Depressive disorders

Depressive disorders are a group of conditions manifesting with symptoms of depression that impair an individual's ability to function. They include major depressive disorder (MDD), premenstrual dysphoric disorder (PMDD), disruptive mood dysregulation disorder (DMDD), persistent depressive disorder (dysthymia), depressive disorder due to another medical condition, and substance/medication-induced depressive disorder. Depressive disorders are typically identified during routine screening or examination. The diagnosis is clinical based on DSM-5 criteria after exclusion of organic causes of depression and differential diagnoses of depressive symptoms. Treatment varies based on the specific diagnosis but typically includes psychotherapy, and/or medication.

Major depressive disorder and premenstrual dysphoric disorder are covered in separate articles.

Epidemiology

Varies depending on the underlying disorder, e.g.:

• Lifetime prevalence for MDD of ∼ 20% ^[1]
• Annual prevalence for PMDD of 1–8% ^[2][3]
• Substance/medication-induced depressive disorder is rare. ^[2]

Clinical features ^[2]

• Symptoms of depression (e.g., low mood, anhedonia)
• Somatic features may be present depending on the condition (e.g., somatic symptoms of PMDD)
• Symptoms may not be reported, but can be identified through screening for depression.

Diagnosis ^[2]

• Clinical diagnosis based on the relevant DSM-5 criteria.
• Exclude differential diagnoses of depressive disorders.
• Depending on symptoms, consider workup for organic causes of depression.

Differential diagnoses of depressive disorders ^[2]

• Bipolar affective disorder
• Personality disorder
• Adjustment disorder
• Bereavement and grief
• Burnout syndrome

Management ^[2]

• Treatment is specific to the underlying disorder but usually includes psychotherapy and/or antidepressants.
• Screen for and treat concurrent disorders (e.g., substance use disorder, anxiety).
• Refer patients with severe or refractory symptoms, suicidal ideation, and/or psychotic features to psychiatry.
• See also:
  • “Treatment for depression”
  • “Management of PMDD”
  • “Treatment of DMDD”

Types of depressive disorders ^[2]

Persistent depressive disorder (dysthymia) is a chronic depression characterized by a consistently low mood and additional depressive symptoms lasting for ≥ 2 years (≥ 1 year in adolescents and children). ^[2]

Diagnosis ^[2][4]

• Diagnosis is confirmed using the DSM-5 diagnostic criteria for persistent depressive disorder.
• Often occurs concurrently with other psychiatric conditions (e.g., MDD, personality disorders).
• Assess severity to help determine management:
  • Mild: Symptoms are manageable.
  • Moderate: Symptoms are mild to severe.
  • Severe: Symptoms are severe, unmanageable, and significantly exceed the requirement for diagnosis.

Depressive disorders are frequently identified during screening for depression. ^[2]

DSM-5 diagnostic criteria for persistent depressive disorder ^[2]

Diagnosis is confirmed in individuals who meet all of the following criteria.

• Depressed mood
  • In adults: most of the day for the majority of days for ≥ 2 years
  • In children and adolescents: irritable or depressed mood for ≥ 1 year
• ≥ 2 of the following clinical features of persistent depressive disorder
  • Overeating or poor appetite
  • Sleep disturbance (insomnia or hypersomnia)
  • Fatigue, loss of energy
  • Poor self-esteem
  • Diminished concentration and decision-making ability
  • Hopelessness
• Symptoms clinically significant distress or impaired functioning in important areas of life (e.g., work, school)
• Periods of remission last ≤ 2 consecutive months.
• Features of differential diagnoses are not present.
  • No history of manic or hypomanic episodes
  • Symptoms are not due to:
    • Persistent schizoaffective disorder or another psychotic disorder
    • Effects of substances or organic disease

Thoughts of suicide, loss of interest, and psychomotor agitation or retardation may manifest in PDD but are not part of the diagnostic criteria. ^[2]

HE'S 2 SAD: Hopelessness, Energy loss or fatigue, Self-esteem is low, 2 years minimum of depressed mood, Sleep is increased or decreased (insomnia or hypersomnia), Appetite is increased or decreased, Decision-making and/or concentration is impaired.

Treatment ^[4]

Treatment of persistent depressive disorder is the same as treatment for depression.

• Depressed mood and/or anhedonia attributable to a general medical condition
• Conditions associated with depressive disorder include the following:
  • Hypothyroidism
  • Primary adrenal insufficiency
  • Stroke (especially anterior cerebral artery stroke)
  • Parkinson disease
  • CNS neoplasms
  • Other neoplasms (e.g., pancreatic cancer)
  • Dementia
  • Parathyroid disorders
• See also “Depression in patients with cancer” and “Depression post myocardial infarction.”

• Depressed mood and/or anhedonia attributable to the use of, or withdrawal from, substances or medications
• Substances or medications associated with depressive disorder include the following:
  • Marijuana, γ-hydroxybutyric acid (GHB), flunitrazepam, ketamine
  • Alcohol
  • Corticosteroids
  • Oral contraceptive pill

Disruptive mood dysregulation disorder (DMDD) is a depressive disorder characterized by extreme irritability and severe recurrent outbursts of anger (verbal or behavioral) that do not meet criteria for bipolar disorder. ^[2]

Epidemiology ^[2]

• ♂ > ♀
• ODD and other depressive disorders are common comorbidities. ^[6]

Etiology

Causes currently being investigated include psychological trauma and/or abuse, malnutrition, vitamin deficiencies, and neurological problems (e.g., migraine).

DSM-5 diagnostic criteria for DMDD ^[2]

• Severe, recurrent outbursts of anger (verbal or behavioral) toward people or property, disproportionate in intensity or duration to the situation that:
  • Are not appropriate to developmental stage (e.g., temper tantrums)
  • Occur on average ≥ 3 times per week
• Persistently irritable mood between outbursts (observed by parents, peers, teachers)
• Symptoms are present:
  • Before the age of 10 years
  • For ≥ 12 months, within which time there has been no consecutive period of ≥ 3 months without symptoms
  • In ≥ 2 settings (i.e., home, school, or with peers); severe symptoms occur in ≥ 1 setting
• The symptoms are not better explained by differential diagnoses of DMDD, e.g.:
  • Criteria for a manic or hypomanic episode have never been met for longer than 1 day
  • Symptoms do not occur exclusively during a major depressive episode
• Substance use disorder and other medical and neurological conditions have been ruled out.
• The diagnosis is made between 6 and 18 years of age.

Differential diagnoses of DMDD ^[2]

• Autism spectrum disorder
• Posttraumatic stress disorder
• Separation anxiety disorder
• Persistent depressive disorder
• Bipolar disorder
• Oppositional defiant disorder
• Intermittent explosive disorder
• ADHD

Some differential diagnoses, e.g., ADHD, can also be comorbid with DMDD, however, individuals with a diagnosis of ODD, intermittent explosive disorder, or bipolar disorder cannot also be diagnosed with DMDD. ^[2][7]

Treatment of DMDD ^[8]

As DMDD is a relatively new psychiatric diagnosis, there is limited evidence for its treatment.

• Treat comorbidities (e.g., ADHD, mood disorders).
• Refer for psychosocial interventions, e.g.:
  • Family support and parenting classes
  • Cognitive behavioral therapy or dialectical behavior therapy
• Refer patients with severe DMDD to a psychiatrist for consideration of pharmacotherapy (e.g., antidepressants). ^[8][9][10]

Prognosis ^[2]

Individuals with DMDD are at increased risk of major depressive disorder and anxiety disorders in adulthood.