18. Psychiatry

Question 1

Depression:
- Define

Answer 1

Definition:
Two of the three core symptoms are present on most days for at least 2 weeks and are associated with at least two further cognitive, biological, physical and/or psychotic symptoms. Classified as:
* Mild: two core symptoms + two other symptoms
* Moderate: two core symptoms + three other symptoms
* Severe: three core symptoms + ≥four symptoms
* Severe with psychosis: three core symptoms + ≥four symptoms + psychosis

Question 2

Depression: Risk factors

Answer 2

Risk factors:
>65 years of age +
Physical chronic comorbidities (e.g., diabetes mellitus, chronic obstructive pulmonary disease (COPD), multiple sclerosis (MS), pain syndromes)
Female
Adverse childhood experiences
Medications (e.g., propranolol, corticosteroids, oral contraceptives, isotretinoin)
Postnatal
Psychosocial events (e.g., family breakdown, unemployment, lower socioeconomic status, social isolation)
Personal or family history of depression

Question 3

Depression: Symptoms
- Core
- Cognitive
- Biological
-Physical
- Psychotic

Answer 3

Core symptoms:
- Anhedonia (a lack of interest in things that were previously enjoyed)
- Low mood
- Anergia (low energy)
- Other symptoms:
Cognitive :
feelings of worthlessness/hopelessness/guilt, decreased memory/concentration, increased irritation, suicidal ideation or intent, Beck’s triad (negative thoughts about themselves, the world, the future)

**Biological: **
Altered sleep (e.g., insomnia, early-morning rising), altered appetite with possible resultant changes in weight, decreased libido, diurnal variation in mood

**Physical: **
Constipation, anergia, aches and pains, dysmenorrhea, agitation or slowing of movements

Psychotic:
Auditory hallucinations and delusions (hypochondriacal, guilt, persecutory, nihilistic)

Question 4

Depression:
- How to diagnosis?
- Rating scales
- Questionnaires
- Blood investigations to request

Answer 4

**Investigations: **
Clinical diagnosis
Rating scales:
Beck’s
**Questionnaires: **
- Patient Health Questionnaire (PHQ)-9 (mild = score of 5–9; moderate = score of 10–14; moderate to severe = score of 15–19; severe = score of >20)
- Hospital Anxiety and Depression Scale (HADS)
- Beck Depression Inventory (BDI)-II
- Edinburgh Postnatal Depression Scale
- Geriatric Depression Scale
**Blood: **
Vitamin B12 and folic acid (since patients with depression have been found to have deficiencies in these compared with non-sufferers; however, not diagnostic)

Question 5

Depression: Beck’s triad state

Answer 5

Question 6

Depression: Differentials

Answer 6

• Physical:
  Hypothyroidism, head injury, Cushing’s disease, obstructive sleep apnoea syndrome
  *** Other: **
  normal sadness, bereavement (numbness, overwhelming ‘pangs of grief’, abnormal if prolonged (>6 months)), adjustment disorder (a state of emotional disturbance arising in the period of adaptation following a stressful event), bipolar affective disorder (BPAD)/schizoaffective disorder/schizophrenia, substance misuse, dementia
• Consider appropriate investigations if the history is suggestive of an underlying organic pathology

Question 7

Depression: Management

Answer 7

All:
SUICIDE RISK and safeguarding concerns
Mild:
* Watchful waiting
* Supportive interventions (e.g., self-help guides, computerised cognitive behavioural therapy (CBT), physical activity programmes), psychotherapy (e.g., CBT or interpersonal psychotherapy).* Antidepressants are not recommended at this stage*
Moderate:
* Antidepressant (selective serotonin reuptake inhibitors (SSRIs)) for 6 months after resolution of symptoms if the first presentation or for 2 years after resolution of symptoms if the second presentation. Lifelong if there are multiple presentations
* Psychotherapy (CBT or interpersonal therapy)
* Severe: optimisation of antidepressant medications with psychiatric input, consider hospitalisation and antipsychotics if exhibiting psychotic symptoms, consideration of electroconvulsive therapy (ECT) by psychiatrist

Question 8

Depression: Prognosis

Answer 8

• 50% of patients will experience another episode in their lifetime.
• Up to 15% of people with a major depressive episode will commit suicide.
• Severe depression with psychotic features has a worse prognosis.