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Major Depressive Disorder – Course, Natural History and Prognosis

This slide covers course, natural history and prognosis of Major Depressive Disorder. It covers the definition for depression based on WHO’s ICD-10 classification system or the American Psychiatric  Association’s DSM-IV and DSM-5 system.

Slide deck scheduled for review summer 2022.

This slide deck covers the course, natural history, and prognosis of Major Depressive Disorder (MDD). This includes the definition of depression based on WHO’s ICD-10 classification system or the American Psychiatric Association’s DSM-IV and DSM-5 system.

This slide deck has been developed in collaboration with the former Lundbeck International Neuroscience Foundation.

Index for slide deck

Course, natural history and prognosis.

Slide deck scheduled for review su…

This slide shows core definitions for depression based on World Health Organization’s ICD-10 classification system or the American Psychiatric Association’s DSM-IV and DSM-5 system.

References: NICE CG90. Depression in adults: recognition and management. 2009. Update Apri…

Reference: American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th edition:  American Psychiatric Association. 2013

Depression is a clinically heterogeneous disorder

References: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

Jaeger J et al. Psychiatry Res 2006; 145: 39–48.

World Health Organization Depression Fact Sheet N3…

Cognitive symptoms of depression have a negative impact on many aspects of the patient’s life

References: McIntyre RS et al. Depress Anxiety 2013; 30(6): 515–527.

Hammar A, Ardal G. Front Hum Neurosci 2009; 3:26. doi: 10. 3389/neuro. 09. 026. 2009.

MDD symptoms – American Psychiatric Association

The American Psychiatric Association (APA) describes nine depressive symptoms for diagnostic purposes. [APA, 2013]

Depressed mood

• Patients may describe their mood as depressed, sad, hopeless, discouraged, or ‘down in the dumps’. [APA, 2013] Alternatively, the patient may …

MDD symptoms – The Montgomery-Åsberg Depression Rating Scale

The Montgomery–Åsberg Depression Rating Scale (MADRS), which was designed to be sensitive to the effects of antidepressants, includes ten depressive symptoms, six of which are described as ‘core symptoms’. [Montgomery & Asberg, 1979; Beck et al., 2002]

MADRS item 1. Appare…

The course of MDD

The optimal outcome for a patient with major depressive disorder (MDD) is a full recovery from the major depressive episode and to never become depressed again. [Nierenberg & DeCecco, 2001] Treatment of MDD is divided into three phases, corresponding to different stages of…

MDD is a complex, often recurrent and remitting disorder

Previous slide illustrates the typical course of illness for patients with depression; either receiving only acute-phase treatment or receiving longer-term treatment designed to prevent relapse. It also highlights that long-term treatment of depression with antidepressant…

Definitions of Clinical Course and Treatment Outcomes I

Source (slide): Nierenberg et al. J Clin Psychiatry 2003; 64 (suppl 15): 13–17; page 13 (‘Remission, relapse, recurrence’ section)

Riso et al. J Affect Disord 1997; 43 (2): 131–142

Nierenberg & DeCecco. J Clin Psychiatry 2001; 62 (suppl 16): 5–9; page 8

Frank et al. Arc…

Definitions of Clinical Course and Treatment Outcomes

MDD is a chronic disorder, most frequently characterised by relapses and recurrences. [Nierenberg et al., 2003] Relapse can be defined as an episode of MDD that occurs within 6 months of response or remission; [Nierenberg et al., 2003; Riso et al., 1997] theoretically, rela…

MDD specifiers – I

References on the slide: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition (DSM-5™). © American Psychiatric Association, 2013.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fou…

MDD specifiers – II

Oxford Concise Medical Dictionary. Second Edition. © Oxford University Press, 1998.

MDD specifiers – III

Mdd specifiers – iv, mdd specifiers – v, depression – dsm-5: updates from dsm-iv.

Highlights of Changes from DSM-IV-TR to DSM-5. American Psychiatric Association 2013. Available from: https://www.psychiatry.org/dsm5 . Accessed April 2016.

While bereavement may precipitate major depression in people who are especially vulnerable (i.e. they have already s…

Recurrent Brief Depressive Disorder

References: American Psychiatric Association (1994)

Angst et al (1990)

Subsyndromal symptoms of Unipolar Depression and Bipolar Depression

References: Howarth et al (1992)

Johnson et al (1992)

Judd et al (1994)

Differential diagnosis

Differential diagnosis is the distinguishing of a disorder from others presenting with similar signs and symptoms.

Manic episodes with irritable mood; mixed episodes (bipolar disorder) Major depressive episodes with prominent irritable mood may be difficult to distinguis…

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Depression: Powerpoint Presentation slides (mhGAP) recommended

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What is depression?

• It is a medical illness that involves the mind and body.
• It is more than feeling blue, down in the dumps, or sad about a particular issue or situation.
• It interferes with a person’s function in daily living, relationship, and work life.
• It is a condition that requires diagnosis and treatment by a trained healthcare provider.

What is NOT depression?

• It is NOT a normal part of aging
• It is NOT something to be a shamed of
• It is NOT a character flaw or sign of weakness
• It is NOT something you can just “snap out of”

Who suffers from depression?

Depression is a common condition that affects

about 19 million American adults every year.

What are the symptoms of depression?

Why do people get depression?

There is no one single cause.

Depression happens because of a combination of things:

• Brain chemistry
• Environment and psychological factors
• Medical conditions / medications - Must rule out!

Two neurotransmitters involved in depression

Concentration

Depressed Mood

Irritability

Thought process

Norepinephrine

Vague Aches and pain

�Can a person have depression and another illness at the same time?

• Anxiety disorders, including
• post-traumatic stress disorder (PTSD),
• obsessive-compulsive disorder (OCD),
• panic disorder,
• social phobia,
• generalized anxiety disorder (GAD);
• Alcohol and other substance abuse or dependence;
• Medical problems, including
• heart disease,
• stroke, cancer,
• Parkinson's disease.

Different forms of depression

• Major Depressive Disorder
• Melancholic
• Dysthymic Disorder
• Double Depression
• Postpartum Depression
• Seasonal Affective Disorder

What are my treatment options?

• Psychotherapy
• Electroconvulsive therapy

Psychotherapy, aka “talk therapy”

• Best treatment for mild to moderate depression
• 2 main types:
• Cognitive-behavorial therapy
• Interpersonal therapy

Medications

• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin & norepinephrine reuptake inhibitors (SNRIs)
• Monoamine oxidase inhibitors (MAOIs)

Electroconvulsive therapy (ECT)

• For severe cases in which therapy and/or medication does not treat depression
• Used to have a bad reputation and was known as “shock therapy”
• Today, ECT has greatly improved and has shown to help those who cannot feel better with other treatments

How can I find help?

• Talk to your family doctor
• Others who can help: Psychiatrists, psychologists, licensed social workers, or licensed mental health counselors, Health maintenance organizations, Community mental health centers, Hospital psychiatry departments and outpatient clinics, Mental health programs at universities or medical schools, State hospital outpatient clinics, Family services, social agencies or clergy, Peer support groups, Private clinics and facilities, Employee assistance programs, Local medical and/or psychiatric societies.

How can I afford treatment?

• Low-fee / sliding scales at some clinics or health centers

�What if I or someone I know is in crisis?

• Call your doctor.
• Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
• Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
• Make sure you or the suicidal person is not left alone.
• National Institute of Mental Health http://www.nimh.nih.gov/
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . �Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.

Stress, Anxiety and Depression

Sep 20, 2012

570 likes | 1.23k Views

Stress, Anxiety and Depression. Presentation for Youthnet, Cottage Boardroom, Nov 16, 2005. Michael Cheng, Psychiatrist http://www.drcheng.ca. This presentation is protected under a Creative Commons Deed ( http://creativecommons.org/licenses/by-nc-sa/2.0/

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Stress, Anxiety and Depression Presentation for Youthnet, Cottage Boardroom, Nov 16, 2005 Michael Cheng, Psychiatrist http://www.drcheng.ca

This presentation is protected under a Creative Commons Deed (http://creativecommons.org/licenses/by-nc-sa/2.0/ • You are free to copy, distribute, display and perform this work, as long as this work is not used for commercial purposes

Goals • An overview about stress, anxiety and depression in youth • What is it • What causes it • What can you do about it • Where to get help (in Ottawa)

Top Questions from Youthnet Facilitators • What is the meaning of life? • What is bipolar? • Common causes of teenage depression? • What to do when having an anxiety attack? • Where to refer someone with mood/anxiety problems (in Ottawa)?

It’s All About Balance

Q. What do normal people need in life?

Everyone needs a healthy body, mind, spirit Body • Body (Physical, Biological Self) • Mind (Psychological, Emotional Self) • Spirit (Spiritual Self) Note: Overlap, e.g. psychological interventions can cause biological changes, and vice versa Mind Spirit

The Triple A Agency / Autonomy / Achievement Activity (as opposed to passivity) Affiliation (Relationships)

The Triple C Control “Chipper” (or being active) Connections with Others

Three P’s Power Proactive People

Point A Point B (Goals)

Obstacles such as stress (at home, school, work), depression, anxiety Point A Point B (Goals)

Life is full of things that cause imbalance (in mind, body, spirit)

Typical stresses in our modern society • Body • Medical / physical illness • Lack of sunlight / Drug Use • Mind / Social • School / Work • Classmates / co-workers • Family • Friends • Boyfriends/girlfriends • Spirit

Life is a balance between coping and stress Demands / Expectations / Stresses Coping Ability

Problems if demands, expectations or stresses outweigh coping Coping Ability Demands / Expectations / Stresses

There are two solutions to restore the balance...  Coping Ability Demands / Expectations / Stresses

Stress can lead to: • Physical problems • Emotional or mood problems such as • Depression • Anxiety • Eating Disorders • OCD • Any problems with mood/coping...

Prevalence of Mental Disorders in Children and Adolescents in Canada (Stats Can, 2002, age 0-19)

Mood Disorders: What is It? • Everyone gets sad from time to time • Just enough sadness is good because it alerts people to do something to change their situation • Mood disorders are when people’s moods are so extreme that it gets in the way of life • It is not normal, and is not something that someone can easily ‘snap out of’

Mood Disorders: To Diagnosis or Not to Diagnosis? • Classified according to the DSM-IV • For formal DSM-IV criteria for disorders, visit www.mentalhealth.com • Although imperfect, the DSM-IV nonetheless reflects an improvement from the past, when there was no common language in talking about what was, or was not a mental condition • Each version of the DSM gives us a greater understanding of mental conditions

Mood Disorders: To Diagnosis or Not to Diagnosis? • Pros • Gives us a common language • Allows people to learn and get support about their condition or problems • Cons • Being ‘labelled’ may carry a stigma (perhaps stigma is the true problem?) • The fact that people may misuse a diagnosis to avoid responsibility for a problem • Being put into a box

My personal bias... • Appropriate use of a ‘diagnosis’ in the right situation can be helpful

Example of How To Use a Diagnosis • “You’ve told me that before having these problems with your mood, you were always a happy, high achieving, outgoing person.” • “You’ve mentioned having problems with your mood, sleep, appetite, concentration and energy, and that you’ve been feeling hopeless.” • It sounds like you may have a medical condition called depression. The good news is that this condition is very treatable and we can help you feel better again.”

Example of How To Use a Diagnosis (Cont’d) • “You are not responsible for causing this condition.” • “However, it is mainly up to you to get better.” • “But the good news is that you are not alone – we will support you in overcoming the depression.”

Mood Disorders: Types • Major Depression (aka Clinical Depression, Major Depressive Episode) • Dysthymic Disorder (aka low grade depression) • Adjustment Disorder (mood problems following a stress, but not severe enough to be major depression • Bipolar Disorder

Major Depression • Problems with mood (sad, angry, irritable), PLUS • Physical problems with • Sleep, Energy, Appetite, Concentration • May also have problems with • Thoughts • Low self-esteem • Hopelessness / Suicidal thoughts • Behaviors • Social withdrawal, loss of function

Dysthymic Disorder • Problems with mood (sad, angry, irritable), PLUS • Some physical problems • Some problems with • Thoughts • Behaviors • BUT is not as severe as Major Depression

Adjustment Disorder • Problems with mood (which are not severe enough to meet for depression or dysthymic disorder) following a stress • Does not involve significant changes

Bipolar Disorder • A condition with severe highs and lows where one’s moods are like a roller coaster, to the point it causes problems • During highs • Mood high or irritable, excessive energy, less need for sleep, excess talking, excess activities • During lows • No energy, depressed mood, more need to sleep, i.e. essentially like being depressed

Anxiety Disorders • Everybody has worries and gets anxious from time to time • Just enough anxiety is helpful because it keeps us cautious and safe • Anxiety Disorders are when one has so many worries that they get in the way of life

Types of Anxiety Disorders (or Conditions) • Generalized Anxiety Disorder • Constant worries with physical symptoms that cause problems • Panic Disorder • Out of the blue feelings of panic that cause problems • Obsessive Compulsive Disorder • Repetitive thoughts or behaviors that cause problems • Social Anxiety Disorder • Extreme shyness that causes problems

Restoring the Balance

A General Approach to Helping Others • Figure out the person’s goals • “What would you like to get from coming here to see me/us?” • Figure out what to do to get to that goal • “What do you think we need to do to get to your goal?”

A General Approach to Helping Others • Figure out what stress is causing (or contributing to) the anxiety or depression • Usual stresses include • School • Family • Friends • Problem-solve and find ways to deal with that stress

Approach to Conflicts • Conflict is when two parties want or expect different things • Solution • Figure out what each party wants or expects from the other • Ensure it is reasonable • For things that each party wants in common, great! • For things that each party disagrees on, negotiate and compromise

Body • Ensure healthy amounts of • Sleep • Diet/nutrition • Exercise • Individual exercise • Group / social exercise • Yoga / Martial Arts • Sunlight (in the case of winter depression)

Body • Medications may be a helpful ‘body’ or physical intervention in certain circumstances • For anxiety and depression, in general • Non-medication strategies are tried first • Medications are used if non-medication strategies are unsuccessful

Body • Common types of ‘self-medication’ • Sweets, carbohydrates, chocolates • May possibly be a way of getting serotonin • Exercise • May be a way of getting adrenaline / dopamine • Caffeine • May be a way of getting adrenaline / dopamine • Street drugs

Mind • Ensure good coping strategies and ways to deal with stress • School / work • Family • Friends and • Boyfriends/girlfriends

Mind • Psychotherapy such as cognitive behavior therapy • Anxiety or depression is caused by cognitive distortions • Fixing cognitive distortions will overcome the anxiety or depression

Spirit • Figure out what gives meaning to the person’s life • Ensure those things are in the person’s life

Types of Help for Anxiety and Depression • Speaking with friends • Speaking with family • Speaking with religious supports (e.g. chaplain, priest, rabbi, iman, etc.)

Types of Professional Help for Anxiety and Depression • School personnel (teachers, guidance counselors, vice-principal, social workers, coach, etc.) • Medical Doctors (family physicians, pediatricians, psychiatrist) • Psychologists • Counselors • Social Workers

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Depression: Dysthymic Disorder

It seems that you like this template, depression: dysthymic disorder presentation, free google slides theme and powerpoint template.

Dysthymia, also known as persistent depressive disorder, is a type of depression that often goes unnoticed. Why is that? Because the patient believes that the symptoms (mainly those from depression) are just part of their own nature, making them believe that there's nothing wrong with them. It's best if we leave the actual definitions to true psychologists, like you! This sober template can be useful to raise awareness about this condition, or to inform about its existence and its signs. Notice the use of shadows on the backgrounds and the neutral color palette to underline the serious side of the matter.

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Patient Case Presentation

Ms. A. M. is a 23 year old biracial female who arrives to her primary care clinic for her annual physical. Ms A.M. has had a 15lb weight gain since her last visit. She complains of feelings of guilt and sadness with her parents’ recent divorce. Patient states she is not sleeping well and feels that she cannot concentrate during her nursing orientation classes. When asked about her interpersonal relationships, she states that she just ended her two-year relationship with her boyfriend and she states that she hasn’t been able to meet new friends or keep up with current friendships.

Past Medical/Surgical History

• Asthma diagnosed at age 8
• Hypothyroidism diagnosed at age 16

Pertinent Family History

• Older sister with suicide attempt 3 years prior.
• Father diagnosed with Bipolar II in his thirties, currently taking medication.
• Mother alive and healthy at age 54
• Uncle with history of substance abuse

Pertinent Social History

• recently graduated college and is starting her career as a nurse at a large teaching hospital on the intensive care unit
• parents recently divorced
• moving out on her own for the first time