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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 378Disruptive mood dysregulation disorderMajor depressive disorderPersistent depressive disorder (dysthymia)Premenstrual dysphoric disorderSubstance/medication-induced depressive disorderDepressive disorder due to another medical conditionOther specified depressive disorderUnspecified depressive disorder

DSM-IV-TR -> DSM-5Unlike 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 moodaccompanied by somatic changesand cognitive changesthat significantly affect capacity to function

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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

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Prevalence this relates to Objective 2, Townsend (2014) page 378 (epidemiology)Disruptive mood dysregulation disorder is common among children presenting to

pediatric mental health clinicsPrevalence estimates of the disorder in the community are unclear but probably

fall in the 2-5% rangeRates are expected to be higher in males & school-age children than in females &

adolescentsDevelopment & Course this relates to Objective 5, Townsend (2014) page 378

Onset must be before age 10yThe diagnosis should not be used for children < 6yApproximately 50% of children with severe, chronic irritability will have a

presentation that continues to meet criteria for the condition 1y laterRates of conversion to bipolar disorder are very low & these children tend to

develop unipolar depressive &/or anxiety disorders as adultsRisk & Prognostic Factors

TempermentalChildren typically exhibit complicated psychiatric historiesPre-diagnostic presentations of chronic irritability may meet the diagnostic

criteria for oppositional defiant disorderChildren may also meet the diagnostic criteria for ADHD and an anxiety disorder

from a relatively early ageFor some children diagnostic criteria for major depressive disorder may also be

metGenetic & physiological

This disorder tends to be associated with familial anxiety disorders, mood

disorders, and substance abuseGender-Related Diagnostic Issues

Children presenting to clinics with features of disruptive mood dysregulationdisorder are predominately maleA male preponderance also appears to be supported in the communityThis is a difference when compared to bipolar disorder, in which there is an equal

gender prevalence

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Suicide RiskIn 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 irritabilityFunctional Consequences

Marked disruption in a childs:family relationships

peer relationships - trouble initiating & sustaining friendshipsschool performance

Common to both DMDD and pediatric bipolar disorder are:dangerous behaviorSuicidal ideation or attemptssevere aggressionpsychiatric hospitalization

Differential DiagnosisBipolar disordersOppositional defiant disorderADHDMajor depressive disorderAnxiety disordersAutism spectrum disorderIntermittent explosive disorder

Co-morbidityRates of comorbidity in DMDD are extremely highIt is rare to find persons whose symptoms meet criteria for DMDD aloneAlso, the range of comorbid illnesses appears particularly diverseHowever, children with DMDD should not have symptoms that meet criteria for

bipolar disorderIf symptoms meet criteria for ODD or IED & DMDD, only the diagnosis of DMDD

should be assignedAlso, DMDD should not be assigned if the symptoms occur only in an anxiety-

provoking context (ex. ASD, OCD, MDD)

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Major Depressive DisorderThis 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 deathB. Symptoms cause clinically significant distress or impairment in social,

occupational or other important areas of functioningC. Episode not attributable to the physiological effects of a substance or to

another medical conditionOccurrence of MDE is not better explained by:

Schizoaffective disorderSchizophreniaSchizophreniform disorderDelusional disorder orOther specified & unspecified schizophrenia spectrum & other

psychotic disordersE. There has never been a manic or hypomanic episode

Diagnostic FeaturesSymptoms of MDD must be present nearly every day with the exception of weight

change and SIDepressed mood must also be present for most of the day in addition to being

present nearly every dayCaution: insomnia or fatigue is often the presenting complaintPsychomotor disturbance much < common but indicative of greater overall severity,

as is delusional or near-delusional guiltAnhedonia is nearly always present to some degreeAppetite & sleep disturbances considered hallmarksDistractible, difficulty thinking may be mistaken for dementia (pseudodementia)

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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 homeOften present:

tearfulirritablebroodingobsessively ruminatingphobicexcessively worrying about physical healthcomplaints of painin 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 60yGender: females 1.5-3x > males beginning in early adolescence

Development & Course

May first appear at any ageLikelihood of onset increases markedly with pubertyU.S. incidence appears to peak in 20sHowever, first onset in late life is not uncommon Course is:

VariableChronicity > underlying personality, anxiety and substance use disordersRecovery typical within 3m of onset for 40% & within 1y for 80%Risk of recurrence becomes progressively lower as duration of remission

increasesRisk & Prognostic Factors this relates to predisposing factors in Townsend (2014)

Temperamental -Neuroticism (negative affectivity)

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Environmental -Adverse childhood experiences & stressful life eventsGenetic & physiological - First-degree family members with MDD increases risk 2-4X >

than the general population (or ~40% heritability)Course modifiers:

Substance abuseAnxietyBPDChronic, disabling medical conditions

Culture-Related Diagnostic IssuesClinicians should be aware that in most countries the majority of cases of

depression go unrecognized in primary care settingsIn many cultures, somatic symptoms are very likely to constitute the presenting

complaint insomnia and loss of energy most commonly reported

Gender-Related Diagnostic IssuesAside from prevalence of MDD there are no clear differences between genders

observed in:SymptomsCourseTreatment responseFunctional consequences

Suicide RiskSuicide 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

populationMost 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:

MaleSingle or living aloneProminent feelings of hopelessness

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Functional ConsequencesImpairment may be mild such that persons who interact with the depressed person

are unaware of his/her depressed symptomsImpairment may range to complete incapacity with the person unable to attend to

basic self-care needs or is mute or catatonicIn general medical settings persons experiencing MDD have > pain and physical

illnessDifferential Diagnosis

Manic episodes with irritable mood or mixed episodesMood disorder due to another medical conditionSubstance/medication-induced depressive or bipolar disorderADHDAdjustment disorder with depressed moodSadness

Co-morbiditySubstance-related disordersPanic disorderOCD

Anorexia nervosaBulimia nervosaBPD

300.4Persistent 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 least2yB. While depressed 2 or > of appetite changes, sleep changes, fatigue, low self-

esteem, poor concentration, feelings of hopelessnessC. During the 2y period (1y for C&A) person never without criteria A & B > 2m at a

time

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D. Criteria continually present for 2yE. Never a manic or hypomanic episode nor cyclothymiaF. Not better explained by persistent schizophrenia spectrum or psychotic disorderG. Not attributable to physiological effects of a substance or another medical

conditionH. Symptoms cause significant distress or functional impairmentSee specifiers, DSM-5 (2013) page 169

Diagnostic FeaturesEssential 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

Prevalence12m U.S. prevalence ~0.5% for persistent depressive disorder and ~1.5% for chronic

major depressive disorderDevelopment & Course- this relates to Objective 5, Townsend (2014) page 378

Onset is often early & insidiousEarly onset associated with a higher likelihood of co-morbid Personality disorders

& Substance use disordersBy definition the course is chronic

Risk &Prognostic FactorsTemperamental

Factors predictive of poorer long-term outcome include:higher levels of negative affectivityGreater symptom severityPoorer global functioningPresence of anxiety disorder or

Presence of conduct disorderEnvironmental

Parental lossParental separation

Genetic & physiologicalPersons with dysthymia will have a higher proportion of

first-degree relatives with dysthymia

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A number of brain regions have been implicated in

dysthymiaPossible polysomnographic abnormalities exist as well

Functional ConsequencesThe degree to which dysthymia impacts functioning likely varies widely, but effects

can be as great or > than with MDDDifferential Diagnosis

MDDPsychotic disordersDepressive or bipolar & related disorder due to another medical conditionSubstance/medication-induced depressive or bipolar disorderPersonality disorders

Co-morbidityHigher risk for psychiatric comorbidity in general & particularly anxiety disorders

and substance use disorders than persons with MDDEarly-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 mensesB. One or > marked affective lability, irritability, depressed mood, anxietyC. One or > must also be present to total 5:

Decreased interest in usual activitiesSubjective difficulty concentratingEasy fatigabilityAppetite changesSleep changesSense of being overwhelmed or out of controlPhysical symptoms such as breast tenderness, joint or muscle

pain, bloating, weight gainD. Clinically significant distress or functional impairment

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E. Not just an exacerbation of another disorders but may co-occurF. Provisional diagnosis made until at least 2 symptomatic cycles are confirmedG. Not attributable to a substance or another medical condition

Recording ProceduresIf symptoms have not been confirmed by prospective daily ratings of a least two

symptomatic cycles, thenprovisionalshould be noted after the name of the

diagnosis:Premenstrual dysphoric disorder, provisionalDiagnostic Features

Mood labilityIrritabilityDysphoriaAnxietyThere must be a symptom-free period in the follicular phase after the menstrual

period beginsAssociated 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 suicidePrevalence

12m prevalence 1.8 5.8% in menstruating womenBest estimate is 1.3% meeting current criteria with functional impairment and

without co-occurring symptoms from another mental disorderDevelopment & Course - this relates to Objective 5, Townsend (2014) page 378

Any time after menarcheSymptoms cease after menopauseCyclical hormone replacement can trigger the re-expression of symptoms

Risk & Prognostic FactorsEnvironmental

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StressHistory of interpersonal traumaSeasonal changesSociocultural factors related to:

Female sexual behaviorFemale gender role

Genetic & physiologic - UnknownCourse modifiers - Fewer premenstrual complaints are associated with use of oral

contraceptivesCulture-Related Diagnostic Issues

Not a culture-bound syndromeUnclear whether rates differ by raceHelp-seeking patterns may be significantly influenced by cultural factors

Diagnostic MarkersDaily Rating of Severity of ProblemsVisual Analogue Scales for Premenstrual Mood SymptomsPremenstrual Tension Syndrome Rating Scale

Functional ConsequencesSymptoms 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 syndromeDysmenorrheaBipolar disorderMajor depressive disorder

Persistent depressive disorder (dysthymia)Use of hormonal treatments

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Co-morbidityA wide range of medical and mental disorders may worsen in the premenstrual

phase:MigraineAsthmaAllergiesSZdepressive disorderBipolar disorderAnxiety disordersBulimia nervosaSubstance 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 symptomsFollowed by specification of onset - Onset during

intoxication or onset during withdrawalExample: 292.84 cocaine-induced depressive disorder, with onset during withdrawalDiagnostic 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 periodPrevalence

In a nationally representative U. S. adult population, the lifetime prevalence of

substance/medication-induced depressive disorder is 0.26%Development & Coursethis relates to Objective 5, Townsend (2014) page 378

Onset must occur while the person is using the substance OR during withdrawalMost often onset is within the first few weeks or 1m use of the substanceOnce the substance is D/Cd symptoms usually remit within days to several weeks

(depending upon half-life)

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A history of certain identified substances may help increase diagnostic certaintyRisk &Prognostic Factors

Temperamental - Pertain to the specific type of drugEnvironmental - Pertain to the specific type of medicationCourse modifiers - more likely to be:

MaleBlackHave at most a high school educationLack insuranceLower family incomeStressful life events in past 12mHigher family history of: substance abuse

and/or APDDiagnostic Markers

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

diagnosisSuicide Risk

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 antidepressantsDifferential Diagnosis

Substance intoxication and withdrawalPrimary depressive disorderDepressive disorder due to another medical condition

Co-morbidityAny DSM-IV mental disorderPathological gamblingParanoid personality disorderHistrionic personality disorderAPD

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Alcohol use disorderDepressive Disorder Due to Another Medical DisorderThis 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 conditionC. Not better explained by another mental disorder in which the stressor is a serious

medical conditionD. 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 episodeWith mixed features

Diagnostic FeaturesClinician must first establish the presence of a general medical conditionMood disturbance is present in time of onset, exacerbation or remission of the

general medical conditionFeatures are atypical of primary mood disorders

Associated FeaturesThe list of medical conditions that are able to induce major depression is never

completeClinicians best judgment is the essence of this diagnosisHowever, there are clear associations with:

StrokeHuntingtons diseaseParkinsons diseaseTBICushings diseaseHypothyroidismMS

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Development & Coursethis relates to Objective 5, Townsend (2014) page 378Example: 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 strokesGender-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 conditionThere is a clear association between serious medical illness and suicide, particularly

shortly after onset or diagnosis of the illness

Functional ConsequencesFunctional consequences pertain to those associated with the medical condition

Differential DiagnosisDepressive disorders not due to another medical conditionMedication-induced depressive disorderAdjustment disorders

Co-morbidityConditions comorbid with depressive disorder due to another medical condition are

those associated with the medical conditions of etiological relevanceDelirium may occur before or along with depressive symptoms in persons with a

variety of medical conditions

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The association of anxiety symptoms is common in depressive disorders regardless

of the cause

311 Other Specified Depressive DisorderThis 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 disorderExamples:

Recurrent brief depressionShort-duration depressive episode (4-13d)Depressive episode with insufficient

symptoms311 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 classUse 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 featuresWith melancholic featuresWith atypical featuresWith psychotic featuresWith catatoniaWith peripartum onsetWith seasonal patternAlso specify if in partial remission or full remissionAlso specify current severity

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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 treatmentmodality 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


article & attach the article to your answer). (2) Describe how psychopharmacology is

used as a treatment modality for depression (supplement your answer with the

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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


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 serotonin-

norepinephrine 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


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


article & attach the article to your answer). (2) Describe the epidemiology of suicide

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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


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.

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Reviewed & revised 2/4/14 -lgf

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