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 5TR. I'm your host, Dr. Donnellice Snipes. In this presentation we're going to explore the current criteria and associated features for 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 etiology 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. Alright, 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 of apathy and depression at the same time, but anhedonia, 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 5% unintentional weight change. Now that means not due to dieting, that means not due to a growth spurt. We, we also want to rule out it's not due to having an illness like the flu or 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 2 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 are 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 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 your nutritional status which can directly impact mood sleep changes. Oh my gosh. You just don't even grasp how important 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 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. But 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 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, 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 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. 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 or increase in energy interspersed with their depression. Melancholic. This is the person who feels anhedonic. 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 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. Call it hyperphagia. Which, remember, in the diagnosis for depression, increasing in eating or decreases in eating is one of the expected symptoms. So I'm not sure why that's in atypical. But hypersomnia, again, 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. Leaden 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, 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 ten 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 is an atypical 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 disorders, 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 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 psychot features are completely unrelated to their mood. They're not depressed in nature. They're not sad, they're not gloomy. 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 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 specifier applies to people who develop major depressive disorders 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 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 substantial 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 best practice. You've got depression, we're going to do xyz 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, 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 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 cur 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 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 the 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. 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 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 of, we tend to have more pain. 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 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 experienced, 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 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 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 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 depression 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 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. 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, an 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 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 bi directional nature here. They know that as serotonin goes down, as depression develops, they've shown that the gut tends to become leakier 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 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 a puppy probably wouldn't persist for long enough to cause major depressive disorder, but you kind of get my point. Circadian rhythm disruption is something that is causing the person from getting adequate quality sleep. 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 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 of increased depression. They 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 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 7% with a 3 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 Erikson 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 10.44% in any one year. And 20.6% of people would experience at least one major depressive episode in their lifetime. So JAMA indicates that it's a lot higher than the 7%. 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, 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, 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, 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 layman's terms. 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 seem, 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 dysregulate. 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 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 a lot of people believe that personality traits are inherent in a person, so they wouldn't be developed. But whatever your philosophy is, it's important to recognize people who have adverse childhood experiences. 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 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, and this is according to the dsm, 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 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 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 3%, including 8% among people who are biologically female and 2% 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. They did not specify. They still use the binary language in the DSM and the cdc. But it is 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% 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 was almost 12% in the early postpartum period. That's important to recognize the early postpartum period, and for some people, the peripartum, the month before delivery, there is a significant increase in the likelihood of major depression and 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 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%. Fathers with postpartum depression were 21% 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 hypomanic episode were 46 times 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. 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's 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 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 distance. Sentence 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 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%. But in people with premenstrual dysphoric disorder, the rate of suicidal ideation is 39.7%. 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, while they're symptomatic, while they're diagnosable. The text also noted in general 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 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. 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 and 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 those remission periods. That's not true in disruptive mood dysregulation disorder. Schizoaffective 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. 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 out medically, and this is in the diagnostic feature section. Diabetes, cancer, pregnancy and postpartum and thyroid issues are 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, 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 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. 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 depression. 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.