Depression Disorders in the DSM 5 TR | Symptoms and Diagnosis

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 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 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   disruptive mood dysregulation disorder  that's going to get its own entire class   premenstrual dysphoric disorder substance  or medication induced depressive disorder   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   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   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   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   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   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   it feels like you are walking or moving  through mud or through a wind tunnel   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   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   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 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   sleep changes oh my gosh you just don't even grasp   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 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 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   considered recurrent there has to be at least a  two-month break before between being symptomatic   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   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 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   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   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   however the diagnosis can be made up to age 18.   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   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   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 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   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   has never been a manic or hypomanic episode so  some people can have that increase in activity   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   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   a much more significant risk of  suicidal ideation or suicide attempts   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   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   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   aspect of it is persistent interpersonal rejection  sensitivity now that isn't a typical feature that   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   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   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 catatonia is another specifier  and this is obviously   very obvious if somebody is presenting with major  depressive disorder with catatonia they are um   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 thyroid dysfunction is relatively  common in people after they give birth 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   affective disorder and younger people are also  at a higher risk for winter depressive episodes   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   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   or in somebody with a family history of bipolar  disorder now why are we making that so painfully   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 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   think about the person in the environment  in context what else is going on   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   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   the unresolved traumas that may be contributing  so we need to get curious for each individual   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   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 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   they present with symptoms of fatigue  sleep changes or body aches and pains   now that kind of sounds like the flu or a cold  or a variety of other things so it may get   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 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 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   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 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   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   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   gaba and serotonin among others are involved  in our pain threshold and when we have   low levels we tend to have more pain we  act our pain perception is more acute   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   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   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   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   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   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   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   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   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   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   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   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   actually can permeate through the intestines into  the bloodstream and then that causes inflammation   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   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   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   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   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   rhythm disruption is something that is causing  the person from getting adequate quality sleep um   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   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 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 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   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   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   caribbean blacks that comes directly  out of the new dsm tr culture section 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   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   neuroticism or do if we see these symptoms do  we also want to make sure we screen for ptsd and borderline personality cptsd complex  post-traumatic stress disorder is still   not a diagnosis okay we cannot make that  official diagnosis for billing purposes however   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   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   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 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   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 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   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 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 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   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 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   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   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   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 the transgender population 42  42.9 of people who are transgender   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 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   there is a significant increase in the likelihood  of major depression as well as suicidal ideation   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   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   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 seasonal affective disorder and seasonal 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   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   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 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   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   the rate of ideation suicidal ideation in  major depressive disorder is about 15.9 percent   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   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 the text also noted in general um that most deaths  by suicide are not preceded by non-fatal attempts   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   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   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 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   adjustment disorder is diagnosed if the  person does not meet the full criteria   for major depressive disorder or  persistent depressive disorder 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 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   or enough to be diagnosed with major depression  so we do want to make sure that we rule those out   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 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   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 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 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   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   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   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   to their presentation i know that was a lot thank  you for bearing with me and i'll see you next time

Channel: Doc Snipes

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Id: q5Npw03I0t8

Length: 59min 24sec (3564 seconds)

Published: Wed Apr 13 2022