Affective disorders- depression and bipolar, post-natal depression and puerperal psychosis Flashcards
What is the prevalence of depression?
The average lifetime prevalence estimate was 14.6% for adults in high-income countries.
The average 12-month prevalence estimate was 5.5% for adults in high-income countries.
The average age of onset was 25.7 years in adults in high-income countries.
The female-male ratio was about 2:1.
What is the presentation of depression, including ICD-10 diagnostic criteria?
From ICD-10:
In typical mild, moderate, or severe depressive episodes:
* Core symptoms: Low mood, anhedonia, low energy
Other symptoms:
* Capacity for enjoyment, interest, and concentration is reduced
* Marked tiredness after even minimum effort is common.
* Sleep is usually disturbed
* Appetite diminished.
* Self-esteem and self-confidence reduced
* Some ideas of guilt or worthlessness are often present.
* Somatic symptoms - weight loss, depression worse in morning, loss of libido, agitation, loss of appetite, EMW, marked psychomotor retardation.
What is required for diagnosis of depression?
Symptoms must be present every day or** nearly every day** for** over 2 weeks **
Must represent a change in personality without use of alcohol/drugs, underlying medical disorder or berevement
At least 2 core symptoms - low mood, anhedonia, low energy
PLUS 2 or more typical symptoms (sleep, appetite, conc etc)
Distinguish between Dx of mild, moderate and severe depression
Mild = 2 core symptoms + 2 other symptoms (able to function)
Moderate = 2 core and 3 or 4 other symptoms
Severe = 3 core + at least 4 other symptoms
What are the somatic symptoms of depression? BB LEC
Loss of libido, weight changes, appetite changes, early morning waking, diurnal variation of mood (depression can be worse in mornings), psychomotor agitation/retardation.
What are cognitive symptoms of depression? BB LEC
Low self esteem
Guilt / self blame
Hopelessness
Hypochondrical thoughts
Poor conc/inattention - may be described as memory loss
Suicidal thoughts
What is psychotic depression?
Presence of severe depression (3 core and 4+ other symptoms) with psychotic symptoms such as hallucinations and/or delusions.
In a history for depression, what two ‘depression identification questions’ do you need to ask?
What should you if answer to these qu is yes?
During the last month, have you often been bothered by feeling down, depressed, or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
If answer is yes - need a more in depth assessment, so ask all qu (e.g. sleep, appetite, EMW, loss of libido, weight loss, guilt, conc etc)
What should you ask in Hx of pt with depression. Name at least 5!
(this answer wil be long)
- **The symptoms **- onset, duration, pattern(diurnal?) severity, impact on daily life, including impact on carer duties (if relevant) and children (?safeguarding concern)
- Current lifestyle - diet, physical activity, sleep, alcohol, substance misuse.
- **PMH **- of depression or self harm. Previous suicide attempts
- **Co-existing MH conditions **(current symptoms or past Hx) - mood elevation, psychotic, psychotic depression, anxiety, bipolar, PTSD, eating disorders, schizophrenia
- **Learning disabilities or cog impairment **(if relevant) - dementia, traumatic brain injurt, parkinsons
- RFs for depression - FHx of depression, suicide, self harm, chronic physical health condition, history of domestic violence.
- Current and previous supportive relationships - partner, family, friends, carers, other organisatiosn (eg samaritans, crisis)
- **Recent or past stressful or traumatic events **- eg job loss, relationship breakdown, divorce, debt, housing, immigration, social isolation.
forensic/criminal Hx - DSH and suicide - thoughts, ideas, plans, intent for DSH or suicide, and protective factors.
- DHx - current meds, previous treatment for depression - did it work? Allergies
How is depression investiagted?
- Take Hx and assess risk !!
- Consider using questionasire - PHQ9, HAD (7 qu on anxiety, 7 on depression)
- MMSE
- Rule out other causes for presentation - TFTs for hypothyroidism, FBC for anaemia, B12 and folate deficiencies, bone profile for hypocalcaemia
How is depression managed?
Mild - General advice - sleep hygiene, exercise, support groups, relaxation, socialising, healthy lifestyle (food chpices, alcohol intake reduced, sleep routine). CBT in group or individualised, self help guides. Consider starting antidepressants if they have a PMHx of moderate to severe depression
Moderate - indivdial CBT (high intensity psychological interventions) and antidepressants - SSRIs recommended as 1st line.
Severe - need rapid specialist mental health assessment with consideration of inpatient admission (using MHA if necessary). Antidepressants, ECT. rTMS, IV ketamine
How long should antidepressants be used for depression? How does this differ to SSRis taken for anxiety?
Should be taken for 6m in depression.
For anxiety, need to be taken for 1yr.
What treatment options are available for depression?
Self help, lifestyle changes, CBT, antidepressants, combo therapy (antidepressant and CBT), interpersonal therapy, psychodynamic psychotherapy, counselling
What are the causes of depression?
Likely due to interaction between biological, psychological and social factors.
Biological - FHx/ genetic, structural brain changes e.g. ventricular enlargement. Brain illness = parkinsons or dementia. Physical illness such as cancer, hypothyroid. Imbalance of 5-HT and NA in the brain and spinal cord (monoamine hypotehseis).
Psychological - personality traits, neuroticism (where you get autonomic hyperarousal, mood lability, negative biases in attention and processing), childhood experiences, view of yourself and the world
Social - life events that are disruptive, stress associated w/ poor social environment and social isolation, lower social class, work, housing, finances, relationships, support.
Prognosis of depression?
Depressive episodes last 3-6m with treatments, and people usually recover within 12m
80% of pts will have further depressive episode
10% will have severe unremitting depression
How does presentation of depression differ in children and the elderly?
**In children **- similar - a sad or irritable mood, anhedonia, decreased capacity to have fun, decreased self-esteem, sleep disturbance, social withdrawal or impaired social relationships, and impaired school performance.
In elderly - may only present with physical symptoms or a deterioration in cognitive functioning
What are the differentials for depression?
Psychological disorders:
* Bipolar - where depression is first episode/pt has not disclosed manic episode/hypomania.
* Schizophrenia
* Anorexia nervosa, bulimia
* Anxiety - GAD, PTSD, Phobia based, Adjustment disorder
* Premenstural syndrome –> relate to Repro
Neurological condition:
* Dementia
* MS
* Parkinsons
Physical illness
* hypothyroid
* anaemia
* sleep disorder - OSA
Medication side effects
* methydopa
* beta blockers
* hormonal contraceptives
* PPIs
* gabapentin
* opioids
* isotretinoin –> relate to Derm
* substance misuse
What is the prevalence of bipolar disorder?
1-2%
Epidemiology of bipolar:
1. What is median age of onset?
2. Male to female ratio?
Median age = 25
M=F
Describe Bipolar affective disorder, including ICD-10 diagnostic criteria
- A disorder characterised by two or more episodes.
- The patient’s mood and activity levels are significantly disturbed → some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression).
- Repeated episodes of hypomania or mania only are classified as bipolar.
