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Mood Disorders
Dawn Vanderhoef, PhD, DNP, PMHNP/CS-BC
N351 Fall 2014
Objectives
Identify and Review Mood Disorders
Epidemiology
DSM 5 Diagnostic Criteria of Disorders
Review Changes Made from DSM IV TR to DSM 5
Screening and Assessment
Modification of the Diagnostic Interview
Phases of Treatment and Nonpharmalogical
Interventions
Quiz
1. Which of the following are medical conditions
that should be ruled out before making a diagnosis of
Major Depressive Disorder?
A. Hypothyroidism and Anemia
B. Hypertension and Thrombocytopenia
C. Pneumonia and Chronic Obstructive Pulmonary
Disease
D. Hyperthyroidism and Steven Johnson Syndrome
Went over the Quiz
All DSM-5 disorders have 2 caveats.
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Quiz
1. Which of the following are medical conditions
that should be ruled out before making a diagnosis of
Major Depressive Disorder?
A. Hypothyroidism and Anemia
B. Hypertension and Thrombocytopenia
C. Pneumonia and Chronic Obstructive Pulmonary
Disease
D. Hyperthyroidism and Steven Johnson Syndrome
Quiz
2. When assessing a patient for Major Depressive
Disorder, which two symptoms are first assessed to
determine if the patient meets criteria for the
diagnosis?
A. Depressed Mood and Anhedonia
B. Sleep and Appetite
C. Suicidal Ideation and Hopelessness
D. Worthlessness and Poor Concentration
Quiz
2. When assessing a patient for Major Depressive
Disorder, which two symptoms are first assessed to
determine if the patient meets criteria for the
diagnosis?
A. Depressed Mood and Anhedonia
B. Sleep and Appetite
C. Suicidal Ideation and Hopelessness
D. Worthlessness and Poor Concentration
PHQ 9 and PHQ 2
one or the other criteria has to be met
before going down the list......
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Quiz
3. To meet the criteria for Bipolar I Disorder a
patient must have had which of the following
mood states?
A. Major Depression and Mania
B. Mania
C. Mania and Dysthymia
D. Hypomania and Major Depression
Quiz
3. To meet the criteria for Bipolar I Disorder a
patient must have had which of the following
mood states?
A. Major Depression and Mania
B. Mania
C. Mania and Dysthymia
D. Hypomania and Major Depression
Quiz
4. What symptom tends to remit first in a
patient treated for Major Depressive Disorder?
A. Appetite
B. Energy
C. Insomnia
D. Mood
A common misconception that bipolar should
have 2 criteria ....
Energy to carry out the deed is essential
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Quiz
4. What symptom tends to remit first in a
patient treated for Major Depressive Disorder?
A. Appetite
B. Energy
C. Insomnia
D. Mood
Quiz
5. When treating someone for Major Depressive
Disorder, which of the following risk factors places an
individual at risk for a poor outcome of treatment?
A. Chronicity and Negative Style
B. High Socioeconomic Status
C. Good Support System
D. Genetics
Quiz
5. When treating someone for Major Depressive
Disorder, which of the following risk factors places an
individual at risk for a poor outcome of treatment?
A. Chronicity and Negative Style
B. High Socioeconomic Status
C. Good Support System
D. Genetics
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The DSM-5 is Here to Stay
Released May 2013 at the American Psychiatric Association
Annual Meeting in San Francisco, CA
Proposed release to coincide with
ICD 10
ICD 10 proposed release is October 2015
Resource
http://www.psychiatry.org/practice/dsm/dsm5
How does the DSM-5 look different
compared to the DSM IV-TR?
No longer have a multiaxial diagnosis
World Health Organization Disability Assessment Scheduled 2.0 (WHODAS)
Lifespan sequence
Chapters based on underlying vulnerabilities
Roman numerals are no longer be used
ICD 9 Code / DSM and ICD 10
Ex. F06.34
No V Codes
What are mood disorders?
Depressive Disorders
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Premenstrual Dysphoric Disorder
Substance/Medication Inducted Depressive Disorders
Depressive Disorders due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder
Clinical sites are yet to transition to DSM-5
Listen to Franscis's lecture on BB
Need to learn the Axis system ,,,
Axis 1 - Major Psych disorder
Axis 2- Personality disorder (retardation)
Axis 3- Major medical conditions
Axis4 -Psychosocial stressors (mild mod or sever)
Axis 5- Global assessment of function
From DSM-5
(New)
NAS is now replaced by
Axis I = clinical psychiatric disorders (ex. depression, schizophrenia)
Axis II = Personality disorders (ex. bipolar, conduct disorder, borderline)
Axis III= General medical conditions (ex. Diabetes, Hypertension, Stroke)
Axis IV= Psychosocial and environmental problems (ex. Death of loved one, Divorce, Job-loss, Bankruptcy)
Axis V= Global assessment function (ex. scale of 1-100) 1 is low level of function and 100 being superior function. The scale is compiled by
a physician.
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What Does Depression Look Like?
http://video.who.int/streaming/NMH/MSD/C
OPR_depression_01OCT2012.wmv
What is Mood and Affect?
Mood sustained emotion that colors the way
we view life
Pervasive and sustained feeling
Influences behavior and how we view the world
Affect external expression of mood
Epidemiology of Depression
The World Health Organization ranked
depression as the forth leading cause of
disability worldwide
In U.S. lifetime prevalence 19.2%
12 month prevalence rate 8.3%
One-third to one-half of lifetime cases have
recurrent episodes in a given year
Kessler & Bromet, 2013
Stigma is a major issue with Depression
Its important to allow the pt. to be okay with it, let loved ones know,
is important.
Mood is like the season
Affect is like the weather
Thoughts, Process and thought content are also
important during a MSE
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Epidemiology of Depression
Median age of onset is 22.7 years of age
In U.S. peak risk period for onset is from mid
to late adolescence to early 40s
Prevalence goes down with age
Women have twofold increase risk compared
to men
Kessler & Bromet, 2013
Major Depressive Disorder and
Morbidity and Mortality
Physical disorders common with MDD
Arthritis, asthma, cancer, CVD, diabetes, HTN, chronic respiratory disorders
and chronic pain
Longitudinal studies have shown that MDD is
consistent predictor of first onset of coronary artery
disease, stroke, diabetes, heart attack and certain
cancers
MDD is associated with significant elevated risk of
early death
Kessler & Bromet, 2013
Major Depressive Disorder and
Morbidity and Mortality
Poor health behaviors linked to MDD
Obesity
Drinking smoking
Low adherence to treatment
Biological dysregulations
Hypothalamic-pituitary-adrenal hyperactivity
Impaired immune function
Kessler & Bromet, 2013
SElf medication is common
CVD and co-morbid depression is common
-Eat too much, drink too much
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National Survey on Drug Use and Health US Dept HHS SAMHSA 2012
National Survey on Drug Use and Health US Dept HHS SAMHSA 2012
National Survey on Drug Use and Health US Dept HHS SAMHSA 2012
12 mo prevalance rate
Females are more likely to get depression
Reducers with age (after 40s....)
4 yrs of life is typically lost to MDD
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Past Year Substance Use (dependence or abuse) and
Mental Illness Adults 18 or Older (2012)
National Survey on Drug Use and Health US Dept HHS SAMHSA 2012
Disruptive Mood Dysregulation
Disorder
New to DSM 5
Potential to address concerns about over diagnosis and
treatment of bipolar disorder in children
Onset before age 10
Not applied to children with developmental age of less
than 6 years of age
Diagnosis determined valid in ages 7-18 and should be
restricted to this age group
DSM-5 MDD
A. Five or more of the following symptoms present for the same 2
week period and represent change in function with at least one of the
symptoms is either 1. Depressed mood or Irritable mood OR 2. Loss of
interest or pleasure
AND at least 34 of the following:
Wishing to be dead or suicidal ideation
Increase or decrease appetite
Increase or decrease sleep
Psychomotor agitation or retardation
Fatigue or loss of energy
Decrease concentration, energy, self worth
Feelings or worthlessness or excessive / inappropriate guilt
With MDD is a co-morbid substance abuse disorder because pts.
usually self medicate
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Note for all Disorders in DSM 5
B. Symptoms must represent change from
previous functioning and produce impairment in
relationships or activities and cause significant
distress or impairment in social, occupational, or
important areas of functioning
C. The episode is not attributable to the
psychological effects of a substance or to
another medical condition
SIGE CAPS
SSleep disturbance. Typically, difficulty staying asleep; less often, difficulty falling
asleep
IInterest, pleasure, or enthusiasm for usual activities is diminished
GGuilt, self-doubt, or loss of self-esteem that is excessive or unwarranted
EEnergy level is diminished
CConcentration (or attention) span is poor or worse than usual
AAppetite is impaired. Typically it is diminished and associated with weight loss, but
in some cases the patient overeats and gains weight
PPsychomotor activity is abnormal. Typically the patient moves and thinks more
slowly; some patients, especially the elderly, can be more restless, explosive, or
agitated
SSuicidal thoughts, hopelessness, or thoughts that the patient (and often others)
would be better off if the patient were dead
DSM-5 Coding and Recording
Severity / Course
Specifier
Single episode Recurrent episode NEW - Specify (can
apply to all dx):
With
Mild 296.21 296.31 Anxious distress
Moderate 296.22 296.32 Mixed features
Severe 296.23 296.33 Melancholic
features
With psychotic
features
296.24 296.34 Atypical features
In partial remission 296.25 296.35 Mood congruent
psychotic features
In full remission 296.26 296.36 Mood incongruent
psychotic features
Unspecified 296.20 296.30 Catatonia /
peripartum onset /
seasonal pattern
305b
co-existance of MDD and susbtance abuse (alcohol) is
common ...almost impossible to tease out the difference sometimes
\
Patients may be drunk when they present themselves.....
Key is not to judge ... listen to the patient ... establish rapport
Criterion for Depression
296 ==Major expression
2 == single episode
3 == recurrent episode

(last #)mild
moderate
severe
incongruence --> Not congruent with the mo state
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Gender Differences in Presentation of MDD
Men present with the following symptoms
Anger
Aggression or irritability
Substance abuse
Risk taking behavior
Workaholics
Relying only on a males report of traditional
symptoms can lead to underdiagnoses
Martin, Neighbors, Griffith, 2013
Remember Depression is a
Syndrome
Clusters of symptoms of depression
Vegetative
Cognitive
Impulsive
Behavioral
Somatic
Stahl, 2004
Risk Factors for MDD
Risk Factor Association
Sex 2:1 Females
Age Peak onset age 20-40 years
Family History 1.5 to 3 times higher with positive
history
Marital Status Separated and divorced persons
report higher rates
married males lower rates
married females higher rates
Postpartum An increased for 6 mths after delivery
Negative Life Events Possible association
Early parental death Possible association
Stahl, 2004
-- candidate for CBT
--
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Tips
1. Always look for a mood disorder
in any new patient, even if it is not
the chief compliant
2. Never assume a mood disorder
is your patients only problem
Morrison, 2014
Epidemiology
of Dysthymia
Persistent Depressive Disorder (Dysthymia)
A. Depressed mood for most of the day, for more days than not, as indicated by either
subjective account or observation by others for 2 years. * in children and
adolescents, mood can be irritable and duration is 1 year
B. Presence, while depressed of two (or more) of the following:
-poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue,
low self esteem, poor concentration or difficulty making decisions, feeling of
hopelessness
C. During the 2 year (1 yr C&A) period the person not without criteria A & B for more
than 2 months
D. Criteria for MDD may be continuously present for 2 years
E. Never been manic or hypomanic episode
F. Not better explained by psychotic illness
G. Not due to effects of a substance or another medical condition
H. Symptoms cause clinically significant distress or impairment in social, occupational
and other areas of functioning
This speaks to the co-morbidity of MDD
Double depressio is when a person with depression who never recovers
reaches dysthymic state
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Other Depressive Disorders
Premenstrual Dysphoric Disorder
Substance / Medication Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder (Was Depressive D/O
NOS 311 in DSM IV-TR - full criteria for other disorders not
met, noes cause clinically significant distress / impairment and
clinician chooses to communicate the reason
Specify type features (as w/ MDD)
Specify is partial or full remission
Specify is mild, moderate, or sever
Unspecified Depressive Disorder clinician chooses not to
specify the reason the criteria are not met for a specific
disorder (i.e. use in ER)
Screening Questions:
Do you ever get so depressed that you cant function
Are you almost always depressed? (Dysthymic Disorder)
Do you have lots of psychological and physical symptoms
occurring around the time of your menstrual periods?
(Premenstrual Dysphoric Disorder)
Might your depressions be related to your use of alcohol,
drugs, or medications? (SubstanceInduced Depressive DO)
Please tell me about your medical illnesses and their
treatment. (Depressive DO due to Medical Condition)
Allen, 2013
Medical Differential Diagnosis: MDD
Endocrine Disorders: hypothyroidism, diabetes,
hyperaldosteronism, Cushing or Addisons disease
Neurological Disorders: Parkinsons, dementing illness, epilepsy,
cerebrovascular disease, tumors, multiple sclerosis, fibromyalgia, sleep apnea
Cardiac Disorders: MI, CHF, HTN
Infectious Disease: mononucleosis, HIV/AIDS, pneumonia, TB
Nutritional Disorders: anemia, Vit D, Folate, Thiamine, B12
PMDD is now its own disorder
Identify if the depression is
substance abuse induced(alcohol)
PMDD
dsm-5 HAS THESE SCREENIGN TOOLS IN THE BACK OF THE BOOK

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Depression Presentation (Morrison, 2014)
Mr. Smith inherited a small business from his father and built it into a large
successful company. He sold the company, invested money and bought a small
farm. He did not need to make money, he felt full value from keeping busy
and fit At age 55 farming started to become a chore, he let the tractor sit in
the barn.
His mood blackened, he was fatigued, going bed at 9 pm and was up at 2-3 am
and could not fall back asleep. He develop obsessive worry and rumination.
Mornings were the worst; hard to get through another damn day. His
appetite decreased and his belt buckle was two notches smaller.
His wife said he just seemed to lose interest in everything and he doesnt
enjoy anything. He worries about debt, but we are doing fine financially.
Mr. Smith would ruminate about his health, and ask his wife to take his b/p
multiple times a day. He paced the house and would check his pulse
constantly.
He told his wife they need to sell the farm even though he had more money
then they needed. On exam MMSE 30/30
Mr. Smith
What additional information do you want to
know?
What are your differential diagnoses?
What is your full DSM 5 diagnosis?
What are mood disorders?
Bipolar and Related Disorders
Bipolar I Disorder
Bipolar II Disorder
Cycolothymic Disorder
Substance / Medication Induced Bipolar and Related
Disorder
Bipolar and Related Disorder Due to Another Medical
Condition
Other Specified Bipolar and Related Disorder
Unspecified Bipolar and Related Disorder
PRE-MORBID LEVEL OF FUNCTIONING
As a PSYCH np YOU WOLD ASK FOR
cbc
THYROID TEST
Rule out medical issues, substance issues
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What Does Bipolar Disorder Look
Like?
https://www.ted.com/talks/joshua_walters_o
n_being_just_crazy_enough
Lifetime and 12-Month Prevalence
and Age of Onset (n = 9282)
Merkiangas, K.R., Akiskal, H.S. & Kessler, R.C. (2007).
BP as something that has helped him rather then debilitate him?
Spectrum of Bp is discussed in this ted talk
Life time prevelance is 4.4 mo (much less than MDD)
Onset is 20s
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Bipolar Disorder
37% of patients with Bipolar Disorder were initially
diagnosed by a mental health professional as having
unipolar depression
72% of patients were misdiagnosed with unipolar
depression in multisite primary care study
19% of patients with Bipolar Disorder commit suicide
DSM-5 Manic Episode
A. Distinct period of abnormal and persistent elevated, expansive, or irritable mood
and abnormally and persistent increase in goal directed activity or energy, lasting
at least a week and present most of the day, nearly all day
B. During the period of mood disturbance and increased energy or activity, three of
the following symptoms (four if mood is irritable) are present to a significant
degree and represent a noticeable change from usual behavior
Inflated self esteem or grandiosity, decrease need sleep, more talkative, flight of ideas, distractibility,
increase goal directed activities, excessive involvement in activities that have a high risk for painful
consequences
C. The mood disturbance is sufficiently server to cause marked impairment in
social, occupational functioning or to necessitate hospitalization to prevent harm
to self or others
D. The episode is not attributable to the physiological effects of a substance or to
another medical condition
NOTE: A full manic episode that emerges during antidepressant treatment but persists at a fully
syndromal level beyond the physiologic effect of treatment is sufficient evidence for a manic
episode
unipolar depression is MDD
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DSM-5 Hypomanic Episode
A. Distinct period of elevated expansive, or irritable mood, lasting at
least 4 days, that is clearly different from nondepressed mood
B. 3 or more (four if mood is irritable) grandiosity, decreased sleep, pressured
speech, racing thoughts, hyperverbal, distractible, increase in goaldirected
activity, and excessive involvement in pleasurable activities that may have negative
consequences
C. Change in behavior in uncharacteristic for the person
D. Other people notice the change in mood and functioning
E. Episode does not cause marked impairment in functioning, does
not require hospitalization and there is no psychosis
F. Symptoms are not d/t substance use or a general medical condition.
Symptoms of mania or a manic
episode include:
Symptoms of depression or a
depressive episode include:
Mood Changes
A long period of feeling "high," or an overly
happy or outgoing mood
Extreme irritability
Behavioral Changes
Talking very fast, jumping from one idea to
another, having racing thoughts
Being easily distracted
Increasing activities, such as taking on new
projects
Being overly restless
Sleeping little or not being tired
Having an unrealistic belief in one's abilities
Behaving impulsively and engaging in
pleasurable, high-risk behaviors
Mood Changes
An overly long period of feeling sad or
hopeless
Loss of interest in activities once enjoyed,
including sex.
Behavioral Changes
Feeling tired or "slowed down"
Having problems concentrating, remembering,
and making decisions
Being restless or irritable
Changing eating, sleeping, or other habits
Thinking of death or suicide, or attempting
suicide
NIMH, 2014
Bipolar I or Bipolar II
Bipolar I Has one or more manic episodes or Mixed Episodes
Individuals usually also have had one Major Depressive episode.
* *Has 6 separate criteria sets BPD I single manic episode, Most recent
episode hypomanic, Most recent episode manic, Most recent episode
mixed, Most recent episode depressed, and Most recent episode
unspecified.
Bipolar II Has one or more Major Depressive episodes and at least one
Hypomanic episode.
**Specifiers are used to indicate the nature of the current episode hypomanic
or depressed. If depressed, specifiers are mild, moderate, severe without psychotic
features or severe with psychotic features, chronic, w/ catatonic features, w/
melancholic features, w/ atypical features or w/ postpartum onset
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Comparing Manic and Hypomanic Episodes
Manic Episode Hypomanic Episode
Duration 1 week or more 4 days or more
Mood Abnormally and persistently high, irritable or expansive
Activity / Energy Persistently increased
Symptoms that are changes from
usual behavior
Three or more of grandiosity, need for sleep, talkativeness,
flight of ideas or racing thoughts, distractibility (self report or that
of others), agitation, goal directed activity, poor judgment
Severity Results in psychotic features,
hospitalization, or impairment at
work, social, and personal levels
Clear change form usual
functioning and others notice
this change and NO psychosis,
hospitalizations or impairment
Other Rule out substance / medication induced symptoms with mixed
features, if appropriate
Morrison, 2014
DSM-5 Cyclothymic Disorder
A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and numerous
periods with depressive symptoms that do not meet criteria for a MDE Note: In children and
adolescents, the duration must be at least 1 year.
B. During the above 2-year period (1 year in children and adolescents), the person has not been
without the symptoms in Criterion A for more than 2 months at a time.
C. No MDE, Manic, or Mixed Episode has been present during the first 2 years of the disturbance.
Note: After the initial 2 years (1 year in children and adolescents) of Cyclothymic Disorder, there may
be superimposed Manic or Mixed Episodes (in which case both Bipolar I and Cyclothymic Disorder
may be diagnosed) or Major Depressive Episodes (in which case both Bipolar II and Cyclothymic
Disorder may be diagnosed).
D. The symptoms in Criterion A are not better accounted for by Schizoaffective Disorder and are not
superimposed on Schizophrenia, Schizophreniform, Delusional Disorder or Psychotic Disorder Not
Otherwise Specified.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse,
a medication) or a general medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
Other Bipolar Related Disorders
Bipolar and Related Disorder Due to Another Medical
Condition
Other Specified Bipolar Related Disorder
Unspecified Bipolar and Related Disorder
BP II is more common than BP I
Neuro syphillis related BP is an unusual depction of BP disease
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Disorder Severity/remission w/ mixed
features
w/
anxious
distress
W/
catatonia
w/
atypical
features
w/
melancholic
features
w/ peripartum
onset
w/
psychotic
features
w/ rapid
cycling
w/
seasonal
pattern
MDD
Single X X X X X X X X
Recurrent X X X X X X X X X
Bipolar I
Manic X X X X X X X X
Depressed X X X X X X X X X X
Hypomanic X X X X X X
Unspecified
Bipolar II
Hypomanic X X X X X
Depressed X X X X X X X X X X
Cyclothymia X
Persistent X X X X X X X
Morrison, 2014
Major Depression
Euthymic
Manic
Hypomanic
Dysthymic
Bipolar Disorders: Screening Questions
Do you have mood swings sometimes way up, other times
way down?
(Bipolar I DO: must have had at least 1 fullblown manic episode,
must have MDD episodes, may have mixed episodes, often enjoy
highs [their normal for feeling good], often more time spent in
depressive episodes)
Do you have mood swingssometimes going up, other times
going down?
(Bipolar II DO: Must have MDD episodes, must have at least 1
clearcut hypomanic episode; must never have had fullblown
manic episode)
Allen, 2013
Read on rapid cycling
Do you feel like you can function with 2 hrs sleep
Answer is yes if you are a BP!
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Medical Differential Diagnosis: Bipolar
Endocrine Disorders: hyperthyroidism, diabetes, cushing or
Addisons disease
Neurological Disorders: Epilepsy, cerebrovascular disease,
tumors, head trauma, lupus, multiple sclerosis
Cardiac Disorders: MI, CHF, HTN
Infectious Disease: HIV/AIDS, lyme disease, syphilis
Bipolar Presentation (Barnhill, 2014)
Olivia is a 22 year old graduate student studying to be an architect. She was
referred by student health for an urgent mental health evaluation after she told
her roommate she was suicidal. Olivia had a history of mood instability, but her
moods were well controlled on Zoloft and Lithium. Her depressive symptoms
returned when she arrived in a new town, at a new school, about 3 months ago.
She has been preoccupied with killing herself. She wants to shoot herself in the
head, while dangling her head out the window. She does not have a gun but has
been searching to web for places she can access a gun.
Her hx is at age 15 she started drinking on a regular basis, smoking marijuana
and having out late at clubs. At age 17 she developed brief intense mood sx:
depressive tearful, feelings of guilt, anhedonia, hopeless, low energy, poor
concentration, and hypersomnia.
After a few weeks of being depressed she would go into periods of pressured
speech, increase energy, unusual creativity and paranoid.
On exam she reports feeling very depressed, cant get out bed or go class,
sleeping a lot, hopeless. She reports feelings of depersonalization and panic
Olivia
What additional information do you want to
know?
What are your differential diagnoses?
What is your DSM 5 diagnosis?
Comorbidity with Borderline personality disorder
Impulsiveness
Attention seeking
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Suicidal Thoughts Adults 18 or
Older (2012)
Suicidal Thoughts and Behavior
Adults 18 or Older (2012)
Suicide Risk Assessment
Demographic Risk Factors:
Male
Caucasian
Rural residence
Teens / young adults / elderly
Imprisoned
Widowed / divorced / separated
Living alone
No children or none living in the home
Jacobs, 2007
college age students are high risk!
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Suicide Risk Assessment
Psychosocial Risk Factors:
Loss of social supports
Loss of job / income
Sense of hopelessness
History of victimization (abuse)
Relationship conflict
Aggressive or impulsive traits
Writing suicide notes, previous notes
Family history of suicide
Gun ownership
Occupational risk: physician, dentist, nurse,
pharmacist, veterinarian, farmer Jacobs, 2007
Suicide Risk Assessment
Medical Risk Factors:
Stroke
Multiple sclerosis
Huntingtons disease
Head injury
Spinal cord injury
Systemic lupus erythematosus
AIDS
Epilepsy
Chronic pain
Malignant cancer
Renal disease
Peptic ulcer
Jacob, 2007
Suicide Risk Assessment
Internal Protective
Factors
Positive coping skills
Spirituality
Frustration tolerance
Optimism
Resiliency
Prior successful response
to stress
External Protective
Factors
Children
Pets
Religious beliefs
Positive relationships
Family
Social support
Financial incentive
Jacob, 2007
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Suicide Risk Assessment: ideation, plan,
means, intent
Have you felt so sad or depressed that you thought life is not worth
living?
Have you thought about hurting yourself or taking your life?
Have you thought about a way or plan to kill yourself?
Do you have the means to complete the plan? (Gun, pills)
Have you practiced or rehearsed this plan to end your life?
Do you have a location picked out?
What has stopped you from acting on this plan?
Have you ever attempted suicide?
Has anyone in your family ever attempted or committed suicide?
Have you ever wished you wouldnt wakeup?
Jacob, 2007
Suicidal Thoughts in Past Year:
Ages 18 22 (2012)
Suicidal Thoughts in Past Year: Adults
18 or Order and Selected Illicit Drug
Use (2012)
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Safety Plan
Removal of firearms
Contracts
Contact individuals
Crisis numbers
Responsible person to stay with suicidal
ideation is gone
Consider the need for hospitalization
Screening Tools for Mood
Disorders
Beck Depression Inventory (BDI)
Hamilton Depression Scale (HRSD)
Mood and Feelings Questionnaire (MFQ) (Daily feeling/mood log)*
Mood Disorders Questionnaire (MDQ)*
Brief Symptom Inventory (BSI)
Center for Epidemiological Studies Depression Scale Modified (CESD)*
Kutcher Adolescent Depression Scale (KADS)*
Patient Health Questionnaire (PHQ2 and PHQ9)*
Edinburgh Postnatal Depression Scale (EPDS)*
Geriatric Depression Scale (GDS)*
Young Mania Rating Scale (YMRS)(Bipolar)*
Massachusetts General Website with screening tools and hotlinks:
http://www2.massgeneral.org/schoolpsychiatry/screeningtools_table.asp
Modification of a Diagnostic
Interview
Tone of voice
Demeanor and body
posture
Redirection of interview
Touch USE with
CAUTION
Validate feelings
Differentiate normal
and clinical
Boundaries
Timing
Setting: quiet, private,
decrease stimuli
Give pts. a sense of hope....
Give pt a choice ..tell him/her I need more data
...I'll set a structure
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Phases of Illness & Treatment
Acute / Initiation: monitor status and safety,
build therapeutic alliance, and provide
education
Stabilization: prevent relapse
Maintenance: prevent recurrence
Risk Factors for Poor Outcome
Greater severity
Chronic or multiple episodes
Negative cognitive style
Family problems
Low socioeconomic status
Exposure to negative events
Prevention
Material Assessment
Early recognition of mood disorders (especially in mothers) results in less
psychiatric disorders in children
Amelioration of Risk Factors
Regular Sleep
Exercise
Coping Plan for Stress (meditation, yoga, exercise, social activities)
Enjoyable and Meaningful Activities
Recurrent Depression
Proactive Lifestyle
Avoid Stressors
Coping Plan for Stress
Planning
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Treatment Planning and
Intervention
Patient Centered
Biopsychosoical Approach to Treatment
Bio: medical
Psycho: individual, group, family therapy,
psychosocial rehab
Social: family, support groups, community, self
care
Patient Education
The outcome of ANY treatment is grounded in the pt/provider relationship
and is a cooperative effort
Patients should be told: dx, prognosis, tx options, including duration and
SE
Inform pts that depression is a medical illness, not a character defect or
weakness
Recovery is the rule, not the exception
An effective treatment can be found for nearly all patients
The goal of treatment is remission, not just getting better, but getting
better and staying well
The risk of recurrence is significant: 50% after one episode, 70% after the
second, and 90% after the third
Pt and family should be alert to early signs/symptoms of recurrence and
seek treatment
Stahl, 2004
Take a piece of paper and answer
the following questions
1. One thing I learned today is
2. One thing that remains unclear is ..
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References
Allen, F. (2013). Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM5.
New York, NY: Guildford Press.
American Psychiatric Association (2013). DSM5 Diagnostic and Statistical Manual of Mental
Disorders, 5th Ed. Washington DC: American Psychiatric Association
Jacobs, DG. (2007). A resource guide for implementing JCAHO 2007
patient safety goals on suicide. http://www.sprc.org/library/jcahosafetygoals.pdf
Kessler, R.C. & Bromet, E.J. (2013). The epidemiology of depression across cultures. Annu
Review Public Health, 34, 119-38.
Martin, L. A., Neighbors, H.W., Griffith, D. (2013). The experience of symptoms of depression
in men vs women: Analysis of the National Comorbidity Survey Replication. JAMA Psychiatry.
Merkiangas, K.R., Akiskal, H.S. & Kessler, R.C. (2007). Lifetime and 12-Month Prevalence of
Bipolar Spectrum Disorder in the National Comorbidity Survey Replication. Arch Gen
Psychiatry, 64(5): 543-552.
References
Morrison, J. (2014). DSM-5 Made Easy The Clinicians Guide to Diagnosis. Gillford
Press: New York, NY.
National Survey on Drug Use and Health US Dept HHS SAMHSA
2012http://www.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/2K12
MHF/NSDUHmhfr2012.htm#sec3-1
Sadock, B.J., & Sadock, V.A. (2007). Kaplan and Sadocks Synopsis of Psychiatry:
Behavioral
Sciences, Clinical Psychiatry (10th ed.) Baltimore: Lippincott Williams & Wilkins.
Stahl, S. Essessential Psychopharmacology (2
nd
ed.) Cambridge University Press:
New York, NY. 2004.
Sommers-Flanagan, J. & Sommers-Flanagan, R. (2014). Clinical Interviewing (5
th
ed.). Wiley: New Jersey.