With this specifier, the name provides most of the information. There has to be a clearly defined relationship between the onset and remission of depression with the changing of the seasons. For example, a patient becomes depressed in the late fall or winter and their depression remits once spring arrives. This is the most common pattern in clinical practice.
The relationship between the depressive episodes and season is present for at least the prior two years. Furthermore, the number of seasonal episodes is significantly more than nonseasonal episodes. Basically, what this means is there must be an established pattern related to the changing of the seasons for two years.
If the depressive episode is clearly related to another factor (e.g. start of school or change in work stats) the specifier does not apply.
In the two-year period where the pattern is established there cannot be any nonseasonal episodes.
For this specifier to apply, the person must clearly become depressed in the months where day light is reduced (possible mechanism for these episodes), and have remission of symptoms once the days become longer. (this is one example, there are others)
Like, Share, and leave a comment below if you ever felt depressed during the winter months
I wanted to finish the discussion on the various specifiers for major depressive disorder. In this post I will discuss melancholic features.
The most distinct feature in MDD with melancholic features is profound loss of interest (anhedonia) in all or almost all activities. This is a common feature in MDD as well, but the loss of pleasure in activities is far more severe. There is also a complete lack of reactivity to anything that would usually be considered by the person as pleasurable.
In addition, at least three of the following are required:
Depressed mood that is experienced as qualitatively different from the feeling experienced after a loss.
Depression that is worse in the morning.
Awakening at least two hours prior to the usual wake time
Marked psychomotor retardation (slow movement) or agitation
Significant anorexia or weight loss
Excessive or inappropriate guilt
I think of this specifier as a more profound form of MDD.
One thing we try to do with modern pharmacology is treat specific symptoms with classes of medication that match the neurotransmitter profile. The medication selection or augmentation strategy may change depending on the symptoms we want to target. For example, fatigue and concentration are largely regulated by norepinephrine and dopamine, so we may choose a medication that targets these neurotransmitters. In this example of melancholic depression sleep and appetite may be the primary issues, we may select a more sedating medication like mirtazapine. I will provide more details on the symptom-based selection of medication for depression in future posts.
I like the DSM-5 and I think it provides us with a conceptual framework for evaluating patients. In clinical practice it’s rare to find patients that fit all diagnostic criteria perfectly. When that does occur it’s nice and makes life easy.
Major depressive disorder with atypical features is one of those situations. Many patients have some of the symptoms but not enough to clearly make the distinction. Nonetheless, some of these symptoms are common and need to be discussed.
What makes this type of depression atypical?
I like to think of the symptoms as the opposite or reverse of major depression discussed in previous posts.
A key distinction to look for is mood reactivity in response to positive events. In major depressive disorder nothing usually makes the patient feel happy. They may even present with a restricted, constricted or blunted affect. In the atypical case, these patients can react and show emotion when positive events occur.
Along with mood reactivity, they must have two of the following features:
Increased appetite or significant weight gain
Hypersomnia (excessive sleep)
Leaden paralysis often described as a heaviness of the arms and legs
A longstanding pattern of sensitivity to interpersonal rejection
It must be impairing social and occupational function
When you look at the list above you see why we can think of these symptoms as the opposite of typical major depression.
Hope this post helps to clear up some question about atypical depression. Please like, share and comment.
In the last post we covered MDD and we introduced the specifiers. In this post I will talk about MDD with psychotic features.
You may have guessed already, but what separates this disorder from MDD is the presence of delusions, and hallucinations along with symptoms of major depression. Fairly simple, right?
First, we need to define psychotic symptoms.
In general, we can think about the following symptoms:
Delusions: which can be defined as fixed false beliefs. Something that the person believes despite evidence to the contrary.
Hallucinations: A hallucination is a sensory perception in the absence of external stimuli. There are several types including auditory (most common, consists of hearing a voice or several voices), visual, olfactory (smell), tactile (touch), and gustatory (taste).
Disorganized speech or behavior: This is an indication of the persons thought process. If the person is not thinking in a clear logical manner their though process may be difficult or impossible to follow for an outside observer.
These psychotic symptoms can be congruent with the depressed mood (content is consistent with depressive thoughts) or mood incongruent (content is not consistent with typical depressive thoughts). Mood congruent psychotic symptoms will consist of depressive themes such as guilt, death, poor self-worth, and punishment. Mood incongruent symptoms include things such as delusions of control, thought broadcasting, or thought insertion. Both mood congruent and incongruent themes can occur in the same episode.
Another key point is the psychotic symptoms only occur during a depressive episode. They are not present when the patient is not depressed. Once psychotic symptoms appear with an episode of depression, they tend to be present on subsequent episodes.
In the next post we will cover atypical features of depression. Please like, comment, and share the content. Feel free to offer suggestions for future posts.
Good morning! Happy Monday. Generating content the way I’ve wanted to has been difficult being home with a little one, working, or working while being home with a little one. I have chosen to take my own advice and be kind to myself, realizing these are unique times and congratulating myself for small victories.
So why am I asking you about shampoo?
This morning was a tough Monday after a tough weekend. Feels a little bit groundhog day and the gray weather is definitely affecting my mood. But as I engaged my glutes in some old-school leg lifts while jazzercising on Facebook, I had a moment of clarity. It’s wild how the mind clears with increased blood flow from exercise. I promise I’m getting to the shampoo.
In other areas on the site, you may have read about depression. We work with people with depressive disorders every day and there are some common themes. One of the questions I frequently ask my patients is, “What brings you joy?” Why do I ask this? It can answer many questions. Not least of all, assessing for anhedonia. If nothing brings you joy, you may be experiencing anhedonia and should check out Dr. G’s series on depression.
I’ve been thinking about the things that bring me joy and have come to the conclusion that I am unable to do many of them right now. Among those include spending time with friends and family, enjoying new restaurants, taking live workout classes, and perhaps the most missed activity, traveling. What that means is that I need to fill the joy bank with other things in order to prevent anxiety and depression. Preventive medicine is the best medicine after all.
Finally, the shampoo.
I shampoo my hair probably every other day. That means I’m spending a decent amount of time engaging with my shampoo. Recently, I determined that I don’t really like my shampoo. It was simply shampoo, got the job done, nothing special. Then, one evening at approximately 1AM, I made the bold decision to try to love my shampoo. (Side bar: the mind readers on Facebook advertising may have nudged this decision ever-so-slightly. Thanks omniscient overlords of Facebook.) While it took three tries, and a few dollars from my pocket, I now love my shampoo. I like the smell, how it feels in my hair, and the overall results. Best part? Creating a little bit of joy. A little bit of joy every day as a result of a small change adds up to serious improvements in mood.
Below I will make some suggestions for ways to increase joy in your daily life. Who knows when I will take my next trip to Key West or participate in my next 10k? It is time to create some joy and prevent dips in my mood that might contribute to the development of depression or anxiety.
If you are like me, social distancing might have you realizing how frequently you were eating out. Cooking and eating-in are definitely increased in my household. When we do order out, it requires more thought and intention about how to acquire the food and if it will be worth the effort involved.
Honest moment: I’m still not that into cooking. If you love to cook, yay you! Keep cooking and generate some joy. Just learning? Even better! America’s Test Kitchen is a tried and true resource and they are having some excellent promotions right now.
As for me, the answer is avocados. Prior to life in social distancing, I never purchased avocados. They either taunt me while being completely unripe at the exact moment I crave guacamole or slowly disintegrate into a pile of mush in the corner of my counter. Now, I have the time to commit to avocados. Each week, I splurge on delicious avocados and excitedly anticipate the moment my thumb gently indents the skin of the avocado easily, indicating nature’s mayonnaise is ready for consumption. I’m currently at a pace of half of an avocado per day. Sliced up with salt, pepper, and parsley on top of toast – maybe with some tomatoes? Go wild. Breakfast is elevated and I am happy. Every time I have this breakfast (which is quite frequently now) I am tempted to document my elegant meal.
Are there any foods that bring you joy? (I’m not referring to in-the-moment joy that leaves you feeling tired and unmotivated afterwards – although of course there is a time and place for that.) Just think, if you could be excited by your breakfast, that would add some serious coin to your joy bank.
Most people I know bathe every day. (This is a judgment free zone, and you may not have left the house in several days, so please continue to do you. Unless the people around you complain. In that case, please take a shower.) For this article, let’s assume you bathe every day for about ten minutes. Why not make those 70 minutes per week joyful? What type of soap do you use? Do you love it? (I love my soap, check out Little Egg Harbor soaps online, loving Citrus Twist right now.) I already addressed the shampoo situation. What about a loofah or new set of plush washcloths? Doesn’t have to be expensive, I am very happy with my set of purple Amazon Basics washcloths. Take the time to assess your shower routine. Are there any ways you can make it better, specifically in a way that increases your happiness?
This category will be different for everyone depending on how you are most comfortable. Are you someone who loves getting dressed up for work every day and now you never change out of sweatpants? That probably isn’t going to add any joy to your life. I’ve spoken to some friends who feel much happier putting on jeans and a cute top, and this simple action of putting on clothes that make you feel good can improve your self esteem and help prevent problems with your mental health.
As for me… if one more person on social media suggests putting on pants with buttons to keep myself in check, I might yell at the computer. Why on earth would I put on pants with a button if that is unnecessary at this time? What an absurd notion. So how has clothing brought me joy? Glorious sweatpants and leggings. Soft flowy tops. Buttery wire-free sports bras.
I have two pairs of sweatpants that I love. One pair has dinosaurs on them and the other I purchased at a brewery a few months back. I also treated myself to a pair of overpriced camo print leggings. Every time I slide them on, I take a moment to deep squat and stretch it all out and bask in the sensation of unrestricted leg movement.
Good sleep is integral to your mental health and I would like to devote a post in the future exclusively to sleep. For the purpose of this post, I’m suggesting improvements to your sleep routine that might make you smile. Do you sleep with an eye mask? These can be wonderful, especially for city living. What about aromatherapy? A touch of lavender on your pillow prior to bed time might trick your senses into thinking you are at an upscale spa hotel. Some other suggestions: update your pajamas, sheets, or pillows.
5. Self Care
Self care means different things to different people. For me, one of the things I think of is makeup. I love makeup, but my relationship with makeup has evolved over the years. In the past, I loved a full face. Bring on the bronzer! When I started my residency training, I wore full makeup (and heels… what was I thinking?) every day. I think it was almost like wearing armor. As I’ve grown more comfortable over the past few years in my role as a resident physician, I feel perfectly comfortable going to work with no makeup.
For me, playing with a new eye palette in preparation for an upcoming wedding or watching a YouTube tutorial on liquid eyeliner or DIY lashes is fun and makes me happy while applying makeup daily does not. I treasure the extra fifteen minutes in the morning to eat my fancy avocado toast with my family (see above.)
I also no longer feel like I need makeup to be attractive. I have my daughter to thank for that… I see her tiny face sprinkled with my features and I never want her to feel anything less than beautiful. If I think I need makeup and her face looks like mine, that would suggest her perfect face needs makeup too – which it most certainly does not.
I’ve also become comfortable with the mascara and lip only makeup which takes exactly one minute. You’ll find me wearing that makeup look in the photo above posing with shampoo. This applies to hair, waxing, nails, and skin care. As much or as little as makes you happy. Does being home and not needing to do your hair feel amazing? Time to harness that and include it as added happiness to your day. Have you perfected the at-home gel manicure? Color me impressed by both your artistic ability and commitment to nail care. It might even save you money in the future.
6. Sexual health
Sexual health is part of your health. This might mean a celibate hiatus due to a lack of interest at this time. Prefer the Netflix portion of Netflix and chill? That’s just fine. Despite what the internet might have you believe, global pandemics and social distancing aren’t an absolute aphrodisiac for most people.
If the mood does strike you, this might present an opportunity to get to know your needs more, with or without assistance from a device or adult entertainment. Or maybe now is the time to revisit your sexual health needs with your partner.
Pro-tip: Continue to use contraception while engaging in partnered sexual activity if you do not wish to grow your family.
I’m sure there are other ways to add joy into your day. We would love to hear suggestions in the comments! Whatever you choose, take time to assess your piggy bank of joy. Don’t let the balance get too low or you may risk experiencing depressed moods or feelings of anxiety.
One further comment on this subject, and I alluded to it above: you don’t actually NEED to do anything. We are in an uncharted time of global pandemic. If you are alive and keeping any persons that depend on you alive, you are doing a fabulous job! This post seeks to protect the integrity of your mental health by way of experiencing happiness in your daily life.
If you are a psychiatrist or patient, chances are there has been a transition to telemedicine for outpatient services. With the COVID-19 pandemic creating chaos for patients and psychiatrists alike, many systems worked frantically to implement telemedicine platforms. As the world of technology moves at ever increasing speeds, we as physicians must keep up. There is a saying barrowed from motivational interviewing that goes “meet the patient where they are at.” Of course, I’m not talking about where they are in the process of change, but rather we can meet the patients literally where they are at. This provides convenient access to psychiatric care for patients who cannot make it to the office.
The current situation is terrible, but it provides us new opportunities to learn and grow. If there is one thing I learned in my residency training, it’s how to be flexible and role with the punches. I have learned over the last several years that resistance to the reality of a situation will lead to unhappiness. While I miss the deep personal connections with my patients during in person visits, I have learned that most of that experience can be maintained through telepsychiatry.
Telepsychiatry is becoming more common, and many younger psychiatrists are making a career out of it. In the past, telepsychiatry required patients be seen in places such as the primary care clinic, now we are able to see patients in their homes. With most patients having access to a smart phone, they are able to complete the consultation in their car, or while on break at work. For busy people such as physicians who need a psychiatric consultation, the convenience of telepsychiatry is unparalleled.
Here are some of the questions I had after I found out I would be doing telemedicine visits.
Are We Compromising Patient care?
One of my biggest concerns moving to a telemedicine platform is the quality of patient care. It’s important to consider, since one of the most therapeutic aspects of a psychiatric consult is the physician patient relationship. Countless articles have detailed the importance of physician patient relationship in treatment outcomes. I believe it influences treatment outcomes even more in psychiatry than other specialties. Multiple studies in the literature have shown that telepsychiatry is just as good as in person visits for many psychiatric disorders including depression, anxiety, and PTSD. If you work with children, it may even be a clinical advantage to use telepsychiatry. Most child and adolescent patients actually prefer using technology to interact, and doctors’ appointments are no different.
Is telepsychiatry HIPAA Compliant?
It’s important to remember that not all video-based systems are HIPAA compliant. The ones we are most familiar with (Facetime, google hangouts) are not HIPAA compliant. There are a number of companies that offer telemedicine platforms that do comply with HIPAA regulations. Skype for business is a HIPPA compliant product but the free version is not for example. The companies that offer HIPAA compliant services will provide you with a Business Associate Agreement (BAA). It’s basically a document that indicates the data transmitted over the service is confidential. The company agrees to provide the service and cannot look at any of that data transmitted over the platform. Ensuring you have the BAA in place will confirm HIPAA compliance.
How does State Licensing Work?
In order to use telepsychiatry you have to be licensed within the state that the patient is located in. For example, if you are licensed in Florida and the patient is located in South Carolina you would need a license in the state of South Carolina. However, the physician is allowed to be located anywhere in the world.
Are There Limitations to Medication Prescribing?
For routine psychiatric medications, these can be electronically sent to the pharmacy like an outpatient visit. The one caveat to be aware of is prescribing controlled substances such as stimulants and benzodiazepines should not be done via telepsychiatry. Careful monitoring of patients on these medications necessitates the need for in person follow up. The legal guidelines are not clear at this point, so it’s best to avoid prescribing controlled substances.
What About High risk situations?
Another area of concern is what to do in the event that a person is suicidal or needs emergency care. These situations are rare, but they can happen, and you need to be prepared. It’s a misconception that someone has to be in the room with the patient during the consult. This is not true, however it’s prudent to have a person you can contact in the event of an emergency. This can be a friend or family member who lives close to the patient and can reach out quickly. You should also get a list of the local police departments in the area where your patients are residing. This is a last resort but may be required in some situations. To summarize you should have the patient’s address, phone number, a friend or family member’s contact information, and the local police departments number. This should be enough information in the event you need to alert emergency services.
What Is The Out of Pocket Cost to Physicians?
One issue that may be more important to the private practice psychiatrist is the equipment required to start telepsychiatry. In many cases the equipment required is already possessed, a laptop computer with built in speakers, camera, and microphone will likely be enough for most practitioners to get started. You can purchase higher end microphones and cameras which may be important to psychiatrists who plan to continue using telepsychiatry after COVID-19 however, it’s not required. The take home point is a basic laptop computer will cover most physician and patient needs.
How Do I Get Vital Signs?
Blood pressure, pulse, height and weight are usually recorded on every patient, at every visit. A simple way to get around this issue is having the patient purchase a blood pressure cuff from the store, which is relatively inexpensive. Have the patient perform the blood pressure check while in the session and show you the monitor. This will allow you to record pulse and blood pressure easily. Many patients will have a scale in the house, and if not one can be purchased.
What about Urine Drug Screen and Routine Labs?
This is a simple situation to handle and much like regular outpatient visits the patient can be sent to LabCorp or Quest diagnostics for these tests. Other examinations like the Abnormal Involuntary Movement Scale (AIMS) test for patient’s taking antipsychotics can be easily completed with telepsychiatry.
In conclusion, I do not think telepsychiatry will replace all in person psychiatric evaluations and follow ups. However, it does provide a convenient option for busy patients with time constraints, and those who are more comfortable communicating electronically. I have embraced the change and I really have enjoyed the process of transitioning to telemedicine.
I would love to hear any thoughts on telemedicine from the patient or physician perspective. Please, like comment, and subscribe to the blog.
This is the beginning of a series on depressive disorders starting with MDD. I want to keep the posts short and to the point, less than 500 words each.
Major depressive disorder (MDD) is very common. The lifetime and 12-month prevalence are 13-17% and 6-7% in American adults over the age of 18. For adults under the age of 50, it’s twice as likely to affect females when compared to males. MDD is associated with high rates of psychiatric and medical morbidity, impaired work function, and disability.
DSM-5 Criteria for Diagnosis
To diagnose MDD you must have at least 5 of the following symptoms over the same two-week period. At least one of the symptoms must be depressed mood or loss of interest.
The symptoms are as follows, depressed mood; diminished interest in pleasurable activities; changes in appetite either increased or decreased; insomnia or hypersomnia (increased sleep); psychomotor agitation (restlessness) or retardation (slow movement); decreased energy; guilt or feelings of worthlessness; diminished ability to concentrate; and recurrent thoughts of suicide. These symptoms must occur every day or nearly every day and last all day over that same two-week period. The symptoms can be either a subjective account, observed by others, or some combination of both.
It must cause significant disruption in social, occupational, and other important areas of function. It cannot be caused by a medical condition or substance use.
Specifiers for MDD:
Mild; Moderate; Severe; without psychotic features; Severe with psychotic features; in partial remission; in full remission; chronic; with catatonic features; with melancholic features; with atypical features; with post-partum onset; with or without full inter-episode recovery; and with seasonal pattern.
In the next post we will cover the highlighted specifiers and what specific symptoms separate them from each other. Please like, share, and comment we want to hear from you.
Inflammation is the body’s natural response to infection or injury. It’s an important response in the acute setting but chronic inflammation can contribute to the development of diseases such as heart disease and even depression. Most psychiatrists now recognize that inflammation plays a role in depressive disorders, although it’s not an inflammatory disease. Much of the research on inflammation and depression is ongoing and will develop over time.
Risk Factors for Inflammation
· Childhood trauma
· High stress levels (work, school)
· Depression that is resistant to treatment
· Severe anxiety
· Obesity BMI> 30
· Medical illness
· Recent injury or surgery
What are some nonpharmacological things we can do to reduce inflammation and thus the risk of disease?
Complementary and alternative therapies
Lifestyle: Exercise, Healthy diet, Mindfulness practice, CBT all have anti-inflammatory effects.
N-acetylcysteine studies with 2000 mg/day improved anxiety and depressive symptoms
L-methyl folate: L-methyl folate 15 mg/day as augmentation to antidepressants
Omega-3: 1000 mg/day of omega-3 fatty acids with DHA to EPA ratio > 60% improved depressive symptoms
This post is significant to me because one area I really enjoy working is the inpatient psychiatric unit. This might seem strange, but it’s a place I just gravitate towards and fell like I’m having a meaningful impact. You can think of it as the equivalent to the medical intensive care unit (ICU). It’s a place to learn about the most severe psychiatric pathologies and medication management.
In this post I will cover some of the signs and symptoms that may indicate inpatient hospitalization could help and possibly be lifesaving.
Signs and Symptoms
If your depression has become so profound that you have thoughts about “killing yourself,” then it might be time for inpatient treatment. Many clinicians, especially those not working in mental health, feel uncomfortable asking direct questions about suicide. Contrary to a common belief, asking about suicide does not increase the risk of suicide. I like to use the term “kill yourself” when doing a suicide assesment. It’s very definitive and clear to the patient what I’m talking about. The concern increases if there is a plan in place for the person to kill themselves, the plan is logical, feasible, and the person intends to carry out the plan. All of these are warnings that the person is at high risk. If these thoughts are persistent that’s another indicator that the problem is more serious.
There is a significant difference between the above situation and the person who has “passive suicidal thoughts.” Passive suicidal thoughts are statements like “If I didn’t wake up tomorrow, I would be okay with it.” It’s not that the person is actively trying to prematurely end their life, rather they would not mind if something happened that hastened the path towards death.
Another validated risk factor for suicide is severe, unremitting hopelessness. Hopelessness consists of feeling that nothing is getting better, nothing will ever get better, and there’s nothing I can do about it. This, independent of other risk factors, puts the person at high risk for suicide.
Loss of Interest:
Severe anhedonia (loss of interest) in previously pleasurable activities is part of the diagnostic criteria for depression, it’s also something that can increase suicide risk. If a person previously went to the gym five days a week or watched every new episode of The Bachelor and suddenly no longer cares about these things, it may be cause for concern.
Poor Response to Outpatient Treatment:
If you have been in traditional outpatient therapy and medication management for many years with minimal or no improvement, and you have never been hospitalized for psychiatric purposes before, then inpatient hospitalization may help. Sometimes the break from the daily life stressors for 3-5 days allows the mind and body to rest. If you tried everything else, then who knows? This could be the intervention that changes your life.
Seeking inpatient psychiatric care is nothing to be ashamed of, and many mental health professionals are working hard to destigmatize psychiatric care. I like to think about inpatient psychiatric care as a mental wellness camp, and not as a punishment for mental illness.
If this information is useful please like, share, and subscribe to the blog and other social media sites. Drop us a comment about what topics you are interested in, and we will try to cover them.
If you or someone you love is at risk for suicide, the following resources are available.