1. How do we diagnose major depression, what are the subtypes and what are the
general characteristics of this disease and what are the most important cognitive
theories?
- What are the diagnostic criteria for MD according to DSM-5?
- What are the diagnostic criteria for persistent depressive disorder (dysthymia) according
to DSM-5?
- What are atypical, psychotic and melancholic features of major depression?
- What is the typical gender distribution in major depression?
- What are the most important risk factors for depression?
- What is the course of depression?
DSM-5 & WHO
MAJOR DEPRESSIVE DISORDER
Diagnostic Criteria:
,NOTE for diagnostic features:
- In children and adolescents, the mood may be irritable rather than sad [compared to
older people]
- Hypersomnia and hyperphagia are more likely in younger individuals, and melancholic
symptoms, particularly psychomotor disturbances are more common in older individuals.
- A symptom must either be newly present or must have clearly worsened compared with
the individuals pre-episode status
- Worthlessness or guilt associated with a major depressive episode may include
unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations
over minor past failings etc.
Some important specifiers:
● W melancholic features
A. One of the following is present during the most severe period of the current episode:
1. Loss of pleasure in all, or almost all, activities
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better (maybe uptı
20-40%), even temporarily, when something good happens)
B. Three (or more( of the following:
1. A distinct quality of depressed mood characterized by despair, moroseness or so called-
empty mood
2. Worse in the morning
3. Early-morning awakening
4. Marked psychomotor agitation or retardation
5. Significant anorexia or weight loss
6. Excessive or inappropriate guilt.
NOTE: only has a modest tendency to repeat across episodes in the same individual, more
frequent in inpatients and older adults, less likely to occur in milder episodes, and are more
likely to occur in those with psychotic features
● W psychotic features
Delusions and/or hallucinations are present
- w/mood congruent psychotic features: the content of all delusions and hallucinations is
consistent with the typical depressive themes of personal inadequacy, guilt, disease,
death, nihilism and deserved punishment. (or mood incongruent)
● W atypical features
,This specifier can be applied when these features predominate during the majority of days of
the current or most recent major depressive episode or persistent depressive disorder
A. Mood REACTIVITY (mood brightens in response to actual or potential positive events) -
higher capacity to be cheered up when presented with positive events
B. Two (or more) of the following
1. Significant weight gain or increase in appetite
2. Hypersomnia
3. Leaden paralysis (feeling heavy, leaden, or weighed down usually in the arms or legs)
4. Interpersonal rejection sensitivity (not limited to episodes of mood disturbance,
pathological and persistent)
C. Criteria not met for ‘with melancholic features’ or ‘with catatonia’ during the same episode
Suicide risk: most consistently described risk factor is a past history of suicide attempts or
threats, but it should be remembered that most completed suicides are NOT preceded by
unseccesful attempts. Others are: male sex, being single, living alone, having prominent
feelings of hopelessness, presence of borderline personality disorder.
- The likelihood of suicide attempts lessens in middle and late life (compared to young),
although the risk of completed suicide does not.
- Risk for suicide attempts higher in women, and risk for suicide completion is lower when
comapred to men
- Suicide completion: higher in females that live in low- and middle-income countries when
compared to females high-income countries VS for males its the other way around
(higher suicide rates in higher income)
[still overall higher in low and middle income countries with 78%]
Bipolar disorder: Many bipolar illnesses begin with one or more depressive episodes so we
must be careful not to misdiagnose. This is more likely in individuals with onset of the illness in
adolescence, those with psychotic features (little note: can transition into schizophrenia), and
those with a family of bipolar illness. The presence of a ‘with mixed features’ specifies also
increases the risk for future manic or hypomanic diagnosis.
Sadness: periods of sadness should not be diagnosed as a major depressive episode unless
criteria are met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day,
nearly every day for at least 2 weeks), and clinically significant distress or impairment.
Prevalence & development and course:
● Prev in 18 to 29-year old individuals is threefold higher than the prev in individuals age
60 years or older (WHO source states otherwise) Likelihood of onset increases
markedly with puberty.
● 4.4% of the population (in 2015, increased by almost 19 percent within the last 10 years)
w/ 5.1% females and 3.5% males
● At least ⅓ of symptomatic cases follow a moderate-severe course
● Higher rates in lower socioeconomic status (mostly income related) countries e.g. the
African Region, and lower in Western Pacific.
, ● Chronicity of depressive symptoms substantially increases the likelihood of underlying
personality, anxiety, and substance use disorders and decreases the likelihood that the
treatment will be followed by full symptom resolution.
● RECENCY of onset (of an episode) is a strong determinant of the likelihood of near-term
recovery (less recent = lower recovery rates)
● Lower recovery rates are also associated with mdd w’ psychotic features, prominent
anxiety, personality disorders, and symptom SEVERITY.
NOTE from WHO source:
Years Lived with Disability (YLD) caused by depressive disorders + Years of Life Lost (YLL) =
Disability-Adjusted Life Years (DALYs) → lead to the global burden of disease (GBD)
- Globally, depressive disorders are ranked as the single LARGEST contributor to
non-fatal heath loss (7.5% of all YLD)
- Suicide accouns for those 1.5% of all deaths worldwide, bringing it into the top 20
leading causes of death (in year 2015), and the seconf leading cause of death amont
15-29 year olds.
Risk and Prognostic Factors:
● Temperamental: neuroticism (negative affectivity) is a well-established risk factor for the
onset of MDD, and more likely to develop depressive episodes in response to stressful
events.
NOTE: neuroticism: a broad personality trait dimension representing the degree to which a
person experiences the world as distressing, threatening, and unsafe
● Environmental: Adverse childhood experiences, stressful life events etcç
● Genetic and physiological: heritability around 40%, and the personality trait
neuroticism accounts for a substantial portion of this genetic liability
● Course modifiers: major non-mood disorders, substance use, anxiety, and borderline
personality disorders, chronic or disabling conditions (e.g. diabetes, obesity,
cardiovascular disease - also higher risk of depressive symptoms becoming chronic) –
higher risk of developing depression.
Comorbidity:
Other disorders with which major depressive disorder frequently co-occurs are substance-
related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, buli- mia
nervosa, and borderline personality disorder.
NOTE for learning goal 4
general characteristics of this disease and what are the most important cognitive
theories?
- What are the diagnostic criteria for MD according to DSM-5?
- What are the diagnostic criteria for persistent depressive disorder (dysthymia) according
to DSM-5?
- What are atypical, psychotic and melancholic features of major depression?
- What is the typical gender distribution in major depression?
- What are the most important risk factors for depression?
- What is the course of depression?
DSM-5 & WHO
MAJOR DEPRESSIVE DISORDER
Diagnostic Criteria:
,NOTE for diagnostic features:
- In children and adolescents, the mood may be irritable rather than sad [compared to
older people]
- Hypersomnia and hyperphagia are more likely in younger individuals, and melancholic
symptoms, particularly psychomotor disturbances are more common in older individuals.
- A symptom must either be newly present or must have clearly worsened compared with
the individuals pre-episode status
- Worthlessness or guilt associated with a major depressive episode may include
unrealistic negative evaluations of one’s worth or guilty preoccupations or ruminations
over minor past failings etc.
Some important specifiers:
● W melancholic features
A. One of the following is present during the most severe period of the current episode:
1. Loss of pleasure in all, or almost all, activities
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better (maybe uptı
20-40%), even temporarily, when something good happens)
B. Three (or more( of the following:
1. A distinct quality of depressed mood characterized by despair, moroseness or so called-
empty mood
2. Worse in the morning
3. Early-morning awakening
4. Marked psychomotor agitation or retardation
5. Significant anorexia or weight loss
6. Excessive or inappropriate guilt.
NOTE: only has a modest tendency to repeat across episodes in the same individual, more
frequent in inpatients and older adults, less likely to occur in milder episodes, and are more
likely to occur in those with psychotic features
● W psychotic features
Delusions and/or hallucinations are present
- w/mood congruent psychotic features: the content of all delusions and hallucinations is
consistent with the typical depressive themes of personal inadequacy, guilt, disease,
death, nihilism and deserved punishment. (or mood incongruent)
● W atypical features
,This specifier can be applied when these features predominate during the majority of days of
the current or most recent major depressive episode or persistent depressive disorder
A. Mood REACTIVITY (mood brightens in response to actual or potential positive events) -
higher capacity to be cheered up when presented with positive events
B. Two (or more) of the following
1. Significant weight gain or increase in appetite
2. Hypersomnia
3. Leaden paralysis (feeling heavy, leaden, or weighed down usually in the arms or legs)
4. Interpersonal rejection sensitivity (not limited to episodes of mood disturbance,
pathological and persistent)
C. Criteria not met for ‘with melancholic features’ or ‘with catatonia’ during the same episode
Suicide risk: most consistently described risk factor is a past history of suicide attempts or
threats, but it should be remembered that most completed suicides are NOT preceded by
unseccesful attempts. Others are: male sex, being single, living alone, having prominent
feelings of hopelessness, presence of borderline personality disorder.
- The likelihood of suicide attempts lessens in middle and late life (compared to young),
although the risk of completed suicide does not.
- Risk for suicide attempts higher in women, and risk for suicide completion is lower when
comapred to men
- Suicide completion: higher in females that live in low- and middle-income countries when
compared to females high-income countries VS for males its the other way around
(higher suicide rates in higher income)
[still overall higher in low and middle income countries with 78%]
Bipolar disorder: Many bipolar illnesses begin with one or more depressive episodes so we
must be careful not to misdiagnose. This is more likely in individuals with onset of the illness in
adolescence, those with psychotic features (little note: can transition into schizophrenia), and
those with a family of bipolar illness. The presence of a ‘with mixed features’ specifies also
increases the risk for future manic or hypomanic diagnosis.
Sadness: periods of sadness should not be diagnosed as a major depressive episode unless
criteria are met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day,
nearly every day for at least 2 weeks), and clinically significant distress or impairment.
Prevalence & development and course:
● Prev in 18 to 29-year old individuals is threefold higher than the prev in individuals age
60 years or older (WHO source states otherwise) Likelihood of onset increases
markedly with puberty.
● 4.4% of the population (in 2015, increased by almost 19 percent within the last 10 years)
w/ 5.1% females and 3.5% males
● At least ⅓ of symptomatic cases follow a moderate-severe course
● Higher rates in lower socioeconomic status (mostly income related) countries e.g. the
African Region, and lower in Western Pacific.
, ● Chronicity of depressive symptoms substantially increases the likelihood of underlying
personality, anxiety, and substance use disorders and decreases the likelihood that the
treatment will be followed by full symptom resolution.
● RECENCY of onset (of an episode) is a strong determinant of the likelihood of near-term
recovery (less recent = lower recovery rates)
● Lower recovery rates are also associated with mdd w’ psychotic features, prominent
anxiety, personality disorders, and symptom SEVERITY.
NOTE from WHO source:
Years Lived with Disability (YLD) caused by depressive disorders + Years of Life Lost (YLL) =
Disability-Adjusted Life Years (DALYs) → lead to the global burden of disease (GBD)
- Globally, depressive disorders are ranked as the single LARGEST contributor to
non-fatal heath loss (7.5% of all YLD)
- Suicide accouns for those 1.5% of all deaths worldwide, bringing it into the top 20
leading causes of death (in year 2015), and the seconf leading cause of death amont
15-29 year olds.
Risk and Prognostic Factors:
● Temperamental: neuroticism (negative affectivity) is a well-established risk factor for the
onset of MDD, and more likely to develop depressive episodes in response to stressful
events.
NOTE: neuroticism: a broad personality trait dimension representing the degree to which a
person experiences the world as distressing, threatening, and unsafe
● Environmental: Adverse childhood experiences, stressful life events etcç
● Genetic and physiological: heritability around 40%, and the personality trait
neuroticism accounts for a substantial portion of this genetic liability
● Course modifiers: major non-mood disorders, substance use, anxiety, and borderline
personality disorders, chronic or disabling conditions (e.g. diabetes, obesity,
cardiovascular disease - also higher risk of depressive symptoms becoming chronic) –
higher risk of developing depression.
Comorbidity:
Other disorders with which major depressive disorder frequently co-occurs are substance-
related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, buli- mia
nervosa, and borderline personality disorder.
NOTE for learning goal 4
