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0:01
hey hey everybody and welcome to this presentation on major depressive and related disorders in the dsm 5 tr i'm your host dr donnelly snipes
0:13
in this presentation we're going to explore the current criteria and associated features from major and persistent depressive disorders in the dsm 5-tr now there are a lot of other depressive disorders but i had to limit myself to what i could cover in an hour
0:33
types of depressive disorders as i've mentioned there is major depressive disorder there is persistent depressive disorder which now includes chronic major depressive disorder and dysthymia so we'll talk about that a little bit
0:50
disruptive mood dysregulation disorder that's going to get its own entire class premenstrual dysphoric disorder substance or medication induced depressive disorder
1:03
depressive disorder due to another medical condition other specified depressive disorders and unspecified depressive disorders there are lots of ways we can diagnose depressive disorders but we need to make sure that what we're dealing with is actually a depressive disorder
1:24
for example depressive disorder due to another medical condition may be diagnosed when there is something like hypothyroid that is contributing to it the common feature in all the depressive disorders is a sad empty or irritable mood and clinically significant associated symptoms
1:46
what differs is the duration the timing or presumed ideology and also the number of symptoms for example persistent depressive disorder has a much lower threshold for meeting diagnostic criteria than major depressive disorder so let's get on with it for major depressive disorder a person has to have five symptoms that are causing clinically significant distress for two or more weeks and it's not due to a substance or a medical condition all right so that's you know
2:22
pretty straightforward one of those five symptoms has to be depressed empty or hopeless mood or apathy you know just a lack of enthusiasm or you know not caring about anything or anhedonia which is an inability to experience pleasure now people can have both the apathy and depression at the same time but anhedonia um well they can they can have both of them but they have to have at least one additionally we want to look for those other
3:01
symptoms other three or four symptoms greater than five percent unintentional weight change now that means not due to dieting that means not due to a growth spurt we also want to rule out you know it's not due to having an illness like the flu or you know other illnesses that might cause
3:25
weight loss sleep changes this can be sleeping more or sleeping less it can also be sleeping and then waking up at maybe two in the morning and not being able to get back to sleep or being up for three or four hours and then going back to sleep so the circadian rhythms start getting all mucked up psychomotor agitation or slowing that it's observable by others
3:54
it feels like you are walking or moving through mud or through a wind tunnel
4:00
and people notice that you just seem to be slower at everything that you're doing or most things that you're doing fatigue that's pretty self-explanatory
4:13
worthlessness or inappropriate guilt now this guilt is not feeling bad about being sick feeling like you should be able to just suck it up and get over it
4:25
but the guilt is more focused on feeling like you were bad as a person feeling guilty for things that you did or shouldn't have done in the past a lot of it is ruminative guilt so to speak poor concentration or indecisiveness and or recurrent thoughts of death or suicide without a plan or attempt we have another diagnosis for um recurrent suicidal ideation with a plan
5:00
so you've got a lot of things to work with but i want you to think about how some of these things relate if you are experiencing a change in your weight that often means you're experiencing a change in you your nutritional status which can directly impact mood
5:19
sleep changes oh my gosh you just don't even grasp
5:25
how important good quality sleep and stable circadian rhythms are to your overall health and happiness when sleep gets disrupted when your circadian rhythms get disrupted you will start feeling fatigued you will start having difficulty with concentration and indecisiveness so sleep is a big bugaboo that we want to make sure that we rule out but i'm getting ahead of myself
5:54
now persistent depressive disorder is somewhat different remember major depressive disorder had to be for at least two weeks persistent depressive disorder has to be for at least two years for adults and one year for children or adolescents additionally in children or adolescents the mood can be irritable
6:16
what we're seeing or one of the differences that we're seeing remember i said that this can include chronic major depressive disorder if the person is experiencing all of the symptoms meet the cr meets the criteria for major depressive disorder and they have no remissions that are longer than two months then they would get a persistent depressive disorder diagnosis in major depression to be
6:45
considered recurrent there has to be at least a two-month break before between being symptomatic
6:55
but with persistent depressive disorder it also now encompasses dysthymia so you can have the really extreme symptoms but you only need to have two or more of the following you have to have the depressed mood for most of the day most days for two years for adults one year for children and then two of the following symptoms appetite changes eating more eating less sleep changes sleeping more sleeping less circadian rhythm disruptions low energy
7:29
low self-esteem which is kind of akin to the guilt and major depressive disorder but they call it low self-esteem in pdd poor concentration or a sense of hopelessness
7:45
my experience has been there are a lot of people who meet the criteria for persistent depressive disorder what we need to recognize is number one the duration has to go be be ongoing and it has to be causing clinically significant distress so that's that's your key phrase here because all of the things in the dsm are symptoms that people experience most of the symptoms most of the things are symptoms people experience occasionally and it's on a continuum you know
8:25
you will experience depression occasionally you will experience anxiety occasionally but is it of sufficient severity and duration that causes clinically significant distress all right so we've got major depressive disorder there we've got persistent depressive disorder and then we have disruptive mood dysregulation disorder and yes it is going to have its own video but it's important enough to put in here for for the rule out reasons disruptive
9:00
mood dysregulation disorder is only going to be diagnosed in a child that is between 6 and 18 with an onset before the age of 10. so the onset of these symptoms has to be between 6 and 10
9:20
however the diagnosis can be made up to age 18.
9:26
now on page 178 it says it applies only for children up to 12 years old that's a typo it used to say up to 12 years old but in the dsm-5tr they changed it to to 18 years old
9:43
the hallmark of disruptive mood dysregulation disorder is persistent irritability it's not just during the course of a depressive episode it's just ongoing persistent irritability uh disproportionate recurrent temper outbursts inconsistent with developmental level that happen at least three times every week in at least two different settings for at least 12 months with no remission greater than three months so the child may be having these outbursts
10:20
at home and at school uh for at least 12 months at least three times a week so that's a lot of outbursts that the child is demonstrating and between outbursts the mood is angry or irritable
10:39
now remember children can be diagnosed with major depressive disorder which is why i brought that to your attention we want to look at the persistence of their irritability does it go on pretty much consistently or is it only tied to a major depressive episode
11:03
major depressive episode specifier or disorder specifiers and there's a lot of them anxious distress so this would be somebody who meets the criteria for major depressive disorder and they have symptoms of anxiety that doesn't meet the full criteria for something like generalized anxiety disorder mixed means they have all of the symptoms of major depressive disorder but they don't fully meet the criteria concurrently for hypomania and there
11:37
has never been a manic or hypomanic episode so some people can have that increase in activity
11:46
and or increase in energy interspersed with their depression melancholic this is the person who feels anthodonic they feel very sad profound despair tends to be worse in the morning they often find that they are in the group that awakens early in the morning in the middle of the night whatever you want to call it and has difficulty getting back to sleep or can't and they may have excessive or inappropriate guilt melancholic specifier also indicates a greater
12:25
severity of major depression this is you know on the ex the far end of the major depression mood scale if you will and people who have the melancholic specifier or who have anhedonia are at
12:43
a much more significant risk of suicidal ideation or suicide attempts
12:49
atypical major depressive disorder specifier and major depressive disorder the person has marked mood reactivity so they feel depressed most of the time but then when something really good happens they actually can have periods of feeling really happy for a moment but then they go back into the depression so there's mood reactivity appetite changes generally eating more they call it hyperphagia which remember in the diagnosis for depression
13:23
in increasing in eating or decreases in in eating is one of the expected symptoms so i'm not sure why that's in atypical but hypersomnia again uh in atypical the person is sleeping a lot more than usual but in your criteria for major depressive disorder sleeping more or sleeping less hypersomnia or insomnia are criteria so that's not really all that atypical either
13:53
lead paralysis feeling like you can't move because your arms are so heavy now this is an extreme end of psychomotor retardation a lot of times when people are experiencing depression my clinical experience and even personal experience is that it feels like i said like you're either trying to move through mud or you're walking into a wind tunnel and it's just it takes 10 times more effort to do everything your your limbs do feel heavier and the unique
14:32
aspect of it is persistent interpersonal rejection sensitivity now that isn't a typical feature that
14:42
is worth noting this would obviously point to some abandonment issues potentially some attachment issues but if you see this persistent interpersonal rejection sensitivity you're also going to want to make sure that you're ruling out cluster b personality disorder specifically borderline personality as well as you know some of your other disorders but
15:10
interpersonal rejection sensitivity is very common in people especially people with cluster b uh disorders mood congruent psychotic features and this is again a specifier so somebody meets all the criteria for mdd and they're also having psychotic symptoms that fit with their current mood their psychotic features are congruent with feeling depressed or angry or hopeless
15:43
mood incongruent psychotic features are completely unrelated to their mood they're not depressed in nature they're not sad they're not gloomy they they can be something else
16:00
catatonia is another specifier and this is obviously very obvious if somebody is presenting with major depressive disorder with catatonia they are um
16:15
catatonic i don't know a better way to explain that one which is why i didn't now peripartum onset may be more common after the first child and if somebody develops postpartum depression or peripartum depression they do have an increased risk for having it again after or in or after future pregnancies one of the things that it does note in the book is to rule out thyroid issues it's just this little fleeting line in the text but it is important to recognize that
16:53
thyroid dysfunction is relatively common in people after they give birth
17:01
and seasonal seasonal uh specifier applies to people who develop major depressive major depressive disorders um as the as a result of the seasons obviously interestingly the prevalence increases with higher latitudes so those that are in lower latitudes don't have as much seasonal uh
17:29
affective disorder and younger people are also at a higher risk for winter depressive episodes
17:36
now you're going to learn some interesting things about seasons and depression and suicide when we get down to that area the course of major depression recurrent major depressive episodes requires a two-month or greater remission between episodes otherwise it'll be categorized under persistent depressive disorder
18:01
it's also important to recognize that bipolar is more common when the onset of the first depressive episode is in adolescence or if the depressive episode has psychotic features
18:16
or in somebody with a family history of bipolar disorder now why are we making that so painfully
18:25
verbose because the treatment for bipolar depression is going to be different especially pharmacologically than the treatment for unipolar depression additionally it's important to be aware of the triggers for the different things and not miss for example a hypomanic episode
18:51
the chronicity of depressive symptoms substantially increases the likelihood of underlying personality anxiety and substance use disorders and decreases the likelihood that treatment will be followed by a full symptom resolution dsm-5tr how horribly depressing is that statement and i would challenge you to
19:15
think about the person in the environment in context what else is going on
19:24
if they have depression and anxiety or depression and personality disorders you know what else is going on that's contributing to these mood or cognitive symptoms that needs to be addressed too often we try to default to a quote best practice you've got depression we're going to do x y z and you'll either get better or you won't and that is a horrible philosophy it's just awful so think about you know why is it get curious what's going on that may be keeping this person
20:03
from developing full symptom remission and why is it that they are experiencing these depressive symptoms so chronically we are now finding as research has progressed there is so much stuff that can contribute to depressive symptoms that has nothing to do with cognitions that i think a lot of times we miss that a lot of times we miss the um lack of emotional intelligence a lot of times we miss the adverse childhood experiences that may be contributing and
20:44
the unresolved traumas that may be contributing so we need to get curious for each individual
20:52
and explore what's going on with them now remember depression is a term that is a label that we assign to a bunch of symptoms it's a it's a word when somebody says i'm depressed that's a label they're applying to a set of physiological and maybe even cognitive
21:18
symptoms or presentations if you will but what causes those is often changes in neurotransmitters and hormones and the reactivity of the nervous system so we need to really get down to the root of it and say what's going on in this person that is triggering this cascade that is triggering this cocktail of hormones and neurochemicals that is maintaining their depressed mood
21:53
additionally cross-culturally somatic or physical complaints are often the primary presenting symptom why because in many cultures mental health issues are not looked upon favorably going to counseling is not seen as something in vogue it's seen as something shameful and i wish that weren't the case but in many cultures it is so when people present they often present to their primary care physician instead of a counselor and
22:24
they present with symptoms of fatigue sleep changes or body aches and pains
22:30
now that kind of sounds like the flu or a cold or a variety of other things so it may get
22:38
missed in primary care and it's important to listen if somebody presents to you if they are talking you know even a friend if they're talking about fatigue and sleep changes and body aches and pains just put it out there that you know those are also symptoms of depression and can be caused when neurotransmitters like serotonin get out of whack
23:05
mood presentation may also focus on increased irritability so not everybody who's depressed presents as sullen and quiet they may present as being more irritable and tearful and easily upset
23:26
associated features you know i love the associated features mris show abnormalities in brain areas for emotion processing reward seeking and emotion regulation in people with major depression their brains are working differently so that is part of where the dysfunction may be happening but we got to figure out why why is their brain wired differently why is it working differently and was it rewired because of trauma in childhood or because of trauma or chronic stress in present
24:06
life it happens chronic stress cptsd we know it causes structural changes in the brain it doesn't mean that the brain can't really relearn or learn new pathways hpa axis dysregulation this actually made the dsm-5tr i was so thrilled to see hpa axis mentioned the hypothalamic pituitary adrenal axis which is our stress response system tends to be dysregulated in people with major depression
24:44
the text also mentioned an increase in pro-inflammatory cytokines people with depression have systemic inflammation people with systemic inflammation often have depression and i know i sound excited right now and it's not because i'm happy about it it really sucks if you've got hpa axis dysregulation and a lot of inflammation because that means you've also got a lot of pain but the fact that we're finally starting to really embrace the mind-body connection and recognize
25:18
that these things go hand in hand if people have inflammation it often triggers depression and vice versa that's something important to know because if we only treat the cognitions and not the inflammation guess what they're probably not going to achieve full symptom remission pain is an associated feature of depression not only because of those pro-inflammatory cytokines but because
25:47
all of the other things that may happen during a depressive episode including sleep disruption etc that cause certain neurotransmitters especially gaba and serotonin to be low
26:04
gaba and serotonin among others are involved in our pain threshold and when we have
26:11
low levels we tend to have more pain we act our pain perception is more acute
26:18
so it's important to recognize that and guess what pain makes it harder to sleep when we don't sleep well then it increases our hpa axis activity and pro-inflammatory cytokines you know it's a vicious cycle obsessive rumination guilt is often associated with major depression and of course they did mention guilt in the
26:46
diagnostic criteria for depression so we want to recognize that but obsessive rumination also can be a treatment target all of these associated features can be treatment targets anxiety you have major depressive disorder with anxious features you also have some people who have major depression and full-blown generalized anxiety disorder at the same time we want to recognize that if it's present we need to treat it we can't just treat the depression over here
27:20
and think okay everything else will get better it may have some positive impacts but we also need to recognize that if their anxiety is ongoing it's burning a lot of energy and it's probably going to keep them from achieving full depression symptom remission
27:38
social isolation loneliness and anger are other associated features that may be more prominent in some cultures over others they didn't really specify which cultures and what to look for but if you've been depressed even if it didn't meet the criteria for major depressive disorder you've probably experience you know social isolation you don't want to be around people you just can't deal with other people's drama or
28:10
people start isolating from you because you've been depressed for so long they call they want you to go out you turn them down after the 17th or 18th time they're like i'm just not even going to call them anymore because they're not going to go out they just they want to stay home and so social isolation works both ways you may intentionally isolate but then unintentionally you may
28:37
stop encouraging people to try to interact with you which can lead to loneliness and anger i mean think about it when you're depressed it's not fair it sucks to feel that way so it's not unusual for people to have feelings of concurrent anger when they are depressed it's not uncommon to for people with major depression to be angry at other people who just don't get it or to be angry at other people who aren't depressed and or who are happy because it's not fair
29:14
so anger is another common issue but anger takes a lot of energy and just dwelling on anger and ruminating on anger burns a lot of energy but contributes to hopelessness and helplessness because unless you do something about it you feel disempowered so that anger can actually contribute or worsen the depression so we need to address it other associate associations with depression major depressive disorders specifically that are not mentioned that i think are
29:49
important for you to be aware of that the research is indicating there's a connection dementia they're not sure whether dementia causes depression or depression causes dementia in older adults but there is a definite connection between depression and major depressive disorder and persistent depressive disorder and development of dementia in later life obstructive sleep apnea is also associated with high rates of depression when people are not sleep when people have
30:29
obstructive sleep apnea they're not getting quality sleep which is you know automatically pushing them down the road to some sort of a mood disorder most likely depression because they're going to be tired they're going to wake up and not feel refreshed they're not clearing out the adenosine that they need to so they're going to have a hard time concentrating but there is a very high correlation or association between obstructive sleep apnea and
30:56
depression nutritional deficiencies now chicken or egg here we don't know but there is evidence that certain nutritional deficiencies do contribute to inflammation and do contribute or are associated with the development of depression likewise we know that in a certain portion of individuals with depression there are going to be alterations in eating habits even if they're not over or under eating they there's often a gravitation towards high fat high carbohydrate foods
31:38
which by their very nature prompt the release of dopamine endorphins and serotonin another interesting thing is the gut microbiome and we're really just starting to understand it but they have seen associations between microbiome dysbiosis or an upset gut microbiome in imbalanced gut microbiome and the development of mood and disorders like depression and anxiety they've also seen that people who are on persistent antibiotics or frequent antibiotics
32:18
tend to have a disrupted gut microbiome and tend to have mood issues as well as other physiological issues and they're also starting to find that or some studies have found that people with depression tend to have what is you know generally called leaky gut their intestines are more permeable than those without depression so people with uh depression oftentimes some of the toxins that are developed in their in their intestines
32:56
actually can permeate through the intestines into the bloodstream and then that causes inflammation
33:03
so there's a bidirectional nature here they know that as serotonin goes down as depression develops they've shown that the gut tends to become leakier um or more permeable and they've also shown that people with leaky gut tend to develop inflammation which also develops depression so it can go both ways which is interesting kind of cool obviously that for most of us who are counselors
33:32
that's out of our lane but if you suspect somebody has some nutritional deficiencies or a disrupted microbiome or leaky gut which they probably do a referral to a registered dietitian
33:48
can be helpful another interesting association is low testosterone uh in men low testosterone in people who are biologically male can contribute to a whole host of symptoms including depressed mood all right so that's not really earth-shattering news what is interesting though is there has been haven't been any studies that i could find that demonstrated that testosterone replacement therapy actually consistently improved depressive
34:28
symptoms now in some people it did but repeated studies and meta-analyses that i read indicated that testosterone replacement therapy is associated with an improved quality of life score but not associated with improved mood so i thought that was interesting
34:49
circadian rhythm disruption is also researched quite extensively and associated with the development of mood disorders particularly depression in people of all ages we do want to rule out circadian rhythm disruption maybe it's a new baby in the house or a new puppy in the house or something that is keeping the person up now per a puppy probably wouldn't persist for long enough to cause major depressive disorder but you kind of get my point if circadian
35:26
rhythm disruption is something that is causing the person from getting adequate quality sleep um
35:35
you know clinical rotations being on call whatever it is those can all contribute to sleep changes hpa axis dysregulation and depression there's also a whole other section in the dsm for circadian rhythm disorders where people fall asleep too early and wake up too early or they can't stay asleep so we do need to rule out circadian rhythm disorders or
36:06
concurrently diagnose it if it's appropriate and finally another really interesting one is hearing loss they fought have found a significant correlation between the development of hearing loss and the development of depression now usually this goes one way as people start to lose their hearing no matter what the age there's often a development in a of
36:37
increased depression hypothesize this is because the person with hearing loss starts misunderstanding things and missing things and they feel like they're not getting anything right they start to feel disconnected from those around them however hearing loss is associated strongly with the development of depression and development of depression especially in later life is associated with worsening cognition and potentially the development of dementia so get the hearing screened
37:17
the prevalence of major depression according to the dsm is seven percent with a three times greater presentation in 18 to 29 year olds versus 60 year olds and over and it's twice as common in women all right this is not really all that new i was a little bit surprised that it was so much less in the 60 plus age range but think about 18 to 29 year olds they're going through that period as erickson called individuation they are graduating from high school they're leaving
37:54
the nest they're going to college or starting a career and maybe starting families there's a lot of stuff that happens during that period and it can be extremely stressful
38:06
according to the journal of the american medical association in april 2018 they evaluated 36 000 subjects and they found that the rate of depression in 2018 was actually 10.4 percent in any one year and 20.6 percent of people would experience at least one major depressive episode in their lifetime so jama indicates that it's a lot higher than the seven percent but the chronicity of major depressive disorder appears to be higher among african americans and
38:47
caribbean blacks that comes directly out of the new dsm tr culture section
38:58
as far as risk and prognostic factors neuroticism is a well-established risk factor for depression now neuroticism means responding poorly to stress interpreting ordinary situations as threatening and experiencing minor frustrations is overwhelming it tends to be temporally stable so it's over time it doesn't change people tend to have difficulty responding it's not just they're overwhelmed right now but across years they have difficulty responding to stress um tend to
39:34
interpret ordinary situations as threatening and get overwhelmed really easily but i want you to think neuroticism has such a negative connotation to it but couldn't somebody also develop these symptoms as a result of early adversity as a result of ongoing trauma so do we want to say
40:02
neuroticism or do if we see these symptoms do we also want to make sure we screen for ptsd and
40:13
borderline personality cptsd complex post-traumatic stress disorder is still not a diagnosis okay we cannot make that official diagnosis for billing purposes however
40:28
a lot of people have started to use that just in in layman's terms and and so i want us to recognize the impact that trauma ongoing trauma early childhood trauma may have on how a person develops if they have early childhood trauma if they have early abandonment they may not learn the skills to respond to stress that means life feels very scary so ordinary situations those of us who have developed coping skills perceive as ordinary seem very threatening to them because
41:09
they don't have the tools to deal with it therefore they're persistently hyper vigilant and exhausted and minor frustrations what most of us perceive as minor frustrations may seem really overwhelming because they don't have the tools to deal with life on life's terms what seems overwhelming for a 13 year old probably doesn't see probably seems like a minor frustration to a 40 year old but we've got to remember we've had all those years to develop and
41:45
all those opportunities to develop but people who haven't had those opportunities because of trauma may more easily disregulate so that's my two cents there either way whatever you want to call it whether you want to call it the personality dimension of neuroticism or you want to call it something else these symptoms are strongly uh associated as a risk factor for depression
42:18
well go figure imagine what it would be like living in a body in a mind that doesn't feel like you've got the ability to handle stress you don't feel like you've got coping skills you don't feel like you've got effective distress tolerance skills and the world seems overwhelming yeah i would start to feel helpless and hopeless and unsafe too so i can imagine how oppressive and stuck somebody may feel so aside from neuroticism multiple diverse adverse childhood experiences
42:57
are strongly associated with the development of depression and guess what probably also the development of neuroticism but um a lot of people believe that personality traits are
43:14
inherent uh in a person so they wouldn't be developed but whatever your your philosophy is it's important to recognize people who have adverse childhood experiences especially especially multiple diverse ones are at much greater risk of developing depression
43:34
a family history of depression we do know there's a genetic component to it major depressive disorder is more likely in people with chronic medical conditions there's a surprise not uh we do need to recognize that if somebody has autoimmune disorders fibromyalgia
43:58
some other chronic health disorder especially if it's one that limits their ability to function as they want to function that it may contribute to a sense of hopelessness and helplessness and depression major depressive disorder has also been noted to complicate cardiovascular disease obesity and diabetes people with depression have more difficulty regulating their blood sugar levels
44:28
in terms of sex and gender related features women tend to have more gastrointestinal symptoms changes in appetite and changes in sleep men now and this is according to the dsm i i really don't like i personally don't like categorizing things by biological gender however according to the dsm men have more maladaptive coping including substance misuse and risk taking i would encourage you to also think about other addictive behaviors like sex addiction porn addiction or even quote
45:07
workaholism some men when they're depressed they just they throw themselves into their work so they all they have to do is think about work they don't have to feel anything and poor impulse control is associated more with people who are biologically male than biologically female according to the dsm
45:31
now in terms of the risk for suicide the prevalence of suicide 14.2 people per 100 000 died by suicide um in a given year i guess the dsm-5tr that's the statistic they use
45:50
between according to the journal of the american medical association between 2014 and 2019 the suicide rate increased by 30 for black individuals and 16 for asian or pacific islander individuals from 2019 to 2020 though now think about what was going on during 2019 and 2020 the suicide rate declined overall by three percent including eight percent among people who are biologically female and two percent among people who are biologically male now i am assuming
46:31
that they meant when they say among females and males they're referring to biological gender uh they did not specify they still use the binary language in the dsm and the cdc but
46:47
it isn't interesting to note that during this period at the beginning of the pandemic and at the height of the pandemic suicide rates allegedly were declining overall what's up with that
47:03
the transgender population 42 42.9 of people who are transgender
47:11
indicated they had depression and suicidal ideation and 29.1 percent of people who identify as transgender had one or more suicide attempts that's important to know
47:27
postpartum women reported lower depression scores and higher suicidal ideation incidents so their depression scores were around 6.65 but their suicidal ideation was almost 12 in the early postpartum period that's important to recognize the early postpartum period um and and for some people the perry pardon the month before uh delivery
47:59
there is a significant increase in the likelihood of major depression as well as suicidal ideation
48:11
now another thing they didn't tell you in the book suicide risk in fathers in the postpartum period and i know i i harp on this topic but i think it is so important because the health of the caregiving system is vital to the health of the infant we can't just pluck out the birth parent and focus on them we need to focus on the caregivers
48:42
so suicide risk in fathers in the postpartum period was 4.8 percent fathers with postpartum depression were 21 percent more likely to present suicide risk and those with mixed episodes so they had depression as well as symptoms of hypomania that didn't quite meet the criteria for a hypomanic episode were 46 times high more likely to present with suicide risk than those who did not suffer from any mood disorder so suicidal ideation in fathers with postpartum depression
49:20
either simple postpartum depression or postpartum depression with mixed features is significant and we need to be aware of that because that is going to impact the health of the caregiving unit
49:40
seasonal affective disorder and seasonal
49:45
patterns in major depressive disorder suicide rates interestingly i told you we're going to get some interesting information here suicide rates increase in spring and summer and actually decrease in december with the lowest trough on christmas um
50:06
they peak on new year's day and go back to the yearly average thereafter now they hypothesize and i say they the researchers hypothesize that the perception of one's own depression and despair is enhanced in the spring by the perceived difference between the outer world that sunny and bright and people are outside you know mowing their lawn and having fun and their inner world which is dark whereas during the winter even though there's uh less daylight hours and circadian rhythms
50:42
get somewhat disrupted the outside feels dark and dreary and the inside feels dark and dreary so there's less dissonance there that's just one hypothesis but i think it's important for us to note a lot of us assume that the holidays is when uh suicide peaks and that's actually not true suicide rates actually increase in the spring and summer so we need to be more cognizant of that
51:16
premenstrual dysphoric disorder now this is a unique diagnosis in the depressive disorders but i thought it was important to mention it here while we're talking about suicide people with premenstrual dysphoric disorder are at greater risk for suicidal ideation and suicide attempts okay however suicide attempts are not related to the menstrual cycle
51:44
so assuming that somebody is going to become more suicidal more emotionally dysregulated and impulsive when their hormones switch is not accurate that's faulty reasoning
52:01
the rate of ideation suicidal ideation in major depressive disorder is about 15.9 percent
52:09
but in people with premenstrual dysphoric disorder the rate of suicidal ideation is 39.7 percent so that's like more than double if you have somebody who is diagnosed with premenstrual dysphoric disorder you need to be aware of the suicide risk
52:29
and be aware that the risk is not just around the time of their period the risk is all month long you know while they're symptomatic while they're diagnosable
52:45
the text also noted in general um that most deaths by suicide are not preceded by non-fatal attempts
52:53
anhedonia has a particularly strong association with suicidal ideation differential diagnosis psychologically we want to rule out bipolar disorder if any if the person has had a manic or hypomanic episode ever then they are diagnosed with bipolar disorder we want to rule out premenstrual dysphoric disorder you know that one the criteria are obvious
53:23
disruptive mood dysregulation disorder number one is primarily a childhood diagnosis remember it has to be diagnosed before it has to have an age of onset before the age of 10 and it can't be diagnosed after the age of 18. additionally in disruptive mood dysregulation disorder the irritability and outbursts are not confined to a depressive episode so a child with major depression may be irritable and have a lot of outbursts during a major depressive episode
53:57
and then have periods where they don't have irritability and outbursts there's there's those remission periods that's not true in disruptive mood dysregulation disorder
54:12
people with this diagnosis psychotic features are present for two weeks without major depression so they have these psychotic features outside of a major depressive disorder
54:26
adjustment disorder is diagnosed if the person does not meet the full criteria for major depressive disorder or persistent depressive disorder
54:37
bereavement is different from major depression because in bereavement the primary feelings are of loss and emptiness versus depressed mood and anhedonia and mood symptoms in bereavement often come in waves or tsunamis if you will and are associated with reminders in depression it tends to be more constant it's not this ebb in and and out
55:05
medically and this is in the diagnostic features section diabetes cancer pregnancy and postpartum and thyroid issues also can cause depressive symptoms so you want to differentially diagnose diabetes because of blood sugar levels cancer because of the pain and fatigue pregnancy and postpartum uh again because of fatigue and hormone fluctuations and overall presentation and thyroid if somebody has hypothyroid they are going to have most of the symptoms
55:45
or enough to be diagnosed with major depression so we do want to make sure that we rule those out
55:52
comorbidity and i'm running short on time here so i'm going to speed it up a little we need to make sure that we recognize that major depression co-occurs you can have multiple diagnoses major depression co-occurs with addiction anxiety ptsd obsessive-compulsive disorder eating disorders bipolar disorder somatoform disorder and bereavement
56:20
other depressions that i mentioned that we're not going to cover today but you need to be aware of if you're making a diagnosis again disruptive mood dysregulation disorder premenstrual dysphoric disorder substance or medication induced depressive disorder
56:38
if somebody is using depressants it may cause depressive symptoms if somebody is withdrawing from stimulants they may experience depressive symptoms some medications that you take will have on the label that it may cause feelings of depression it's important to be aware of what medications a person is taking as well as what substances they may be using
57:06
depressive disorder due to a medical condition we talked about a whole bunch of medical conditions but it's almost limitless i can't remember exactly how the dsm said it but there continues to be and additions to the different types of medical conditions that can cause
57:27
depression so we do need to rule that out you know is are all of these symptoms being caused by a medical condition or something else and then you have other specified depression and unspecified depression there are a variety of different ways that depression presents and different depressive disorders major depression persistent depression premenstrual dysphoric disorder medication or substance abuse substance induced depression
57:59
due to another medical condition and disruptive mood dysregulation disorder additionally depressive disorders are associated with a host of physiological changes including changes in the microbiome when people get depressed when people get stressed it alters their vagus nerve sends out signals it alters their microbiome
58:21
when their microbiome gets out of whack it actually can contribute to depression so it's a bi-directional problem uh inflammatory cytokines inflammation causes is strongly associated with depression and depression is strongly associated with developing systemic inflammation
58:42
and nutritional deficiencies just to name a few and depressive disorders are also associated with a host of comorbid disorders we need to make sure we're addressing the whole person we're addressing all of the trauma all of the personality issues all of the mood issues you know anything that's going on that's in our wheelhouse but also that we're addressing the physiological issues that may be complicating or contributing
59:15
to their presentation i know that was a lot thank you for bearing with me and i'll see you next time
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