The document discusses Major Depressive Disorder, including its symptoms, the bereavement exclusion criteria, issues with the exclusion, prevalence and risk factors. Key symptoms include depressed mood or loss of interest for 2+ weeks. The bereavement exclusion aims to distinguish normal grief from depression but has logical inconsistencies. Prevalence is about 12% in the US, higher in younger adults and females. Risk increases with puberty, comorbidities, and family history of bipolar disorder or psychosis.

1. Major Depressive
Disorder
Brent Scobie, PhD

2. Major Depressive Disorder
 Symptoms must persist nearly every day, most of day for 2-weeks
 Depressed mood
 Loss of interest or pleasure in nearly all activities
 Irritability common in children and adolescents
 Four additional symptoms (appetite/weight change, anergia, guilt,
worthlessness, suicidality or thoughts of death, insomnia (particularly middle &
terminal)
 When emotion is described as bland can infer depression from facial
expression/demeanor or somatic complaints
 Symptoms must be differentiated from pre-onset state

3. Major Depressive Disorder:
Bereavement Exclusion
 Aimed to prevent False positives (i.e.
 diagnosing Normal grief as MDE)
 • Also aimed to prevent False negatives (i.e.
 recognizing that grief can trigger true MDE,
 indicators of true MDE are provided
 – Duration more than 2 months
 – Symptoms not characteristic of Normal grief,
 such as marked functional impairment,
 psychosis

4. Major Depressive Disorder:
Bereavement Exclusion
 Problem with Bereavement Exclusion:
 nothing particularly different about loss of a
 loved one to trigger normal grieving process;
 how about loss of a relationship? Loss of one’s
 home in a natural disaster? Loss of one’s
 livelihood after job is eliminated ? Why not
 exclude other stressors as well?
 Proposal to eliminate Bereavement Exclusion was made to fix this logical
inconsistency
 One option would be to extend the Bereavement Exclusion to include all significant
losses
 Problem: concern that there was insufficient empirical support and could lead to False
negatives; most patients do report that MDE appears to occur after a stressor

5. Normal Grief vs Major Depressive
episode
Normal Grief MDE
Predominant Affect Feelings of
emptiness/Loss
Persistent depressed
mood
Duration Decrease in intensity over
days to weeks, occur in
waves “pangs of grief”
More persistent
Positive emotions May be Present Absent
Thought content Preoccupation with
thoughts and memories of
deceased
Self critical, pessimistic
ruminations
Self esteem Generally preserved Worthlessness/self
loathing
Thoughts of death Focused on joining the
deceased
Suicidal thoughts because
of worthlessness

6. Prevalence and Risk Factors
 High mortality rates not only by suicide (e.g. older adults)
 12-month prevalence in US approx. 12%
 Higher among 18-29 y.os and females
 Likelyhood of onset increases with puberty, peaks in 20’s
 Comorbidities increase with chronicity of depression
 Prominent anxiety, personality disorders, symptom severity and psychosis
worsen prognosis
 Many bipolar illnesses begin with depressive episode
 Psychosis, adolescent onset and family hx bipolar increase liklihood

7.  Females have higher risk for suicide attempts, lower completion rates
 No gender difference identified relative to course
 Differential diagnoses
 Bipolar disorders
 Medical conditions
 Substance use disorders
 ADHD
 Sadness
 Adjustment disorder with depressed mood