Major Depressive Disorder

Major Depressive Disorder The next slide shows the sources for this series of questions and answers. As of 1 February 2014.

MDD - sources Unless otherwise noted, the questions are from: • DSM-IV-TR, pages 369-376 • Practice Guideline for the Treatment of Patients with Major Depressive Disorder, second edition, published as supplement to AJP, April 2000 • Guideline Watch on above Disorder, available at www.psych.org., 2005.

DSM-IV-TR • Since the Boards will be based on DSM-IV-TR through 2014 [and maybe beyond], these screens use DSM-IV-TR, NOT YET DSM-5.

Dx criteria for MDD Q. List the dx criteria for Major Depressive Disorder. Assume rule outs of other disorders, such as never had a manic episode, and just list the signs/symptoms of “depressive event.”

MDD criteria Ans. Five or more of nine: • *Depressed mood [irritable mood is also an option in children and adolescence] • *Markedly diminished interest in activities. • Weight loss of gain of 5%/month. • Insomnia or hypersomnia *Has to have one of these two. [see next screen for other five]

MDD criteria Continued: 5. Psychomotor agitation or retardation 6. Anergy 7. Feelings of worthlessness or guilt 8. Decreased ability to think or to decide 9. Ideation of death or suicide. Except for #3 above, “every day” applies to each of these signs

Melancholic specifier Q. What is the criteria for the melancholic specifier?

Melancholic specifier Ans. Meets both A and B infra. • Either or both: 1. loss of pleasure in virtually all activities 2. Feels dysphoric even when something good happens B. See next screen

Melancholic specifier Continued B. At least three: • Dysphoric feeling is more profound than what the pt experienced in the past as grief. • Dysphoria worse in AM • Awakes early in AM • Psychomotor retardation or agitation • Significant weight loss • Inappropriate guilt

Atypical specifier Q. Basic criteria of atypical specifier is?

Atypical Specifier Ans. • Reacts positively to good news/events. • Two or more of: -- increase appetite or weight gain -- hypersomnia -- heavy/leaden feeling in arms/legs -- very prone to disabling interpersonal rejection sensitivity

Melancholic studies Q. What lab studies are more common in pts with melancholic specifier than other MDD pts?

Melancholic studies Ans. More likely to have: • Nonsuppression of dexamethasone • Plasma, urine and saliva elevated cortisol levels • Abnormal tyramine challenge test • Abnormal asymmetry on dichotic listening tests.

Neurotransmitters monoamine Q. Name the three major monoamine systems that are disturbed in MDD.

Neurotransmitters - monoamine Ans. -- serotonin -- norepinephrine -- dopamine [Kandel ER et al: Principles of Neural Science. 1991]

Neurotransmitters – non-monoamine Q. Two non-monoamine neurotransmitters system that are often disturbed are?

Neurotransmitters – non-monoamine Ans. -- Corticotropin-releasing factor [CRF] -- Substance P [Schecter LE et al: NeuroRx 2005;590-611.]

5-HT Q. In depression, 5-hydroxytryptamine [serotonin] levels are?

5-HT Ans. Low in CSF, blood platelets and postmortem brain tissue. [Cheetham SC et al: Brain Res 1988;443:272-280]

MDD - suicide • Q. Rate of suicide in people with MDD?

MDD - suicide Ans. Up to 15%.

Suicide prediction Q. The ability of clinicians to predict suicide is?

Suicide prediction Ans. “Poor.” It remains a clinical judgment. No rating scales are useful to facilitate clinical judgment, and no “scores” should be relied upon to be predictive.

MDD – death rate, >55 y/o Q. What is death rate of people with MDD and > 55 y/o in comparison to those without MDD?

MDD – death rate, > 55 y/o • Ans. Fourfold increase in death rate.

Dysthymia >> MDD Q. What percentage of people with dysthymia, who have not yet had MDD, will go on to have MDD within one year of onset of dysthymia if not treated?

Dysthymia >> MDD Ans. 10% [Text not clear if this is also true of those treated.]

Prevalence Q. About what percent of the population will have symptoms of MDD over a year from onset?

Prevalence Ans. 7% [Kessler RC et al: Arch Gen Psychiatry 2005:62:617-627]

MDD – prevalence – gender Q. Life-time prevalence by gender? Community sample prevalence by gender?

MDD – prevalence - gender Ans. Life-time: women: 10-25% men: 5-12% Community sample at a given time: women: 5-9% men: 2-3% {So, depending on how the question is asked, at least 2/3 are women.}

MDD – prevalence - ethnicity Q. How does ethnicity relate to prevalence?

MDD – prevalence - ethnicity Ans. DSM says “unrelated.”

MDD – prevalence - education Q. How does education relate to MDD?

MDD – prevalence - education Ans. DSM says “unrelated.”

MDD – prevalence - income Q. Prevalence of MDD and income?

MDD – prevalence - income Ans. Unrelated.

MDD – prevalence – marital status Q. Marital status’s relationship to MDD?

MDD – prevalence – marital status Ans. DSM says unrelated.

MDD – prevalence - generation Q. Prevalence of MDD and more recent generations, e.g., born in 1930 in comparison to born in 1940.

MDD – prevalence - generation Ans. More recent generations have a higher rate of MDD. Thus, people in their 60ies born in the 1940s will have a higher rate that people who were in their sixties who were born in the 1930s. Bottom line, the rate in the population is increasing.

Prevalence - atypical Q. Among MDD pts, roughly what proportion have the atypical specifier?

Prevalence - atypical Ans. About 1/5. [Quitkin F: J Clin Psychiatry 2002;4:94-99.]

MDD - onset Q. Most common age of onset?

MDD - onset Ans. Mid-20s.

MDD – second episode Q. You are seeing a pt who is having her first episode of MDD. What are chances of a second?

MDD - second A. 60%

MDD - third Q. You are seeing a pt who is having his second episode of MDD. What are the chances of a 3rd?

MDD – third episode Ans. 70%

Major Depressive Disorder