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Chapter: Essentials of Psychiatry: Mood Disorders: Depression

Depressive Disorder not Otherwise Specified

Depressive disorder NOS refers to a variety of conditions listed in DSM-IV that are distinguished from MDD, DD, adjustment dis-order with depressed mood, or adjustment disorder with mixed anxiety and depressed mood.

Depressive Disorder not Otherwise Specified


Depressive disorder NOS refers to a variety of conditions listed in DSM-IV that are distinguished from MDD, DD, adjustment dis-order with depressed mood, or adjustment disorder with mixed anxiety and depressed mood. These conditions involve a large number of depressed individuals who do not meet formal criteria for MDD or DD. In the ECA study, 11% of subjects had DD NOS. In a primary care outpatient sample, the prevalence of DD NOS was 8.4 to 9.7%. DD NOS is associated with impairment in over-all functioning and general health. Among the conditions listed as occurring within this category are premenstrual dysphoric disorder, minor depressive disorder, recurrent brief depressive disorder, postpsychotic depressive disorder of schizophrenia and depressive episode superimposed on delusional disorder or other psychotic disorder.


Premenstrual Dysphoric Disorder


Premenstrual DD is characterized by depressed mood, marked anxiety, affective lability and decreased interest in activities, experienced during the last week of the luteal phase which re-mits during the follicular phase of the menstrual cycle. This pattern occurs for most months of the year. The severity of symptoms is comparable to MDD, but the duration is briefer by definition. The symptoms disappear with the onset of menses. Current criteria emphasize the disturbance in mood as well as impairment in social functioning associated with premenstrual


Current assessments require that the typical cyclical pat-terns be confirmed by at least 2 months of prospective daily ratings. Premenstrual DD often worsens with increasing age, but then diminishes at menopause. Premenstrual DD appears to respond to standard SSRI treatments including fluoxetine as well as sertraline and dual acting agents but may not respond to other types of antidepressants, such as bupropion. This re-sponsiveness to SSRIs suggests a premenstrual serotonergic hy-poactivity which may account for the premenstrual dysphoric symptomatology.


Minor Depressive Disorder


Minor depressive disorder is characterized by episodes lasting 2 weeks and characterized by at least two but fewer than five de-pressive symptoms. Minor depressive disorder is also associated with less psychosocial impairment than MDD. The prevalence of minor depressive disorder reported in primary care settings ranges from 3.4 to 4.7%. A number of general medical condi-tions have been associated with minor depressive disorder in-cluding stroke, cancer and diabetes. Maier and colleagues report increased symptoms of minor depressive disorder in families in which a proband with MDD is present. In the differential diag-nosis of minor depressive disorder, one must consider adjustment disorder with depressed mood and other experiences of sadness that may be part of grieving. Because of frequent cooccurrence with general medical condition, one must rule out a secondary mood disorder due to a general medical condition.


Minor depressive disorder tends to begin in late adoles-cence and probably affects men and women equally. Minor de-pressive disorder is often associated with greater impairment of routine activities in older adults. Consultation psychiatrists should pay careful attention to depressive symptoms in associa-tion with medical illness in order to establish the impact of de-pressive disorder on the overall course and recovery from general medical conditions (Cassem, 1990).


Recurrent Brief Depressive Disorder


Recurrent brief depressive disorder refers to brief episodes of re-current depressive symptoms that last for at least 2 days but less than 2 weeks and meet full criteria (except duration) for MDD. These episodes typically occur monthly for 12 months, but are not specifically related to menstrual cycles. These depressive epi-sodes typically cause clinically significant distress and impair-ment in social and occupational functioning. In some individu-als, RBDD is associated with a high degree of suicidality.


Associated clinical features may include comorbid sub-stance dependence or anxiety disorders. By definition, recurrent brief depressive episodes are not associated with menstrual cy-cles and are equally common among men as women.


Up to 12 to 20% of first-degree relatives of patients with recurrent brief depressive disorder have MDD. Ongoing research focusing on familial aggregation and associated comorbid condi-tions is important. It will be particularly important to address its association with personality characteristics and the overlap between personality disorder and the syndrome of RBDD.


Mixed Anxiety–Depressive Disorder


The syndrome of mixed anxiety–depressive disorder is commonly diagnosed in outpatient medical practices internationally and it is included as a disorder in ICD-10. It is typically associated with dysphoric mood lasting at least 1 month and at least four associ-ated clinical symptoms which are derived from both symptoms associated with MDD, DD, panic disorder and generalized anxiety disorder. These symptom characteristics include: difficulty con-centrating or mind going blank; sleep disturbance characterized by difficulty falling or staying asleep or restless; unsatisfying sleep; fatigue or low energy; irritability; worry; being easily moved to tears; hypervigilance; anticipating the worst; hopelessness and pessimism about the future; and low self-esteem or feelings of worthlessness. The symptoms cause significant impairment in so-cial and occupational functioning or other aspects of functioning. These symptoms must not be due to the direct physiologic effects of a substance or a general medical condition. Finally, the symp-toms are present in the absence of criteria being met for MDD, DD, panic disorder, or generalized anxiety disorder. The presence of these common mixed anxious and depressive symptoms is esti-mated to range from 1 to 2% in primary care settings.


Post-psychotic Depressive Disorder of Schizophrenia


The diagnosis of postpsychotic depressive disorder of schizophre-nia is intended to cover depressive episodes occurring during the residual phase of schizophrenia. In the residual phase there may be associated negative symptoms which can be difficult to dif-ferentiate from mood symptoms. The diagnosis should be made only if the full criteria are met for a major depressive episode and if the symptoms are not due to substance abuse, akinesia, or other antipsychotic medication effects.


Features associated with the development of a postpsy-chotic depressive episode include limited social support, the impact of prior hospitalization, or the trauma of having a major mental illness. It is estimated that up to 25% of individuals with schizophrenia experience postpsychotic depressive disorder. There is no significant age of onset difference between men and women. Individuals who have a family history of MDD may be at higher risk for postpsychotic depression. Treatment studies have demonstrated the efficacy of standard antidepressive medication in the postpsychotic depressive disorder of schizophrenia.



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