3. Depressed mood Flashcards
1
Q
Describe: Major depressive disorder (MDD) (3)
A
- MDD is a mental disorder with primarily depressive features.
- The DSM defines a mental disorder as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biologic, or developmental processes underlying mental functioning.”
- This definition gives MDD more specificity than the general term “depression.”
2
Q
Describe epidemiology: Major depressive disorder (MDD) (4)
A
- The 12-mo prevalence of MDD in the United States is 7%.
- MDD can first occur at any age, but the incidence peaks in the second decade.
- Females experience MDD at 1.5x to 3x higher rates than males.
- According to the World Health Organization, depression is the leading cause of disability worldwide.
3
Q
Describe: Pathogenesis of depression (5)
A
- Multifactorial. Contributing factors include
- genetics
- neurotransmitter and/or endocrinological dysregulation
- cognitive processing deficits
- and possible structural and histologic pathologies.
- Psychological theories have also been described.
4
Q
Describe: Main neurotransmitters involved in depression (5)
A
- serotonin
- norepinephrine
- dopamine
- Neuropeptides such as somatostatin and neuropeptide Y act as cotransmitters, and may also be involved.
- Moreover, the roles of the hypotha- lamic–pituitary–adrenal and hypothalamic–pituitary–gonadal axes and of thyroid hormones on human emotions have been studied.
5
Q
Name DDX categories of depressed mood (4)
A
- Psychiatric
- General medical conditions
- Substance or medication induced
- Bereavement*
6
Q
Name PSYCHIATRIC DDX of depressed mood (5)
A
- Depressive disorders
- Major depressive disorder
- Persistent depressive disorder (Dysthymia)
- Premenstrual dysphoric disorder
- Bipolar disorders
- Bipolar I &II disorders
- Cyclothymic disorder
- Psychotic disorders
- Adjustment disorder with depressed mood
- Dementia
7
Q
Name SUBSTANCE OR MEDICATION INDUCED DDX of depressed mood (7)
A
- Medications
- Anticonvulsants, CNS depressants, opioids
- Beta-blockers, calcium channel blockers
- Corticosteroids, hormones
- Fluroquinolones
- Interferon alpha
- Substances of abuse
- Alcohol, CNS depressants
- Stimulant withdrawal
8
Q
Name GENERAL MEDICAL CONDITIONS DDX of depressed mood (5)
A
- Chronic illness
- Endocrinologic
- Adrenal disorders
- Thyroid disorders
- Malignancy
- Metabolic
- Electrolyte abnormalities
- Vitaminde deficiencies
- Neurologic
- Multiple sclerosis
- Stroke
- Tumor
9
Q
Describe HX: Depressed mood (15)
A
- Patient identifiers: name, age, occupation
- Social and contextual information: relationship status, living arrangement, work or source of income, children, caregivers of children besides the patient
- Ask about the DSM -5 criteria for MDD
- Screen for symptoms of mania/hypomania, anxiety, or psychosis. The following screening questions may be asked:
- Mania/hypomania: “Has there ever been a time when you weren’t sleeping as usual and yet your energy was higher than normal and you were engaged in a lot of activities? Did people around you think this was unusual?”
- Anxiety:“Doyouconsideryourselfasa‘worrier?’”“Anysuperstitionsorrituals like counting, washing, checking?” “Or thoughts that come into your head that are hard to get rid of?” “Have you ever had panic attacks?”
- Psychosis: “Do you ever worry that people might be plotting to harm you?” “Do you have any special abilities that other people don’t usually possess?”
- “Are you hearing voices or messages?” “What about visions?”
- Recent and current stressors: personal losses that have occurred or anticipated (e.g., death in family, loss of work, property), role transitions, financial difficulties, interpersonal conflict, isolation
- Social supports available
- Suicide
- Substance use
- Forensic history
- Psychiatric history
- Family psychiatric history
- Medical history
- Medications
- Allergies
- Personal history: childhood relationships, performance in school at different stages, highest level of education, occupations held, relationships in adolescence and adulthood, history of abuse at any stage in life
10
Q
Name risk factors: Depressed mood (12)
A
SAd PerSOnS
- Sex is Male
- Age
- depression
- Previous attempt
- ethanol or drugs
- rational thinking loss
- Separated, divorced, widowed
- Organized plan
- no socialsupport
- Stated future intent (e.g., suicide note)
Based on recent evidence, SAD PERSONS is not a reliable scale to determine risk of suicide. However, it can be used as an acronym for risk factors to think about.
Important for acute risks: hopelessness, current psychiatric illness, non-compliance/response to treatment, impulsivity, anxiety, high distress, drug and alcohol use, organized plan, chronic illness, terminal illness (especially recent Dx) access to lethal means, recent loss, poor access to social supports
11
Q
Name protective factors: Depressed factors (3)
A
- Children, close family members, pets
- Religiosity
- Good therapeutic relationship with care providers
12
Q
Describe physical exam: Depressed mood (7)
A
- Mental status examination: psychomotor retardation, agitation (fidgeting, moving about, hand-wringing, nail biting, hair pulling, lip biting)/decreased eye contact/ slowness of speech/depressed mood, dysphoric affect with a decreased range/ suicidal ideation and plan, homicidal intent and plan
- Examine vital signs
- Pupils
- Skin for previous suicide attempts
- Stigmata of drug, and/or alcohol use
- Thyroid gland
- Weight loss
13
Q
Describe investigations: Depressed mood (13)
A
- Blood work =
- CBC
- electrolytes
- BUN
- creatinine
- fasting blood glucose
- liver profiles
- thyroid profiles (TSH)
- toxicology/drug screen (alcohol, cannabis, opioid, amphetamine/stimulant or cocaine withdrawal or intoxication)
- Urinalysis, urine drug screen
- Additional screening:
- neurologic consultation
- CXR
- ECG
- CT scan as indicated
14
Q
Describe dx: Major Depressive Disorder (4)
A
- At least five of the following symptoms (MSIGECAPS) with at least one of depressed mood or anhedonia presented within the same 2-wk period with a change from previous functioning:
- M: mood depressed
- S: sleep decreased or increase
- I: interest decreased (anhedonia)
- G: guilt
- E: energy decreased
- C: concentration decreased
- A: appetite decreased or increased
- P: psychomotor agitation or retardation
- S: suicidal ideation
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The symptoms are not due to the direct physiologic effects of a substance or GMC.
- The symptoms are not better accounted for by other psychiatric disorders.
- For features and specifiers of MDD, see Table 19.3.
- For differentiating MDD from grief during bereavement
15
Q
Name: Features and specifiers of MDD (9)
A
- With anxious distress
- With mixed features
- With melancholic features
- With atypical features
- With mood-congruent psychotic features
- With mood-incongruent psychotic features
- With catatonia
- With peripartum onset
- With seasonal pattern
16
Q
Describe this feature/specifier of MDD: With anxious distress (5)
A
Two or more of the following:
- feeling tense
- restless
- concentration problems
- worry that something awful may happen
- worry that self-control might be lost
25
Q
Differentiate MDD from grief during bereavement
- Predominant affect
- Dysphoria
- Associated features
- Thought content
- Self-esteem
- Suicidal ideation
A
