Posted: March 12th, 2023

DB

What are the three most important things you learned this week?

What questions remain uppermost in your mind?

Is there anything you did not understand?

Just a few sentences for each question based on powerpoint

Depressive disorders

Feb 20 2023

Announcements
Office hours – Wed Feb 22 at 1030am
Writing the HPI and other note writing resources

APA
surviving
residency guide

Canvas
Course related questions?

What were your takeaways from the learning materials?
Podcast – diet and exercise as treatments
Quiz question #5 – depressive disorder due to another medical condition
TMS/ECT/ketamine treatment – research is ongoing, effects of ketamine are variable, ECT is effective, past hx of efficacy of ECT can predict future outcomes
Refer for ECT/TMS evaluation
Differences between MDD and dysthymia – diagnoses can co-exist, may change diagnoses over time
ECT for treatment resistant cases
DSM description of co-existing diagnoses – something like bereavement can cause symptoms that meet criteria for MDD

What questions do you have?
When is ECT recommended/used?
What would warrant ECT during pregnancy?
Anticonvulsants during ECT – hold the night before treatment
Is a seizure disorder a contraindication to ECT? No?

Review of pathophysiology of depressive disorders
What can contribute to depressive symptoms?
Heterogeneous diagnostic category
The only depressive disorders diagnoses that require a certain etiology are medication/substance induced and due to a medical condition

Assessing patients presenting with depressive symptoms
Terminology: Depressed vs. distressed
Communication approaches
Other factors: Grief and loss, stress, trauma, medical conditions
Specific symptomatology
Duration and course of illness
Appearance on MSE
SAFE-T

Treatment options
It’s not all about medication
What are other evidence based treatment recommendations?
How to make treatment decisions
How to talk about these with patients

DSM Depressive disorders category
Disruptive mood dysregulation disorder (DMDD)
Major depressive disorder (MDD)
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

DMDD (F34.8)
History of this diagnosis (new to DSM-5)
Diagnosed between the ages of 6 and 18, age of onset before 10
Severe recurrent temper outbursts that are not developmentally appropriate
Differentiating between mood elevation/mania/hypomania
Childhood bipolar should not be diagnosed based on irritability, distractibility, poor judgment
Elated mood, decreased need for sleep (not the same as insomnia), and episodicity are more diagnostic
Note mutually exclusive diagnoses: ODD, IED, bipolar
Can be diagnosed along with: MDD, ADHD, substance use disorders, conduct disorder

MDD (F32 [single episode] or 33 [recurrent episodes] plus
Heterogenous diagnostic category, several diagnoses were combined in DSM-III
Can be episodic or chronic based on DSM criteria
At least 5 criteria need to be met (must incl. depressed mood OR loss of interest or pleasure), at least two weeks, change from previous level of functioning
Mutually exclusive with psychotic disorders (but there is MDD with psychotic features)
No history of manic or hypomanic episodes
Specifiers (next slide)

Specifiers
With anxious distress
With mixed features – includes at least 3 specific manic/hypomanic symptoms present nearly every day for the majority of days of the MDE
With melancholic features
With atypical features
With mood congruent or mood incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern
In partial remission, in full remission
Mild, moderate, severe

Dysthymia (F34.1)
Used to be considered a personality trait (depressive personality disorder)
Depressed mood more days than not for at least 2 years (chronic)
In children/adolescents, mood can be irritable and lasting 1 year
Also needs 2 or more of 6 other symptoms
If full criteria for MDD have been met at some point, MDD should be diagnosed
No manic or hypomanic episodes or cyclothymia or psychotic disorders
Specifiers (next slide)

Dysthymia specifiers
Many are the same as MDD
With early onset (prior to age 21), with late onset (21 or older)
With pure dysthymic syndrome
With persistent MDE
With intermittent MDE, with current episode
With intermittent MDE, without current episode

Premenstrual dysphoric disorder (N94.3)
In the majority of menstrual cycles in the past year, at least 5 symptoms must be present in the week before the onset of menses and improve with onset of menses
Symptoms are not the result of an exacerbation of another disorder

Substance/medication induced depressive disorder (various ICDs)
Prominent and persistent disturbance in mood, includes depressed mood or anhedonia
Requires direct evidence that symptoms developed after exposure to the substance, and the substance is capable of producing the symptoms
Not better explained by a different depressive disorder
Does not occur during delirium

Depressive disorder due to another medical condition (F06.31, 32, or 34)
Mood symptoms must be the direct physiologic effect of the medical condition
Symptoms are not better explained by another disorder
Does not occur in the context of delirium

Other specified depressive disorder (F32.8)
Depressive symptoms with an explanation of why the symptoms don’t meet criteria for another disorder
Examples of designations:
Recurrent brief depression
Short-duration depressive episode
Depressive episode with insufficient symptoms

Unspecified depressive disorder (F32.9)
Symptoms do not meet full criteria for another disorder and no explanation of why
May include situations where there is insufficient information to make another diagnosis

Group work
Start out by discussing group norms for communication and workflow, will you use google docs, how will you all agree when the assignment is ready to submit, etc.
Consider assigning group leads for all of the modules you’ll be working on with this group
Group leader should be responsible for creating working documents, submitting assignments, and organizing the work for the week
Two assignments for each week: case study and mini-paper
Mini-paper is due as a DB post by Wednesday, case study is due as an assignment submission by Saturday

Student responsibilities
You are responsible for developing a working knowledge and understanding of all of the other diagnoses in the week’s diagnostic category
You are responsible for reviewing all other group mini-paper DB submissions and using them to guide your studying of the other diagnoses for that week
You are responsible for sharing anything you are confused about on your one minute paper for the week
There is no requirement for responses to DB posts, but feel free to reply if you want

Other follow ups
Be sure to rotate tasks/jobs within your group so everyone gets a chance to write different sections of the note
Check in at the beginning of each week’s class to review how things went the previous week and whether you need to revise any of your group norms
APA format NOT needed
Citations – do not need to cite the DSM, if you are mentioning statistics/numbers, etc., let us know where you got them from with a link or name of the reference
Paraphrase the information to “teach” your classmates
DSM diagnostic criteria vs. symptom presentation