Depressive Disorders: An Overview of Full Spectrum. Dr. Ashok Kumar Batham.

Depressive Disorders:
An Overview of Full Spectrum
Dr. Ashok Kumar Batham, MB,BS, MD, DCR
Chief Consultant
Dr Batham Pharma Consultants
Phone: +91 93280 18777
Email: ashokpharmacol@gmail.Com
Ashok Kumar Batham 1

Depressive Disorders
Major Depressive Disorder (MDD)
Persistent Depressive Disorder (PDD) or Dysthymia
Disruptive Mood Dysregulation Disorder (DMDD)
Premenstrual Dysphoric Disorder (PMDD)

Depressive Disorders
Substance/Medication Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder

Major Depressive Disorder (MDD)

Major depressive Disorder: DSM-5 Diagnostic
Criteria
Major Depressive Episode:
Five (or more) of the following symptoms 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.
1. Depressed most of the day, nearly every day as indicated by
subjective report (e.g., feels sad, empty, hopeless) or observation
made by others (e.g., appears tearful)
2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by
subjective account or observation)

Criteria
Major Depressive Episode:
3. Significant weight loss when not dieting or weight gain (e.g., change
of more than 5% of body weight in a month), or decrease or
increase in appetite nearly every day.
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)

Criteria
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

Criteria
• The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
• The episode is not attributable to the physiological effects of
a substance or to another medical condition.
Note: The above criteria represent a major depressive
episode.

Criteria
• The occurrence of the major depressive episode is not better
explained by schizoaffective disorder, schizophrenia, schizophreniform
disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
• There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or
hypomanic-like episodes are substance-induced or are attributable to
the physiological effects of another medical condition.

Diagnosis of Major Depressive Episode
• Essential features: Either depressed mood or loss of interest or
pleasure plus four other depressive symptoms
• Duration: At least two weeks
• Common rule outs: Medical condition, medications, substance use,
bipolar disorder, or a psychotic disorder [major depression following a
significant loss, such as death of near one, representing a normal grief
may resemble a depressive episode].

Diagnosis of Major Depressive Episode
Essential Diagnostic Criteria:
Meets criteria for a Major Depressive Episode
No history of a Manic or Hypomanic Episode Coding Steps:
Document whether it is:
– Major Depressive Disorder, single episode
– Major Depressive Disorder, recurrent episodes
Indicate the severity/course specifier term after single or recurrent
episode: Mild, moderate, severe, with psychotic features and in full or
partial remission

Diagnosis of Major Depressive Episode - Specifiers
Specify Major Depressive Disorder:
• With anxious distress
• With mixed features
• With melancholic features
• With atypical features
• With mood-congruent psychotic features or with mood-incongruent psychotic
features
• With catatonia
• With peripartum onset
• With seasonal pattern

Treatment of Major Depressive Episode
Indications for psychotherapy:
• Presence of significant stressors
• Interpersonal problems
• Patient preference
• Pregnant, lactating or planning
pregnancy
• Personality Disorder
Indications for pharmacotherapy:
• Prior positive response
• Presence of major somatic
symptoms
• Patient preference

Persistent Depressive Disorder (Dysthymia)

Persistent Depressive Disorder (Dysthymia):
DSM-5 Diagnostic Criteria
A. Depressed mood for most of the day, for more days than
not, as indicated by either subjective account or observation
by others, for at least 2 years.
(In children and adolescents, mood can be irritable and
duration must be at least 1 year)
Dr.Ashok Kumar Batham

B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.

C. During the 2-year period (1 year for children or adolescents) of the
disturbance, the individual has never been without the symptoms in
Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present
for 2 years.
E. There has never been a manic episode or a hypomanic episode, and
criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective
disorder, schizophrenia, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

Diagnosis of Persistent Depressive Disorder
(Dysthymia)
• Essential feature: Depressed mood & at least two other
depressive symptoms.
May include periods of major depressive episodes (double
depression)
• Duration: The symptoms persist for at least two years (one
year for children and adolescents)
• Rule outs: Another psychotic disorder, substance abuse,
other medication or medical condition

Diagnosis of Persistent Depressive Disorder
(Dysthymia)
• Severity: Mild, moderate or severe
• Remission status: In partial or full remission (if applicable)
• Onset: Early (before 21) or late (21 or older) onset
• Specify mood features: With anxious distress, mixed features, melancholic
features, atypical features, mood- congruent or mood-incongruent psychotic
features, and peripartum onset
• Course specifiers:
• With pure dysthymic syndrome
• With persistent major depressive episode
• With intermittent major depressive episodes, with current episode
• With intermittent major depressive episodes, without current episode

Disruptive Mood Dysregulation Disorder (DMDD)

Disruptive Mood Dysregulation Disorder (DMDD):
A. Severe recurrent temper outbursts manifested verbally (e.g.,
verbal rages) and/or behaviorally (e.g., physical aggression
toward people or property) that are grossly out of proportion in
intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental
level.
C. The temper outbursts occur, on average, three or more times
per week.
D. The mood between temper outbursts in persistently irritable or
angry most of the day, nearly every day, and is observable by
others (e.g., parents, teachers, peers).

E. Criteria A–D have been present for 12 or more months. Throughout that
time, the individual has not had a period lasting 3 or more consecutive
months without all of the symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of the three settings (i.e., at
home, at school, with peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or
after age 18 years.
H. By history or observation, the age of onset of Criteria A-E is before 10
years.
I. There has never been a distinct period lasting more than 1 day during
which the full symptom criteria, except duration, for a manic or
hypomanic episode have been met.
Note: Developmentally appropriate mood elevation, such as occurs in the
context of a highly positive event or its anticipation, should not be
considered as a symptom of mania or hypomania.

J. The behaviors do not occur exclusively during an episode of major
depressive disorder and are not better explained by another mental disorder
(e.g., autism spectrum disorder, posttraumatic stress disorder, separation
anxiety disorder, persistent depressive disorder [dysthymia]).
• Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive
disorder, or bipolar disorder, though it can coexist with others, including major depressive
disorder, attention-deficit/ hyperactivity disorder, conduct disorder, and substance use disorders.
Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and
oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation
disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of
disruptive mood dysregulation disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a
substance or to another medical or neurological condition.

Diagnosis of Disruptive Mood Dysregulation Disorder
(DMDD)
Essential feature: Severe temper outbursts with underlying
persistent angry or irritable mood.
Temper outburst frequency: Three or more times a week.
Duration: Temper outbursts and the persistently irritable mood
between outbursts lasts at least 12 months.

Diagnosis of Disruptive Mood Dysregulation Disorder
(DMDD)
Severity: Present in two settings and severe in at least one.
Onset: Before age 10 but do not diagnose before age 6. Can
not diagnose for the first time after age 18.
Common rule-outs: Bipolar disorder, intermittent explosive
disorder, depressive disorder, ADHD, autism spectrum disorder,
separation anxiety disorder, Substance, medication or medical
condition.

Treatment of Disruptive Mood Dysregulation
Disorder (DMDD)
• No established treatment available.
• Use of drugs used in bipolar disorder to be avoided.
• CBT for depression in children.
• Coping skills for thoughts, feelings and behaviour.
• Parent training.
• Parent support group.

Premenstrual Dysphoric Disorder
(PMDD)

Premenstrual Dysphoric Disorder:DSM-5 Diagnostic
Criteria
Criterion A: At least 5 of the following 11 symptoms (including at least
1 of the first 4 listed) must be present in the final week before the
onset of menses, start to improve within a few days after the onset of
menses, and become minimal or absent in the week post-menses.
1. Marked lability (e.g., mood swings)
2. Marked irritability or anger
3. Markedly depressed mood
4. Marked anxiety and tension
5. Decreased interest in usual activities

Criteria
6. Difficulty in concentration
7. Lethargy and marked lack of energy
8. Marked change in appetite (e.g., overeating or specific food cravings)
9. Hypersomnia or insomnia
10.Feeling overwhelmed or out of control
11.Physical symptoms (e.g., breast tenderness or swelling, joint or muscle
pain, a sensation of ‘bloating’ and weight gain)[

Criteria
Criterion B: One (or more) of the following symptoms must be
present:
• Marked affective lability (e.g., mood swings; feeling suddenly sad or
tearful, or increased sensitivity to rejection).
• Marked irritability or anger or increased interpersonal conflicts.
• Marked depressed mood, feelings of hopelessness, or self-deprecating
thoughts.
• Marked anxiety, tension, and/or feelings of being keyed up or on edge.

Criteria
Criterion C: One (or more) of the following symptoms must be present
additionally, to reach a total of five symptoms when combined with
symptoms from Criterion B above.
• Decreased interest in usual activities (e.g., work, school, friends, hobbies).
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite; overeating; or specific food cravings.
• Hypersomnia or insomnia.
• A sense of being overwhelmed or out of control.
• Physical symptoms such as breast tenderness or swelling, joint or muscle
pain, a sensation of "bloating," or weight gain.

Criteria
Criterion D: The symptoms are associated with clinically
significant distress or interference with work, school, usual
social activities, or relationships with others (e.g., avoidance
of social activities; decreased productivity and efficiency at
work, school, or home).
Criterion E: The disturbance is not merely an exacerbation of
the symptoms of another disorder, such as major depressive
disorder, panic disorder, persistent depressive disorder
(dysthymia), or a personality disorder (although it may co-
occur with any of these disorders).

Criteria
• Criterion F: Criterion A should be confirmed by prospective daily
ratings during at least two symptomatic cycles.
• Criterion G: The symptoms are not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication, other
treatment) or another medical condition (e.g., hyperthyroidism).

Diagnosis of Premenstrual Dysphoric Disorder
(PMDD)
Essential feature: Significant affective symptoms emerging in the week prior
to menstruation and quickly disappearing with the onset of menstruation.
Symptom threshold: Presence of atleast five symptoms which include
marked affective lability, depressed mood, irritability, or tension.
Duration: Present in all menstrual cycles in the past year and documented
prospectively for two menstrual cycles.
Impairment: Clinically significant distress or impairment.
Rule outs: An existing mental disorder (e.g., MDD), another medical
condition (e.g., migraines that worsen during the premenstrual phase) or
substance or medication use.

Health problems with Premenstrual Dysphoric
Disorder (PMDD)
• Increased risk of postpartum depression – Increased risk of
suicidal thinking, planning and gestures
• Impact on the individual’s quality of life
• Impact on psychosocial functioning

Treatment of Premenstrual Dysphoric Disorder
(PMDD)
1. Cognitive behavioural therapy (CBT)
2. Drugs: Selective Serotonin Reuptake Inhibitors
(SSRIs)
3. Dietary changes

Thank You

Depressive Disorders: An Overview of Full Spectrum. Dr. Ashok Kumar Batham.

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