history, physical exam or lab findings that the disturbance is the direct consequence of another medical condition C. Not better explained by another mental disorder in which the stressor is a serious medical condition D. Does not occur exclusively during the course of a delirium E. Causes clinically significant distress or functional impairment Specify if: With depressive features With major depressive-like episode With mixed features

Diagnostic Features

Clinician must first establish the presence of a general medical condition Mood disturbance is present in time of onset, exacerbation or remission of the general medical condition Features are atypical of primary mood disorders Associated Features The list of medical conditions that are able to induce major depression is never complete Clinicians best judgment is the essence of this diagnosis However, there are clear associations with: Stroke Huntingtons disease Parkinsons disease TBI Cushings disease Hypothyroidism MS
15

Development & Course this relates to Objective 5, Townsend (2014) page 378 Example: Following stroke the onset of depression has been observed to be very acute, occurring within 1d or a few days of the CVA; however, cases have been noted where onset of depression was weeks to months following CVA Risk & Prognostic Factors Risk of acute, early onset of MDD following CVA appears to be strongly correlated with lesion location, with the greatest risk associated with (L) frontal strokes Gender-Related Diagnostic Issues Gender differences pertain to those associated with the medical condition (ex. SLE, CVA) Diagnostic Markers Diagnostic markers pertain to those associated with the medical condition (ex. Cushings) Suicide Risk No epidemiological studies providing evidence to differentiate risk from suicide related to MDD versus MDD due to another medical condition There is a clear association between serious medical illness and suicide, particularly shortly after onset or diagnosis of the illness Functional Consequences Functional consequences pertain to those associated with the medical condition Differential Diagnosis Depressive disorders not due to another medical condition Medication-induced depressive disorder Adjustment disorders Co-morbidity Conditions comorbid with depressive disorder due to another medical condition are those associated with the medical conditions of etiological relevance Delirium may occur before or along with depressive symptoms in persons with a variety of medical conditions
16

The association of anxiety symptoms is common in depressive disorders regardless of the cause 311 Other Specified Depressive Disorder This section relates to Objective 6, Townsend (2014) page 378 (symptomatology) Used in situations in which the clinician chooses to communicate the specific reason this presentation does not meet the criteria for any specific depressive disorder Examples: Recurrent brief depression Short-duration depressive episode (4-13d) Depressive episode with insufficient symptoms

311 Unspecified Depressive Disorder

Applies to presentations in which symptoms characteristic of a depressive disorder causing clinical significant distress or functional impairment do not meet the full criteria for any of the disorders in this depressive disorders diagnostic class Use this diagnosis in situations in which you choose not to specify the reason that the criteria are not met for a specific depressive disorder (possibly due to insufficient information to make a > specific dx such as in the emergency department) Specifiers for Depressive Disorders With anxious distress With mixed features With melancholic features With atypical features With psychotic features With catatonia With peripartum onset With seasonal pattern Also specify if in partial remission or full remission Also specify current severity
17

Objectives 7 -12, Townsend (2014) will be discussed in class 2/7/14. Student assignments:

Herbert: (1) Describe how individual psychotherapy is used as a treatment

modality for depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe how group therapy is used as a treatment modality for depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Allyson: (1) Describe how family therapy is used as a treatment modality for
depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe how cognitive therapy is used as a treatment modality for depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Shauntay: (1) Describe how electroconvulsive therapy (ECT) is used as a treatment

modality for depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe how transcranial magnetic stimulation is used as a treatment modality for depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Erica: (1) Describe how light therapy is used as a treatment modality for depression
(supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe how psychopharmacology is used as a treatment modality for depression (supplement your answer with the
18

information from at least one current scholarly article & attach the article to your answer).

Tatyana: (1) Describe the interactions the nurse needs to be aware of that may
occur when a patient is prescribed a tricyclic antidepressant (TCA) to treat depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe the interactions the nurse needs to be aware of that may occur when a patient is prescribed a monoamine oxidase inhibitor (MAOI) to treat depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Denea: (1) Describe the interactions the nurse needs to be aware of that may occur
when a patient is prescribed a selective serotonin reuptake inhibitor (SSRI) to treat depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe the interactions the nurse needs to be aware of that may occur when a patient is prescribed a serotoninnorepinephrine reuptake inhibitor (SNRI) to treat depression (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Sophie: (1) Describe the most common side effects that occur with SSRIs
(supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe the most common side effects that occur with MAOIs (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Samantha: (1) Describe the client/family education related to antidepressants

(supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe the epidemiology of suicide
19

(supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Cheryl: (1) Describe how to assess the client for suicide potential (supplement your
answer with the information from at least one current scholarly article & attach the article to your answer). (2) Describe protective factors for suicide risk (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Garrett: (1) Identify nursing diagnoses and related outcomes for the suicidal client
(supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) Identify appropriate nursing interventions for the suicidal client (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Anna: (1) What suggestions should be made for the family and friends of a person
who is suicidal? (supplement your answer with the information from at least one current scholarly article & attach the article to your answer). (2) What are appropriate nursing interventions for families and friends of suicide victims? (supplement your answer with the information from at least one current scholarly article & attach the article to your answer).

Juliana: (1) How does the RN conduct evaluation of the suicidal client? (supplement
your answer with the information from at least one current scholarly article & attach the article to your answer). (2)

Juliana & Dana: Remaining questions will be

assigned for chapter 17: Bipolar and Related Disorders.

20

Reviewed & revised 2/4/14 -lgf

21