29: Mood Disorders: Major Depressive Disorder and Dysthymic Disorder

CHAPTER 29 Mood Disorders: Major Depressive Disorder and Dysthymic Disorder



Maurizio Fava, MD, Paolo Cassano, MD, PhD




KEY POINTS



• Unipolar mood disorders (especially major depressive disorder [MDD]) are prevalent conditions that are typically associated with significant suffering, high morbidity and mortality rates, and psychosocial impairment.

• Despite the availability of numerous effective treatments for these conditions, these disorders are often under-recognized and undertreated in the community.

• Several factors contribute to the under-recognition of depression; these include the stigma of depression itself and the relative lack of systematic ascertainment of depressive symptoms by health care professionals.

• The public health significance of depression is noteworthy; depression affects the course and mortality risk associated with other medical diseases, and patients affected by chronic medical illnesses have a higher risk for depression compared to the general population.

• Depression is also highly co-morbid with chronic medical diseases.


UNIPOLAR DEPRESSIVE DISORDERS: CLINICAL FEATURES


Patients who suffer from unipolar depressive disorders typically have a constellation of psychological, behavioral, and physical symptoms. Tables 29-1 through 29-3 list some of the most common psychological and cognitive (Table 29-1), behavioral (Table 29-2), and physical and somatic (Table 29-3) symptoms reported by patients with major depressive disorder (MDD).


Table 29-1 Unipolar Depressive Disorders: Common Psychological and Cognitive Symptoms





Depressed mood
Lack of interest/motivation
Inability to enjoy things
Lack of pleasure/anhedonia
Apathy
Irritability
Anxiety/nervousness
Excessive worrying
Reduced concentration/attention
Memory difficulties
Indecisiveness
Reduced libido
Hypersensitivity to rejection/criticism
Reward dependency
Perfectionism
Obsessiveness
Ruminations
Excessive guilt
Pessimism
Hopelessness
Feelings of helplessness
Cognitive distortions (e.g., “I am unlovable”)
Preoccupation with oneself
Hypochondriacal concerns
Low/reduced self-esteem
Feelings of worthlessness
Thoughts of death or suicide
Thoughts of hurting other people

Table 29-2 Unipolar Depressive Disorders: Common Behavioral Symptoms





Crying spells
Interpersonal friction/confrontation
Anger attacks/outbursts
Avoidance of anxiety-provoking situations
Social withdrawal
Avoidance of emotional and sexual intimacy
Reduced leisure-time activities
Development of rituals or compulsions
Compulsive eating
Compulsive use of the Internet/video games
Workaholic behaviors
Substance use/abuse
Intensification of personality traits/pathological behaviors
Excessive reliance/dependence on others
Excessive self-sacrifice/victimization
Reduced productivity
Self-cutting/mutilation
Suicide attempts/gestures
Violent/assaultive behaviors

Table 29-3 Unipolar Depressive Disorders: Common Physical and Somatic Symptoms





Fatigue
Leaden feelings in arms or legs
Difficulty falling asleep (early insomnia)
Difficulty staying asleep (middle insomnia)
Waking up early in the morning (late insomnia)
Sleeping too much/hypersomnia
Frequent naps
Decreased appetite
Weight loss
Increased appetite
Weight gain
Sexual arousal difficulties
Erectile dysfunction
Delayed orgasm/inability to achieve orgasm
Pains and aches
Back pain
Musculoskeletal complaints
Chest pain
Headaches
Muscle tension
Gastrointestinal upset
Heart palpitations
Burning or tingling sensations
Paresthesias

However, the traditional diagnostic approach to depressive disorders has identified depressed mood and loss of interest/pleasure in most activities as key features of these conditions. Both can be present at the same time, but one of them is sufficient to define depressive disorders, if certain associated symptoms are present. The cluster of associated symptoms, the duration of the syndrome, and the degree of functional impairment are essential to distinguish depressive disorders from physiological mood variability. The continuum of depression from mild, short-lasting syndromes toward severe, chronic/recurrent and disabling disorders has been repeatedly stressed.1,2 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)3 defines MDD as depressive mood (irritable mood in children and adolescents), accompanied by at least physical, somatic, psychological, cognitive, and behavioral symptoms, lasting for at least 2 weeks. The accompanying symptoms (captured in the mnemonic SIG: E CAPS, a prescription for energy capsules) include insomnia or hypersomnia (S), reduced interest or pleasure (I), excessive guilt/feelings of worthlessness (G), reduced energy or fatigue (E), diminished ability to concentrate or make decisions (C), loss or increase of either appetite or weight (A), psychomotor agitation or retardation (P), and thoughts of suicide or death/suicidal behavior (S). In order to meet criteria for MDD, patients must report either depressed mood (it can be irritable mood in children and adolescents) or reduced interest/pleasure or both, as these are considered “core” symptoms of MDD, and they must report four or more of the other symptoms (depressed mood and SIG: E CAPS symptoms) (Table 29-4).


Table 29-4 DSM-IV Diagnostic Criteria for Major Depressive Episode









Presence of at least one core symptom and at least five of the following symptoms:

• Depressed mood (core symptom—can be irritable mood in children or adolescents)

• Sleep disturbances (insomnia or hypersomnia—S)

• Interest/pleasure in activities diminished (core symptom—I)

• Guilt/feelings of worthlessness (G)

• Energy decreased/fatigue (E)

• Concentration diminished or indecisiveness (C)

• Appetite or weight disturbed (increased or decreased) (A)

• Psychomotor agitation or retardation (P)

• Suicidal thoughts or thoughts of death or dying (S)
These symptoms cannot meet mixed-episode criteria, and must be cause for significant impairment in daily functioning. Symptoms cannot be direct effects of a substance or medical condition, or be better attributed to bereavement.

The DSM-IV classification of MDD has traditionally had a greater focus on the psychological symptoms of depression (such as depressed mood, lack of interest, excessive guilt, suicidal thoughts, feelings of worthlessness, and indecisiveness). Although some of the physical/somatic symptoms of MDD (primarily fatigue and both sleep and appetite disturbances) are included in the DSM-IV classification of this disorder, it is apparent that physical symptoms are underrepresented in the current nosology, despite the fact that they represent the chief complaint for a substantial proportion of patients who suffer from MDD. In fact, somatic symptoms are highly prevalent in MDD and are associated with significant disability and health care utilization. One could argue that the current, DSM-IV–based conceptualization of MDD that emphasizes psychological symptoms as key features of the disorder has led to a bias toward the underestimation of the rate of MDD in populations that primarily complain of somatic symptoms.


When this syndrome persists for at least 2 years it is called chronic depression. On the other hand, when depressed mood or lack of interest/pleasure are associated with only a few of the previously mentioned symptoms (not exceeding three), that mild syndrome lasting at least 2 weeks is called minor depression, or depressive disorder not otherwise specified (NOS). The persistence of this syndrome for at least 2 years is called dysthymic disorder (Table 29-5).3 In dysthymic disorder, the presence of a chronically (or at least intermittently) depressed mood for at least 2 years is heterogeneous clinically and etiologically, although it is clearly related to MDD. More than 70% of the patients with dysthymic disorder go on to develop MDD and to have recurrent major depressive episodes that are superimposed on the dysthymic disorder (i.e., double depression). As in the case of MDD, the majority of dysthymic patients have co-morbid medical or psychiatric disorders. Although milder than MDD, dysthymic disorder may have profound consequences on quality of life and for effective function in multiple life roles; this degree of morbidity is more reflective of the duration of dysthymic disorder than is the number of symptoms experienced.


Table 29-5 DSM-IV Diagnostic Symptom Criteria for Dysthymic Disorder











Presence of depressed mood (can be irritable mood in children/adolescents for longer than 1 year), for more days than not, for at least 2 years
Presence of at least two of the following:

• Poor appetite or overeating

• Insomnia or hypersomnia

• Low energy or fatigue

• Low self-esteem

• Poor concentration or difficulty making decisions

• Feelings of hopelessness
These symptoms cannot be better accounted for by chronic major depressive disorder, or major depressive disorder, in partial remission. There cannot be a history of a prior manic episode, a mixed episode, or a hypomanic episode. This disturbance does not occur exclusively during a chronic psychotic disorder. Symptoms cause significant impairment in daily function and are not direct effects of a substance or medical condition.


DSM-IV SUBTYPES OF MDD


MDD is a fairly heterogeneous clinical entity, and the DSM-IV classification has attempted to capture these clinically variable presentations by providing specifiers that allow clinicians and clinical researchers to subtype it.



MDD with Melancholic Features


The DSM-IV uses the term melancholic depression to describe severely depressed patients who are unable to experience pleasure (i.e., anhedonia) or who lose normal emotional responsiveness to positive experiences. These patients also exhibit three or more of the following characteristics: a distinct quality of depressed mood, a worsening of mood typically in the morning, excessive/inappropriate guilt, early morning awakening, reduced appetite/weight loss, and marked psychomotor retardation/agitation.



MDD with Atypical Features


In the DSM-IV, atypical depression refers to a subtype of depression characterized by mood reactivity (defined as an ability to temporarily respond to positive experiences), accompanied by two or more associated symptoms (such as rejection sensitivity, hypersomnia, hyperphagia [that is often related to carbohydrate craving], and prominent physical fatigue [leaden paralysis, with feelings of heaviness in the arms and legs]).



Seasonal MDD


The operational criteria for seasonal affective disorder (SAD) have undergone several changes since first proposed in 1984. SAD is currently included as a specifier of recurrent MDD in the DSM-IV. The key characteristic of SAD is that the symptoms usually arise during the winter and remit in the spring, with the symptoms tending to remit when the patient is exposed to daylight or to bright-light therapy. The cognitive, psychological, and behavioral symptoms are as in other types of depression, but the somatic symptoms are typically the opposite of classic depressive vegetative symptoms, namely the patient reports increased sleep and increased appetite.



MDD with Psychotic Features (Psychotic Depression)


Psychotic depression is characterized by the presence of delusions or hallucinations (or both). The content of these psychotic symptoms is typically consistent with the depressive themes (i.e., it has mood-congruent psychotic features), but a patient may also report mood-incongruent psychotic features. Psychotic depression is typically accompanied by significant cognitive symptoms and has shown distinctive responsiveness to treatment, with the combination of antidepressants and antipsychotics being superior to use of either drug alone.



Catatonic MDD


Catatonic features are present in MDD when there are at least two of the following symptoms: motoric immobility (as evidenced by catalepsy or stupor); excessive motor activity (apparently purposeless and not influenced by external stimuli); extreme negativism (motiveless resistance to all instructions or maintenance of rigid posture against attempts to be moved) or mutism; posturing, stereotyped movements, prominent mannerisms, or prominent grimacing; and echolalia or echopraxia.



Postpartum MDD


Postpartum MDD is characterized by its onset within 4 weeks of the delivery of a child. The symptomatology does not differ from nonpostpartum mood episodes, and may include psychotic features (such as negative delusions involving the newborn infant). Other common symptoms are mood fluctuations, severe anxiety, panic attacks, suicidal thoughts, spontaneous crying, insomnia, and a general disinterest in the infant.



Other, Non–DSM-IV Subtypes of MDD


The DSM-IV classification of MDD has failed to point out other subtypes of depression that have emerged in the past two decades: depression with anger attacks and anxious depression.



MDD with Anger Attacks


A significant proportion (30% to 40%) of outpatients with MDD are predominantly irritable when depressed, and they manifest intermittent outbursts of anger, termed anger attacks. Anger attacks emerge abruptly with minimal interpersonal provocation and are associated with a paroxysm of autonomic arousal reminiscent of panic attacks, but featuring explosive verbal or physical anger, usually directed at close companions or family members. These patients have distinctive clinical features associated with the anger attacks, and they also appear to have decreased central serotonergic activity compared with patients without anger attacks.4



MDD with Anxious Features (Anxious Depression)


Though the DSM-IV does not recognize anxious depression as a subtype, emerging evidence suggests a number of distinguishing features for this potential subtype. Consistent with the results of previous studies among outpatients with MDD, where the lifetime co-morbidity for anxiety disorders was about 50%, in two large, distinct subsamples of outpatients with MDD participating in the multicenter Sequenced Treatment Alternatives to Relieve Depression (STAR*D) project,5

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Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on 29: Mood Disorders: Major Depressive Disorder and Dysthymic Disorder

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