depression


As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

Major Depressive Disorder is one of the most common diagnoses given in the mental health field, almost 15 million adults at a time in the US, according to NIHM. The DSM-IV-TR says that it occurs equally throughout ethnicities, education and income strata, and for married and unmarried people. It does not occur equally by gender, however, with something like three times as many women as men carrying the diagnosis. It’s also not spread equally by nationality. Here’s a Wikipedia map of the distribution. The red countries have twice as much Major Depressive Disorder:

800px-Unipolar_depressive_disorders_world_map_-_DALY_-_WHO2004

Here are the diagnostic criteria for Major Depressive Disorder, first Single Episode then Recurrent, word for word quoted from the DSM-IV-TR, pages 375 and 376. Note that most of the diagnostic action happens in the criteria for Major Depressive Episode, not Major Depressive Disorder. Also, it is interesting (and frustrating, in my case) that most prescribers and a great many diagnosticians use Major Depressive Episode’s criteria A and B, but disregard criteria C, D and E. That is, the symptom lists are considered important but the disqualification by environmental and historical factors are not.

Diagnostic criteria for 296.2x Major Depressive Disorder, Single Episode

A.      Presence of a single Major Depressive Episode (see p. 356)

B.      The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episode, specify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

Diagnostic criteria for 296.3x Major Depressive Disorder, Recurrent

A.      Presence of two or more Major Depressive Episodes (see p. 356)

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

B.      The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizzophreniform disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C.      There has never been a Manic Episode (see p. 362), a Mixed Episode (see p. 365), or a Hypomanic Episode (see p. 368). Note:   This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects  of a general medical condition.

If the full criteria are currently met for a Major Depressive Episodespecify its current clinical status and/or features:

Mild Moderate, Severe Without Psychotic Features/Severe With Psychotic Features (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

If the full criteria are not currently met for a  Major Depressive Episodespecify the current clinical status of the Major Depressive Disorder or features of the most recent episode:

In Partial Remission, In Full Remission (see p. 412)

        Chronic (see p. 417)

With Catatonic Features (see p. 417)

With Atypical Features (see p. 420)

With Postpartum Onset (see p. 422)

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As I wrote recently, I am in the strange position of boning up on the soon-to-be-obsolete diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders IV-TR.

These “Mood Episodes” are the building blocks for the DSM‘s major “Mood Disorders”: Major Depressive Disorder, Bipolar I Disorder, and Bipolar II Disorder. That is, the experiences described below are necessary but not necessarily sufficient to get you one of the big Mood Disorder diagnoses. Please do not use this post to diagnose yourself or anyone else you know. (Read my disclaimer here.)

These are word-for-word from the DSM-IV-TR, page 356 for Major Depressive Episode, page 362 for Manic Episode, page 365 for Mixed Episode, and page 368 for Hypomanic Episode.

Criteria for a Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1)    depressed mood most of the day, nearly every day, as indicated by either subsjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2)    markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3)    significant weight loss when not dieting or weight gain (e.g., a  change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4)    insomnia or hypersomnia nearly every day

(5)    psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6)    fatigue or loss of energy nearly every day

(7)    feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8)    diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9)    recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B.      The symptoms do not meet criteria for a  Mixed Episode (see p. 365).

C.      The symptoms are not due to the direct distress or impairment in social, occupational, or other important areas of functioning

D.      The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abus, a medication) or a general medical condition (e.g., hypothyroidism).

E.       The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Criteria for a Manic Episode

A.      A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration of hospitalization is necessary).

B.      During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

(1)    inflated self-esteem or grandiosity

(2)    decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)    more talkative than usual or pressure to keep talking

(4)    flight of ideas or subjective experience that thoughts are racing

(5)    distractibility (i.e., attention to easily drawn to unimportant or irrelevant external stimuli)

(6)    increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)    excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C.      The symptoms do not meet criteria for a Mixed Episode (see p. 365)

D.      The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E.       The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Criteria for Mixed Episode

A.      The criteria are met both for a Manic Episode (see p. 362) and for a Major Depressive Episode (see p. 365) (except for duration) nearly every day during at least a 1-week period.

B.      The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others., or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

C.      The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Mixed-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Criteria for Hypomanic Episode

A.      A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

B.      During the period of mood disturbance, three (or more) of the following symptoms have persisted (four of the mood is only irritable) and have been present to a significant degree:

(1)    inflated self-esteem or grandiosity

(2)    decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)    more talkative than usual or pressure to keep talking

(4)    flight of ideas or subjective experience that thoughts are racing

(5)    distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6)    increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)    excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C.      The episode is associated with an  unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D.      The disturbance in mood and the change in functioning are observable by others.

E.       The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

F.       The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

I read Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America as a counterpoint assignment in one of the diagnosis classes in my Couples & Family Therapy program. It was an excellent book about the history and science of several psychological problems, both as phenomena and diagnoses, including depression, depression, bipolar disorder, ADHD, and schizophrenia. As a university student, I had the opportunity to check out for free any of the many academic citations in the book that piqued my interest, and each one that I looked at seemed indeed to provide the evidence he claimed. I haven’t read anything like all of them (there are nearly 700), but enough to satisfy myself that Whitaker has done some good journalism here, and that his hypotheses are credible.

Two of these hypotheses is about childhood bipolar disorder, the first of which he calls the “ADHD to bipolar pathway.” The side effects of stimulants such as those used to treat ADHD are substantially similar to bipolar symptoms, as shown in the table below, from p. 238. (The formatting is slightly different than Whitaker’s, thanks to an Open Office/Wordpress interaction.) Multiplying the estimated rate of stimulant-induced bipolar-like symptoms by the 3,500,000 children and teens taking those medications, Whitaker estimates we should see approximately 400,000 “bipolar youth” as a result.

The ADHD to Bipolar Pathway

Stimulant-Induced Symptoms

Bipolar Symptoms

Arousal

Dysphoric

Arousal

Dysphoric

Increased lethargy

Intensified focus

Hyperalertness

Euphoria

Agitation, anxiety

Insomnia

Irritability

Hostility

Hypomania

Mania

Psychosis

Somnolence

Fatigue, lethargy

Social withdrawal, isolation

Decreased spontaneity

Reduced curiosity

Constriction of affect

Depression

Emotional lability

Increased energy

Intensified goal-directed activity

Decreased need for sleep

Severe mood change

Irritability

Agitation

Destructive outbursts

Increased talking

Hypomania

Mania

Sad mood

Loss of energy

Loss of interest in activities

Social isolation

Poor communication

Feelings of worthlessness

Unexplained crying

The second part of Whitaker’s thinking on childhood bipolar disorder is an SSRI to bipolar pathway. Estimates of the rate of the well-know SSRI side effect of mania, multiplied by 2,000,000 children and adolescents on the medications, give us the possibility of producing at least 500,000 SSRI-induced bipolar disorders in young people.

If true, these hypotheses could go a long way to explain the skyrocketing rates of childhood bipolar disorder diagnoses, as most diagnoses of childhood bipolar disorder are made on children who are already taking stimulants and/or SSRIs. The primary alternative, and more mainstream, hypothesis is not that stimulants and SSRIs are iatrogenic, but that since those medications solve the problems of ADHD and depression, the symptoms of bipolar disorder that emerge show that the diagnostician had initially guessed wrong, and that bipolar disorder was the previously-existing and underlying cause of the ADHD and/or depression. This, of course, may be true, but it seems very important to discover for certain whether it is!

I just finished the biggest project so far for my couples and family therapy masters program. It’s a paper about depression in couples and how it might be treated by a metaframeworks-oriented therapist. Most of it is probably of limited interest to non-therapists, but I wrote a very brief summary of  what we know and think about depression as an introduction that might interest anyone psychologically-minded. If you are interested in the research about depression in couples, my references section might be quite helpful. It would have been for me…

If you’re interested, I posted it here.

I’m learning about child abuse and neglect in my Child and Family Assessment class. Today I read about the ACE study, by the US Center for Disease Control. It is a huge study, with over 17,000 participants, where they gathered information about childhood abuse, neglect, and household dysfunction, and then proceeded to see what health outcomes and behaviors they could predict with that information. It turns out they can predict a lot. They’ve published 50 articles on the study and the research is ongoing–they are continuing to collect health information as the participants in the study age. I’ll present a few of their findings below. For more, see the ACE Study.

Here are some of their findings. I’ll paste in the definitions of the categories of adverse childhood experiences below. Strong correlations were found with the following:

  • alcoholism and alcohol abuse (4 or more categories of ACE meant 4-12 times increase)
  • chronic obstructive pulmonary disease (that is, lung disease)
  • depression (4 or more categories of ACE meant 4-12 times increase)
  • fetal death
  • health-related quality of life (way more inactivity, severe obesity, bone fractures)
  • illicit drug use
  • ischemic heart disease (IHD)
  • liver disease
  • risk for intimate partner violence
  • multiple sexual partners (4 or more categories of ACE correlated with 50 or more sexual partners)
  • sexually transmitted diseases (STDs) (4 or more categories of ACE meant 4-12 times increase)
  • smoking
  • suicide attempts (4 or more categories of ACE meant 4-12 times increase)
  • unintended pregnancies

Here are the kinds of abuse, neglect, and dysfunction they asked about, quoted from the site:

Abuse

Emotional Abuse:
Often or very often a parent or other adult in the household swore at you, insulted you, or put you down and/or sometimes, often or very often acted in a way that made you think that you might be physically hurt.

Physical Abuse:
Sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at you and/or ever hit so hard that you had marks or were injured.

Sexual Abuse:
An adult or person at least 5 years older ever touched or fondled you in a sexual way, and/or had you touch their body in a sexual way, and/or attempted oral, anal, or vaginal intercourse with you and/or actually had oral, anal, or vaginal intercourse with you.

Neglect

Emotional Neglect1

Respondents were asked whether their family made them feel special, loved, and if their family was a source of strength, support, and protection. Emotional neglect was defined using scale scores that represent moderate to extreme exposure on the Emotional Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form.

Physical Neglect1

Respondents were asked whether there was enough to eat, if their parents drinking interfered with their care, if they ever wore dirty clothes, and if there was someone to take them to the doctor. Physical neglect was defined using scale scores that represent moderate to extreme exposure on the Physical Neglect subscale of the Childhood Trauma Questionnaire (CTQ) short form constituted physical neglect.

Household Dysfunction

Mother Treated Violently:
Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, and/or ever repeatedly hit over at least a few minutes and/or ever threatened or hurt by a knife or gun.

Household Substance Abuse:
Lived with anyone who was a problem drinker or alcoholic and/or lived with anyone who used street drugs.

Household Mental Illness:
A household member was depressed or mentally ill and/or a household member attempted suicide.

Parental Separation or Divorce:
Parents were ever separated or divorced.

Incarcerated Household Member:
A household member went to prison.

Psychology hit the actual headlines last week, with Sharon Begley’s “The Depressing News About Antidepressants” in Newsweek. The story is that, if you look at all the evidence, not just the “successful” trials, SSRIs like Prozac and Paxil do not work better than a placebo for mild and moderate depression. Begley also tells the story as if she’s sorry to break the news and spoil the placebo effect. Here’s my version of the headlines from this story:

Pharmaceutical Companies Have Known For At Least Ten Years That SSRIs Work No Better Than Placebos: At least, anyone there who understood statistics and paid any attention to their research.

The Idea That SSRIs Are Better Than Placebos Was Propagated By Publishing Only the “Successful” Trials: This, obviously, was quite unethical.

The FDA Almost Certainly Knew That SSRIs Were No Better Than Placebos, Too: They had all of the research. Perhaps they did not read it.

People Who Read Psych Journals Knew SSRIs Were No Better Than Placebos Two Years Ago: The news caused a stir in my undergrad psych lab in 2008.

We Do Not Know What Causes Depression: The idea that depression has to do with the neurotransmitter serotonin was based largely on the (incomplete) evidence that SSRIs (selective serotonin re-uptake inhibitors) cured depression. In fact, we have pretty limited knowledge of what goes on inside a living brain. In fact, we have no ethical way to measure how much serotonin or any other neurotransmitter is where inside anyone’s living brain, so when a doctor tells you something like, “You are depressed because you have overactive serotonin re-uptake mechanisms,” they are passing on speculation, not science.

If You Recovered From Mild to Moderate Depression While On An SSRI, It Was Probably Your Own Hope That Lifted You Out: The thing about placebos is that they work pretty well. If you benefited from the placebo effect, it was your own strength, your own hope, that made the difference. You overcame that challenge. I think that’s pretty cool.

While SSRIs Do Not Treat Depression Better Than Placebos, They Do Have Side Effects: Here’s a list from wikipedia: Decreased or absent libido, Impotence or reduced vaginal lubrication, Difficulty initiating or maintaining an erection or becoming aroused, Persistent genital arousal disorder despite absence of desire, Muted, delayed or absent orgasm (anorgasmia), Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia), Premature ejaculation, Weakened penile, vaginal or clitoral sensitivity, Genital anesthesia, Loss or decreased response to sexual stimuli, Reduced semen volume, Priapism (persistent erectile state of the penis or clitoris)anhedonia, apathy, nausea/vomiting, drowsiness or somnolence, headache, bruxism (involuntarily clenching or grinding the teeth), extremely vivid and strange dreams, dizziness, fatigue, mydriasis (pupil dilation), urinary retention, changes in appetite, changes in sleep, weight loss/gain (measured by a change in bodyweight of 7 pounds), may result in a double risk of bone fractures and injuries, changes in sexual behaviour,increased feelings of depression and anxiety (which may sometimes provoke panic attacks), tremors (and other symptoms of Parkinsonism in vulnerable elderly patients), autonomic dysfunction including orthostatic hypotension, increased or reduced sweating, akathisia, liver or renal impairment, suicidal ideation (thoughts of suicide), photosensitivity (increased risk of sunburn), Paresthesia, Mania, hypomania, sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido, a severe and even debilitating withdrawal syndrome, a slight increase in the risk of self-harm, suicidal ideation, and suicidality in children, neonatal complications such as neonatal abstinence syndrome (NAS) and persistent pulmonary hypertension, and platelet dysfunction.

Until Your Medicated Kids Are Old, We Will Not Know What All of the Side Effects of Treatment by SSRIs Are: This is true for any new drug, and it’s worth considering. If your child is on Prozac or other new drug, they are essentially part of a massive experimental trial.

Pharmaceutical Companies Pay for Psychiatric Educations: Why would it surprise anyone that treatment equals drugs in this case?

Most Antidepressant Prescriptions Written by Health Care Providers With No Significant Psychiatric Training: GPs, OBGYNs, pediatricians, etc account for 80% of SSRI prescriptions.

This is part 3 of a series of things I learned during my Bachelor’s degree in psychology that I thought should have been headlines in the mainstream news. If you missed them, here’s part 1 and part 2. Again, if you’re interested or skeptical, leave me a comment with a specific question and I’ll give you my references.

Egaz Moniz Was Given the Nobel Prize for Medicine in 1949 for Developing the Prefrontal Lobotomy: This “psychosurgery” involved slicing or scrambling the front part of the brain, and tended to produce more manageable behavior in “patients.”

40,000 Human Beings Were Lobotomized in the United States Between 1936 and 1977: These were men, women, and children with “illnesses” like schizophrenia, PTSD, depression, anxiety, homosexuality, criminal behavior, and being hard to manage.

Antipsychotic Thorazine Hailed as “Chemical Lobotomy”: Yes, this was meant as a compliment.

200,000,000 Prescriptions for Antidepressants in the US in 2007: That’s quite a few prescriptions.

80% of Antidepressant Prescriptions in the US Not Written by Psychiatrists: Consider that it may be a good idea to at least see a specialist in mental illness before taking psychotropic drugs or giving them to your kids.

Some Psychopharmaceuticals as Effective as Exercise in Treating Depression: But who wants to exercise when you’re depressed?

Sleep Deprivation the Most Effective Treatment For Depression, By Far: Never heard of this one? Maybe it’ll hit the news when someone figures out how to make money from sleep deprivation.

The World Health Organization Found That Schizophrenics Recover, But Only in Countries Without Easy Access to Psychopharmaceuticals: Schizophrenics can recover? Well, yes, it looks like they can. And yes, the WHO data shows a correlation, not necessarily causation, but an interesting correlation!