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.
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
Suicidal Ideation:
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.
Hopelessness:
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.
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If you or someone you love is at risk for suicide, the following resources are available.
Images that show what it feels like to suffer from mental illness. Bringing the inside to the outside.
Depression is not always easy to spot, and in a world filled with social media it always seems like everyone is living their best life.
In the most severe states people can have suicidal thoughts and profound hopelessness. The symptoms can be mild, moderate, or severe. Depression can affect anyone.
Depression is an illness like any other disease (diabetes, hypertension, heart disease) that affects thoughts, feelings, physical health, and behaviors.
People with major depressive disorder have several of these symptoms every day or nearly every day for 2 weeks or more.
Here are some signs that you may have depression
At least one of the following, loss of interest in things you previously enjoyed or depressed mood
At least 3 of the following
Feeling slow or restless
Feeling guilty or worthless
Increased or decreased appetite
Suicidal thoughts
Problems concentrating, making choices, or remembering things
Difficulty sleeping or sleeping too much
Having low energy
Potential physical signs of depression include
Headaches
Muscle tension
Digestive symptoms
Sexual problems
Feeling “keyed up”
This can be summed up in the mnemonic SIGECAPS taught to medical students everywhere. The mnemonic comes from the prescription a doctor might write for a depressed patient
SIG: 1 energy capsules per day
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