Depressive Disorders

Presented by: KEPRO SW PA Health Care Quality Unit (KEPRO HCQU)

December 2017 es

Disclaimer

Information or education provided by the HCQU is not intended to replace medical advice from the individual’s personal care physician, existing facility policy, or federal, state, and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented.

Certificates for training hours will only be awarded to those attending the training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.

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1 Objectives

• Define depressive disorders

• Identify the symptoms of depressive disorders

• Recall effective support methods used for depressive disorders in people with I/DD

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Definition

• Changes in mood, thinking, physical activity/well‐being (APA, 2013; NIMH, 2011) – Sad, low, or irritable mood – Diminished interest in previously enjoyed activities – Reduced ability to experience pleasure (APA, 2013)

• Symptoms interfere with daily life and ability to function

• Symptoms last weeks, months, years

• Typically requires treatment

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2 Prevalence

• General Population – 7% have depression at some point in their lives

– Twice as many women as men are affected (APA, 2013)

• People with I/DD

– No clear estimates, though studies suggest 5% to 10% (NADD, 2007)

• Majority of cases recurrent (APA, 2013)

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Possible Causes

• Heredity (Coryell and Winokur, 2016)

• Physiology (Coryell and Winokur, 2016; Teicher, Anderson, and Polcari, 2011)

• Psychological factors / life experiences (Coryell and Winokur, 2016; Teicher, Anderson, and Polcari, 2011)

• Medical conditions (APA, 2013)

• Alcohol and other drugs (Coryell, 2013; NIMH, 2011; Dantzer, et al, 2008)

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3 Depressive Disorders

• Major Depressive • Substance / Medication Disorder Induced Depressive Disorder • Persistent Depressive Disorder (Dysthymia) • Depressive Disorder due to Another Medical Condition • Disruptive Mood Dysregulation Disorder • Other/Unspecified Depressive Disorder • Premenstrual Dysphoric Disorder (APA, 2013)

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Major Depressive Disorder: Criteria

• Depressed mood and/or loss of interest or pleasure

• Interferes with daily living

• Lasts two weeks or more

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4 Major Depressive Disorder: Criteria – continued 5 or more symptoms must be present • Depressed mood most of day, • Fatigue or loss of energy nearly every day. • Feelings of worthlessness, • Diminished interest in inappropriate guilt, helplessness pleasurable activities • Diminished ability to think, • Significant weight loss or concentrate, indecisiveness weight gain • Recurrent thoughts of death / • Insomnia or hypersomnia suicide • Psychomotor agitation / (APA, 2013; Coryell, 2013) retardation nearly everyday

If an individual expresses thoughts about harming him or herself, seek medical/psychiatric help immediately!

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What Depression Symptoms Can Look Like in I/DD

• Depressed Mood • Change in Appetite – Crying, tearful, or a – Refusing to eat or eating more ‘blank’ facial expression than usual

• Irritability • Fatigue – Yelling, screaming, rude – Unable to stand or walk, behavior towards or wanting to sit or lay down lashing out at others frequently (Sovner and Hurley, 1983)

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5 Persistent Depressive Disorder (Dysthymia): Symptoms

• Depressed mood for more days than not over 2 year period

• Never without symptoms for more than 2 months (APA, 2013)

• At least two symptoms must be present – Poor appetite or overeating – Difficulty falling asleep or sleeping more than usual – Low energy or fatigue – Low self‐esteem – Poor concentration or difficulty making decisions

– Feelings of hopelessness (APA, 2013)

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Persistent Depressive Disorder (Dysthymia): Behavioral Effects and Concerns

• Difficulty with relationships (UC Irvine Health, 2017)

• Irritability, hostility, or aggression (UC Irvine Health, 2017)

• Running away or threats of running away from home (UC Irvine Health, 2017)

• Emotional hypersensitivity (UC Irvine Health, 2017; Berger, 2016)

• Suicidal ideation (UC Irvine Health, 2017; Berger, 2016)

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6 Other Depressive Disorders

• Disruptive Mood Dysregulation Disorder (diagnosed in children)

• Premenstrual Dysphoric Disorder

• Substance/Medication Induced Depressive Disorder

• Depressive Disorder Due To Another Medical Condition

• Other or Unspecified Depressive Disorder (APA, 2013)

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Difficulties in Diagnosis

• Symptoms vary (NIMH, 2011)

• Intensity varies (APA, 2013; NIMH, 2011)

• Duration varies (APA, 2013)

• Difficulty recognizing and describing symptoms (NADD, 2007; APA, 2013; NIMH, 2011)

• Gender differences (Martin, Neighbors, and Griffith, 2013)

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7 Handout

What Depression Might Look Like in

Someone Who Has an

Intellectual and Developmental

Disability (I/DD)

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Treatment

• Medical evaluation

• Medication(s)

• Psychotherapy

• Electroconvulsive therapy (ECT) (Coryell and Winokur, 2016; NIMH, 2011)

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8 Supporting Someone with a Depressive Disorder

• Offer emotional support – kindness, compassion, respect

• Offer hope

• Respond appropriately to comments about suicide

• Engage in conversation (NIMH, 2011)

• Encourage activity (NIMH, 2011)

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Supporting Someone with a Depressive Disorder ‐ continued

• Avoid power struggles

• Reduce demands during times of stress

• Practice empathy (NIMH, 2011)

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9 In Conclusion

• Depressive disorders have emotional and physical effects

• Individuals with I/DD are as susceptible to depression as those in the general population

• Treatment requires time, care, and understanding

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Related Training Topics

• Behavior is Communication

• Bipolar Disorder

• Trauma

• Trauma and Attachment Disorders

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10 References

• American Psychiatric Association (APA). (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association, Washington D.C. • Berger, MD., F. (2016, July 29). Persistent depressive disorder. U.S. National Library of Medicine ‐ MedlinePlus. Retrieved August 23, 2017, from https://www.nlm.nih.gov/medlineplus/ency/article/000918.htm • Coryell, MD, W., and Winokur, G. (2016, August). Depression. Carver College of Medicine at University of Iowa. Retrieved August 23, 2017, from http://www.merckmanuals.com/home/mental‐health‐ disorders/mood‐disorders/depression • Dantzer, R., O’Connor, J., Freund, G., Johnson, R., and Kelley, K. (2008). From inflammation to sickness and depression: When the immune system subjugates the brain. Nature Reviews Neuroscience, 9 (1), 46‐56.

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References

• Martin, L., Neighbors, H., and Griffith, D. (2013). The experience of symptoms of depression in men vs. women: Analysis of the national comorbidity survey replication. JAMA Psychiatry, 70 (10), 1100‐1106. • National Institute of Mental Health (2011). Depression. (NIH Publication No. 11‐3561). Bethesda, MD. Office of Science Policy, Planning and Communications, Science Writing, Press and Dissemination Branch. • National Association for the Dually Diagnosed (NADD). (2016). Diagnostic Manual ‐ Intellectual Disability: A Textbook of Mental Disorders in Persons with Intellectual Disability (DM‐ID 2). National Association for the Dually Diagnosed, New York, New York. • Sovner, R. & Lowry, MA. (1990). A behavioral methodology for diagnosing affective disorders in individuals with mental retardation. The Habilitative Mental Healthcare Newsletter, 9, 55‐61.

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11 References

• Teicher, M., Anderson, C., and Polcari, A. (2011). Childhood maltreatment is associated with reduced volume in the hippocampal subfields CA3, dentate gyrus, and subiculum. Proceedings of the National Academy of Sciences of the United States of America, 109 (9). • UC Irvine Health. (2017). Persistent Depressive Disorder (Dysthymia). University of California, Irvine. Retrieved August 23, 2017, from http://www.ucirvinehealth.org/medical‐services/psychiatry/adolescent‐ psychiatry/dysthymia/

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12 Test and Evaluation

Please take a few moments to complete the test and evaluation forms for this training.

Thank you!

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13 Depression

MAJOR DEPRESSIVE EPISODE‐ SOVNER & HURLEY

(BEHAVIORAL PRESENTATIONS IN A PERSON WITH A DEVELOPMENTAL DISABILITY) 1. Depressed Mood/Irritability

Description by others of a change from being happy and smiling or laughing, of having a sense of humor to an absence of these characteristics. Tearfulness, spontaneous episodes of crying and or whining, the person rarely smiles. Increase in somatic complaints. The person might be complaining constantly or regularly asks to return to a previous residential setting.

The person can be easily provoked to scream and swear. Onset of or increased shouting, yelling, blaming or spitting on others. The person is becoming uncooperative and can have “tantrums” when any request is made. Onset or increase in severity of non‐compliance. 2. Markedly Diminished or Decreased Interest or Pleasure in All, or Almost All Activities

Loss of interest in friends and refusal to participate in previously favored social/work activities. The person is more withdrawn, spends excessive time alone. The person does not respond to the typical reinforces or previously enjoyed activities. 3. Decrease/Increase in Appetite ‐ Significant Weight Loss/Weight Gain

The person might refuse to go to the dinner table or refuse to eat anything once there. Others may describe this as non‐compliance and should be asked about it specifically. The person might reject favorite foods and lose some weight. The person may be requesting and eating extra food or start stealing or hoarding food. The person begins to engage in pica (or there is an increase in frequency). Others might notice weight gain. 4. Insomnia or Hypersomnia

Behavioral disturbances in the evening might overshadow underlying sleep disturbances. The person might have difficulties falling asleep and maintaining sleep, or wake up early in the morning. Behavior difficulties (or an increase in frequency or severity) may occur at those times. The person starts sleeping 12 or more hours in a day, takes excessive naps. Sleep is the preferred activity. 5. Psychomotor Agitation or Retardation

Pacing, running, spinning may be a manifestation of agitation. The person appears to be “wired”, may be unable to sit still and is generally described by others as more restless. The onset of or increase in self‐injurious behavior, stereotypy, running away or aggression may also be a manifestation of agitation. The person is emotionally needy, seems clingy and might continually repeat words or phrases in anxious and fearful tones of voice. Retardation may be manifested by a decrease in speech inflection, volume and content or in having trouble completing activities of daily living. The person may also manifest extremely slow body movements and thinking. The person can remain virtually motionless for long periods of time.

1 Depression in Persons with Developmental Disabilities MAJOR DEPRESSIVE EPISODE‐SOVNER & HURLEY Page 2 (BEHAVIORAL PRESENTATIONS IN A PERSON WITH A DEVELOPMENTAL DISABILITY)

6. Fatigue or Loss of Energy

Others may notice a decrease in productivity or regression in skills. The person spends excessive time lying or sitting down. The person rarely initiates activities and appears unmotivated. Apathy.

7. Feelings of Worthlessness or Excessive or Inappropriate Guilt

The person makes (or communicates in some way) negative self‐statements such as “I am bad,” “It’s my fault,” “Nobody likes me,” “I can’t do this job” or “I should be punished.” Onset of or increase in ruminations, worries or preoccupations with previous placements and relationships.

8. Diminished Ability to Think or Concentrate, or Indecisiveness

Reduced work productivity or regression in skills. The individual may begin a task but not follow through. The person’s workshop or day program performance has deteriorated. Decreased attention to the task may also occur. Diminished self‐care skills and increased dependence on others.

9. Recurrent Thoughts of Death, Suicidal Ideation or Attempts

The person talks regularly about the death of relatives or friends, and/or expresses an interest in funerals. The person talks often about heaven and hell, or makes suicidal threats or attempts. Deliberate potentially lethal acts. Onset of or increase in self‐injurious behavior. Offering oneself up to peers who are known to aggress.

Associated Features

 Clinging or holding onto others.  Fearfulness.  Decreased interest in sexuality.  Repeated complaints of aches, pains, physical ailments.  Onset of or increase in aggression and/or self‐injurious behaviors (SIB).  Incontinence of urine and/or feces.  Catatonic stupor and/or rigidity.  A family history of mood disorder, alcoholism, and mental illness (Sovner and Hurley, 1983)

Reviewed 12.17/es

2 What Depression Might Look Like in Someone Who Has an Intellectual and Developmental Disability (I/DD) Adapted from the Diagnostic Manual – Intellectual Disability (DM‐ID) 2007

Symptoms (seen nearly every day) What you might see (must be a change in Behaviors to look for / Track the person) Depressed or irritable mood Tearfulness, sad facial expression, Frequency of crying, aggressive behaviors in absence of emotional expression, rarely response to distress or irritability (self‐injurious, smiles, irritability or aggression (may be verbal, physical, property destruction) described as grouchy, angry facial expression, increase in agitation Loss of interest in pleasurable activities Withdrawal from activities, spends How much time is spent alone, refusals of preferred (things the person used to enjoy) excessive time alone, appears withdrawn, activities, aggression in response to request to may participate but doesn’t show engage in the things they used to like, aggresses or enjoyment, not motivated by the same becomes agitated when prompted to attend a social things anymore, avoids social activities activity Insomnia / Hypersomnia Difficulty falling asleep, early awakening, Total sleep time, hours of sleep per night, frequency excessive sleeping, frequent naps, sleeps and duration of naps, bedtimes, agitations around little at night (up/down all night), seems bedtimes tired, possible agitation at night or early in the morning Weight loss when not dieting or weight Eating to excess, obsessing about food, Change in weight, meal refusals, throwing food, gain, decrease in increase in appetite stealing food, refusing meals, agitated possible screaming when meal arrives behaviors around food/meals Psychomotor agitation (restlessness) / Rarely sits down, up and down from seat, Amount of time sitting, pacing, fidgeting; frequency retardation (feelings of being slowed paces, walks rapidly, fidgets, has slowed of vocalizations down) movements, decrease or stopped talking, vocalizes more or less than usual, less physically active Fatigue or loss of energy Appears tired, reports feeling tired, Time spent sitting or lying, refusals or agitated refuses or become agitated about behavior in response to requests to engage in activities that require physical effort, physical activities spends excessive amount of time sitting or lying down, dark circles under eyes Feelings of worthlessness or Makes negative self‐statements, identifies Frequency of negative self‐statements – “I am bad,” inappropriate guilt as a “bad” person, excepts punishments “Everything is my fault,” or “Everyone hates me.” (without a history of harsh treatment), Frequency and rate of reassurance seeking blames self for problems, unrealistically behaviors. Difficult to determine in people with fears that others will be angry or Severe/Profound I/DD rejecting, excessively seeks reassurances from others that are good, may appear clingy Decreased concentration or Reduction in productivity at work or Rate of production at program or work, frequency of distractibility, indecisiveness program, doesn’t complete tasks they incomplete tasks, frequency of agitated or once were able to complete, diminished aggressive behaviors when asked to complete tasks, self‐care skills, appears easily distracted, changes in memory, changes in hygiene or self‐care increase in agitations when asked to perform tasks that involve concentration, memory problems that “come and go”, possibly has to leave programming due to poor performance Recurrent thoughts of death or suicide Often talks about death or people who Frequency of talking about death related issues, have died or other morbid frequency of physical complaints or fears of preoccupations, unrealistic or unfounded illness/death, number of attempts to harm self. physical complaints and fears about Difficult to assess in people with Sever/Profound illness or death, makes threats to harm I/DD. self, attempted suicide (runs in front of cars – may seem impulsive but may also be suicidal in nature)

The purpose of this tool is to assist program/behavior specialists in becoming “diagnostically specific” when gathering information for tracking/charting. Aggression, for example, is not diagnosis specific, however, it can be a manifestation of an irritable mood or a response to distress.

If you are seeing changes in a person’s behavior, it may or may not be due to a mental illness. Seek the advice of a physician.

National Association for the Dually Diagnosed. (2007). Diagnostic Manual – Intellectual Disability: A Textbook of Diagnosis in Person’s with Intellectual Disabilities. New York.

Sovner, R. & Lowry, MA. (1990). A behavioral methodology for diagnosing affective disorders in individuals with mental retardation. The Habilitative Mental Healthcare Newsletter, 9, 55‐61.