DSM-5 and ICD-10: Major Depression Guidelines

• Diagnostic Guidelines for Major Depression as defined by DSM-5 and ICD-10 are:

DSM-5 Major Depressive Episode

• Symptoms present nearly every day for at least 2 weeks
• Key symptoms include depressed mood and markedly diminished interest or pleasure in almost all daily activities (anhedonia) most of the day, nearly every day
• Ancillary symptoms include significant change in appetite or weight (increased or decreased), insomnia or hypersomnia, psychomotor retardation or agitation nearly every day, fatigue or loss of energy nearly every day
• Ancillary symptoms also include feelings of worthlessness or excessive or inappropriate guilt nearly every day, diminished ability to think, poor concentration or indecisiveness nearly every day, and recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific suicide plan
• Criteria for diagnosis and severity includes one key symptom and at least 5 symptoms in total plus clinically significant distress or impairment in social occupational, educational functioning
• In mild depression there are enough symptoms to meet criteria, symptoms are mild, and there is limited functional impairment
• In severe depression there are many severe symptoms and extreme functional impairment
• Moderate severity falls between mild and severe extremes
• Exclusions include no history of manic or hypomanic episode, not due to effects of a substance or a general medical condition, and not better explained by another disorder like schizoaffective disorder
• Recurrent depression includes two or more major depressive episodes with at least 2 months between episodes when criteria are not met for a major depressive disorder

ICD-10 Depressive Episode

• Symptoms present nearly every day for at least 2 weeks
• Key symptoms are depressed mood and loss of interest or pleasure in pleasurable activities; decreased energy or increased fatigability
• Ancillary symptoms include change in appetite or weight (increased or decreased), disturbed sleep, psychomotor retardation or agitation, low self-esteem or confidence, self-reproach or guilt, reduced concentration and attention, ideas or acts of self-harm or suicide
• For mild depression, 2 key and 4 symptoms in total
• For moderate depression, 2 key and 6 symptoms in total
• For severe depression 3 key and 8 in total
• Exclusions include no history of manic episodes, not due to substance abuse, an organic disorder or schizophrenia or schizoaffective disorder
• Recurrent depression requires at least one previous episode of 2 weeks' duration
• Somatic syndrome includes 4 items from the following list and is commonly associated with severe depression: loss of interest or pleasure in pleasurable activities, lack of emotional reactivity, waking in the morning 2 hours or more before the usual time, depression worse in the mornings, psychomotor retardation or agitation, marked loss of appetite or weight (5% in a month), marked loss of libido
• Psychotic symptoms include any of the following and are usually associated with severe depression: delusions, hallucinations, depressive stupor

DSM-5 sub-types of Major Depressive Episode

• With melancholic features includes loss of pleasure in almost all activities or lack of reactivity to pleasurable stimuli during worst phase of episode and 3+ of the following: distinct quality of depressed mood, worse in the morning, early morning waking, marked psychomotor agitation or retardation, significant weight loss, excessive guilt
• With mood congruent psychotic features include delusions and hallucinations with theme of inadequacy, guilt, disease, death, nihilism, or deserved punishment
• With mood incongruent psychotic features include delusions and hallucinations without depressive theme
• With anxious distress includes 2+ of the following: tense, restless, poor concentration due to worry, fear something awful will happen, fear of loss of control
• With mixed features includes 3+ of the following which are not due effect of a drug and do not meet criteria for bipolar disorder: elevated mood, grandiosity, pressure of speech, flight of ideas, increased energy, excessive risk taking, decreased need for sleep
• With atypical features includes most days with mood reactivity and 2+ of the following: increased appetite or weight gain, hypersomnia, leaden paralysis, chronic interpersonal rejection sensitivity, melancholic and catatonic features are absent
• With catatonia includes 3+ of the following: stupor, cataplexy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, grimacing, echolalia, echopraxia
• With peripartum onset includes onset during pregnancy or within a month of delivery
• With seasonal pattern includes onset in fall and winter and remission in spring over a 2-year period

Clinical Features of Depression

• MDD with panic disorder is currently not a recognised form of MDD
• Clinical features may be linked by assuming that depressed individuals have usually suffered a loss of some sort
• Perception includes a bias towards negative events and mood congruent hallucinations
• Cognition includes a negative view of self, world and future, over-general memory, cognitive distortions, inability to concentrate and indecision
• Mood includes depressed mood, diurnal variation in mood, irritable mood, anxiety and apprehension, loss of interest in pleasurable activities (anhedonia), distinct quality of depressed mood and lack of emotional reactivity
• Behaviour includes self-defeating behavior, psychomotor retardation or agitation, depressive stupor and self-harm
• Somatic state includes fatigue, diminished activity, loss of appetite or overeating, aches and pains, early morning waking, change in weight and loss of interest in sex
• Relationships include deterioration in family relationships, withdrawal from peer relationships and poor work or educational performance
• *These features are associated with melancholic depression and are referred to as vegetative features or the somatic syndrome
• §These features occur in psychotic depression
• Having suffered a loss, depressed individuals tend to perceive the world as if further losses were probable, selectively attend to negative features of the environment, leading them to engage in depressive cognitions and unrewarding behaviour patterns, which further establishes their depressed mood
• In severe cases of depression, individuals may report mood congruent auditory hallucinations.
• Auditory hallucinations also occur in schizophrenia, however, the hallucinations that occur in schizophrenia are not necessarily mood congruent. depressed individuals describe themselves, the world and the future in negative terms
• They evaluate themselves as worthless and are critical of their occupational and social accomplishments (i.e guilt for not living up to certain standards or letting others down), also see their world as unrewarding, critical and hostile or apathetic
• They report extreme hopelessness and excessive guilt for which they believe they should be punished, suicidal ideas or intentions may be reported
• They display logical errors in their thinking and concentration problems, maximizing the significance and implications of negative events and minimize the significance of positive events, also have over-general autobiographical memories, and have concentration, attention and decision-making problems
• Key features of depression include low mood (a feeling of sadness, emptiness, loneliness or despair), diurnal variation in mood (mood being worse in the morning) and anhedonia (diminished interest in doing things that they previously found pleasurable)
• Extreme anhedonia occurs in severe melancholic depression
• During an episode the increasing number and intensity of symptoms may lead to intense anxiety
• Irritability may also occur, with the person expressing anger at the source of their loss
• Depressed individuals may show either reduced and slowed activity levels (psychomotor retardation) or increased but ineffective activity (psychomotor agitation)
• Suicidal behaviour-self-harm is primarily motivated by the intention to end one's life
• Non-suicidal deliberate self-harm include other motivations
• Typically depressed people have difficulty sleeping and eat little due to appetite loss (vegetative features).
• In atypical cases of depression people may sleep too much due to constant feelings of exhaustion and eat excessively due to increased appetite or because eating may temporarily reduce their distress
• Headaches and medically unexplained chest, back, or abdominal pain are other somatic features of depression, also dysregulation of neurobiological, endocrine and immune functions and that sleep architecture is also affected
• Depressed individuals report a deterioration in their relationships

Classification of Subtypes of Mood Disorders

• Major depression features episodic mood disorders, characterized by episodes of low mood, negative cognition, and sleep and appetite disturbance.
• Bipolar disorder is is also episodic mood disorders, but consists of episodes of mania in which elation, grandiosity, flight of ideas and expansive behaviour occur.
• Dysthymia features non-episodic chronic conditions of at least 2 years' duration, characterized by depressive symptomatology (at least three symptoms in addition to low mood).
• Cyclothymia features non-episodic chronic conditions of at least 2 years' duration, characterized by similar but less extreme mood fluctuations than bipolar disorder.
• Evidence from stressful life event research shows that all episodes of depression, regardless of quality or severity, are preceded by stressful life events and in that sense are reactive.
• Treatment outcome research has shown that only about 2 out of 3 cases of depression respond to available treatments
• Symptom type or severity does not always predict which patients will respond to physical or psychological interventions
• For most patients multimodal therapy involving a combination of medication and psychotherapy is most effective
• The older psychotic/neurotic and endogenous/reactive distinctions have been incorporated into DSM-5 and ICD-10, insofar as depressive episodes may be specified as having either psychotic features or melancholic/somatic features, typical of what formerly was referred to as endogenous depression.
• With regard to the overt/masked distinction, this was introduced to take account of those whose depression was masked by scientifically unexplained symptoms such as headaches and chest pains.
• Some cases that would formerly have been described as having masked depression are classified in DSM-5 and ICD-10 as having somatoform disorder, a condition characterized by multiple medically unexplained symptoms.

Predisposing Factors

• Genetic factors may predispose people to developing depression and family history of depression, anxiety or neuroticism (genetic vulnerability to mood dysregulation).
• Heritability estimates: 40–70%
• The annual prevalence of depression is 4% and 12% for children born to depressed parents, and 88% will not develop it.The precise biological characteristics that are genetically transmitted and the mechanisms of transmissions are still largely unknown.
• Results of studies on structural and functional brain abnormalities, neurotransmitter dysregulation, endocrine abnormalities, immune system dysfunction, sleep architecture and circadian rhythm abnormalities suggest that vulnerability to dysregulation of one or more of these systems is probably inherited
• The vulnerability is polygenetically transmitted

Precipitating Factors

• First episodes of MDD are typically precipitated by major stressful life events (loss such as separation, divorce bereavement, illness, injury and unemployment)
• Seasonal depression occurs in winter, probably in response to low levels of sunlight and is marked by hypersomnia, overeating, carbohydrate craving and weight gain
• For people who have experienced three or more episodes, only minor stresses may precipitate a full-blown major depressive episode due to the neurobiological process of kindling and the cognitive process of rumination

Maintaining Factors

• Depressed mood is maintained by ongoing high levels of environmental stress, with demands exceeding personal coping and self-regulation resources and a tendency to inadvertently create stressful life situations; low activity levels; a constricted lifestyle with little positive social interaction; poor social skills; unsupportive relationships with family members; a depressive cognitive style; and probably by dysregulation of neurobiological systems mentioned earlier

Protective Factors

• Particularly in cases where childhood adversity occurred, include at least one positive early relationship with an adult in childhood, high intelligence or a unique talent
• Protective factors in adulthood include social support in the form of a confiding relationship, a supportive marriage, a good social support network, learned and self-regulation skills and functional coping strategies

Course

• 85% of clients experience recurrent episodes of depression, and on average people with MDD have five to nine episodes of 20-30 weeks each over the course of their lifetimes
• As the condition progresses the frequency and duration of depressive episodes increases
• Relapse rates for those recovering from a first or second episode of depression who are treated with antidepressants and who do not receive psychological or pharmacological maintenance treatment is 20–35%, but for those with a history of three or more previous episodes is about 60-80%
• Recurrent depression has distinctive features, mainly, early morning waking, diurnal variation in mood, lack of responsivity to environmental circumstances and high levels of cortisol
• US and UK studies show that after 14–24 months, 50–80% clients who only receive antidepressants relapse, compared with 20-35% of those who also receive CBT
• Maintenance therapies that include continuation of antidepressant pharmacological treatment or psychological maintenance treatment can reduce relapse rates from about 60–80% to about 20–37%
• For pregnant women, those undergoing surgery, those who cannot tolerate the side effects of antidepressants, and those ideologically opposed to medication, psychological maintenance treatment is vital, altogether this group constitutes 30-40% of cases

Risk and Protective Factors in the Aetiology of Depression

• Risk factors: female gender, genetic factors (family history of depression, anxiety or neuroticism), dysregulation of limbic system and prefrontal cortex, dysregulation of serotonergic and noradrenergic neurotransmission systems, dysregulation of neuroendocrine and immune systems, dysregulation of circadian rhythm's sleep architecture, childhood adversity (maltreatment or significant loss), attachment insecurity
• Protective factors: male gender, no family history of mood dysregulation
• Family-of-origin factors: childhood adversity, attachment insecurity
• Protective factors: positive childhood experiences, at least one positive relationship with a supportive adult in childhood, high intelligence or a unique talent
• Precipitating factors: major stressful life events, particularly loss, including separation, divorce, bereavement, illness, injury and unemployment; low levels of sunlight; after 3+ previous major depressive episodes, minor stressful life events; 3+ previous major depressive episodes
• Protective factors: absence of major stressful life events and losses, high levels of sunlight
• Psychological disorder related risk factors: neuroticism
• Protective factors include good mental health
• Personality traits and cognitive style risk factors include pessimistic cognitive style and self-regulation skills deficits
• Protective factors include emotional stability (low neuroticism), optimistic cognitive style, self-regulation skills and functional coping strategies
• Previous depressive episodes risk factor: prior episodes of depression produce changes in neurobiological systems that make depression more likely in response to small stresses
• Protective factors: less than 3 prior episodes of depression
• Current family risk factors: absence of a confiding relationship and unsupportive marriage
• Protective factors include a confiding relationship and supportive marriage
• Wider social system risk factors: poor social support network, high levels of environmental stress, low socio-economic status
• Protective factors: good social support network and low levels of environmental stress
• Treatment system risk factors: no treatment or unimodal treatment (psychological or pharmacological only)
• Protective factors include multimodal treatment including brief evidence-based psychological intervention and antidepressant medication