Clinical Depression Tutorial

Question 1

Case video: 38F

What are the key symptoms from the video?

Answer 1

Feels fed up, can’t be bothered ‘What’s the point?’
Guilty over feeling useless
Cannot cope with everyday life
Takes her ages to get to sleep
Wakes up in the middle of the night - cannot get back to sleep afterwards
Feels exhausted
Decreased appetite
Lack of concentration
Anhedonia
2 children, 9 and 11 - difficulty looking after them, doesn’t cook for them
Feels like she is a mess, can’t be bothered to look after herself
Partner = Dave, worsened relationship
Low libido

Question 2

What are the key mental state examination points from the video?

Appearance
Behaviour
Speech
Mood
Thought
Perceptions
Cognition
Insight

Answer 2

Appearance = overweight, white British, appropriately dressed, greasy hair = neglecting self-care

Behaviour = 
Fiddling with her fingers
Lack of eye contact
Crying / Tearful
Slumped 

Speech =
Monotonous
Incomplete sentences
Talking quietly but normal rate

Mood / Affect =
Objective = persistent low mood, looks depressed, flat effect = lack of expressed emotions, tearful
Subjective = fed up, biological and psychological symptoms i.e. disturbed sleep, decreased appetite, anhedonia, guilt etc.

Thought =
No formal thought disorder - logical
Content = evidence of hopelessness

Perceptions =
No abnormal perceptions reported / observed

Cognition =
Well orientated to time, place, person

Insight =
Recognises she isn’t coping with things

Question 3

What questions could we ask her next?

Answer 3

Is there any family history of mental illnesses?
Any thoughts or self-harm or harming others?
Medication history?
Past psychiatry history?
Any episodes of feeling high / mania?
Any drug or alcohol abuse?

Question 4

What could happen if you give a bipolar patient anti-depressants?

What do you give instead?

Answer 4

Could trigger another manic episode

Mood stabilisers

Question 5

How do you explore the history of the presenting complaint?

Answer 5

Insidious VS acute onset

Core / psychological / physical symptoms?

How long do the episodes last? Diurnal variation?

Exacerbating and relieving factors: any medications?

is it helping? Psychosocial stressors / support?

Associated disorders: general anxiety disorder/OCD/personality disorder/bipolar disorder/substance misuse/psychotic illness/hypothyroidism

Any previous episodes? How severe is this episode? Can use likert scale

Question 6

How do you explore past psychiatric history?

Answer 6

Previous episodes of depression?

Did previous episode(s) resolve with or without treatment?

History of any other mental illness? – Important to rule out manic episodes

Previous admissions? (informal versus under the mental health act)

Collateral history (mainly important when risks / patient being guarded)

Medical notes if available

Question 7

How do you explore family history?

Answer 7

Any mental illness?

Who e.g. first degree relative?

What are the family relationships like?

Question 8

How do you explore medication / substance misuse history?

Answer 8

Antidepressants / antipsychotics / mood stabilisers / side effects / ET / psychology?

When treated? 
How long? 
What exact medication?
What doses?
How well tolerated?
Did it help?

Question 9

How do you explore forensic history?

Answer 9

Arrests/cautions/incarcerations/forensic mental health act admissions/probation officer

Question 10

How do you explore personal history?

Answer 10

Birth & early life

School & qualifications

Higher/further education

Employment

Psychosexual history

Premorbid personality

Question 11

How do you conduct a risk assessment?

Answer 11

To self:
Current suicidal ideation / plans / intent
Previous attempts (method / how many episodes / how did they feel when they survived)
Self harm / cutting
Self neglect . poor care of physical illness

To others:
More rare in depression but still ask!
Thoughts/plans to harm others?

From others:
Vulnerability to exploitation

Question 12

What are the possible differentials?

Answer 12

Bipolar vs Unipolar ?
Bipolar (and depression) vs Borderline Personality Disorder ?
Bipolar vs Schizophrenia ?
Bipolar vs Attention Deficit Disorder ?

Question 13

What is the importance of distinguishing between bipolar and unipolar disorders?

Answer 13

Yes – because antidepressants:

Appear to be mostly ineffective in acute bipolar depression and in prophylaxis

Can cause acute manic/hypomanic episodes

Have been shown to worsen the long-term course of bipolar illness in some subjects, especially those with a rapid- cycling course

In rapid-cycling cases appear to lead to more mood episodes, including depressive states, over time

Question 14

What are the personality disorders?

What are the 3 clusters according to the DSM-5 and what are the different disorders within them?

Answer 14

Personality Disorders: Maladaptivepatterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual’s culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.

A =

Paranoid : pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent
Schizoid: lack of interest and detachment from social relationships, apathy, and restricted emotional expression
Schizotypal: extreme discomfort interacting socially, and distorted cognition and perceptions

B =
Antisocial : pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behavior
Borderline: pervasive pattern of abrupt mood swings, instability in relationships, self-image, identity, behavior andaffect, often leading to self-harm and impulsivity
Histrionic: pervasive pattern ofattention-seekingbehavior and excessive emotions

C =
Narcissistic: pervasive pattern ofgrandiosity, need for admiration, and a perceived or real lack of empathy
Avoidant: pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation.
Dependent: pervasive psychological need to be cared for by other people
Obsessive-compulsive personality disorder: rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct fromobsessive-compulsive disorder)

Question 15

What are the 3 personality disorders that often get confused with bipolar disorders?

Answer 15

Antisocial : Disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behavior.

Borderline: Abrupt mood swings and instability

Histrionic:Attention-seekingbehavior and excessive emotions

Question 16

What are the similarities and differences between Bipolar Affective Disorder (BPAD) and Borderline Personality Disorder? (BPD)

Answer 16

Similarities = 
Rapid mood swings 
Unstable interpersonal relationships 
Impulsive sexual behaviour  
Suicidality

BPAD =
Runs in family (heritability)
Grandiosity
Mood states typically less affected by environment

BPD =
Poor self image
Fear of abandonment
Feelings of emptiness

Question 17

What are the similarities and differences between Bipolar Affective Disorder (BPAD) and Schizophrenia (SZ?

Answer 17

Similarities =
Hallucinations (present in 50% of mania & 10% of depression)
Cognitive impairment
Depression & Negative Symptoms of schizophrenia (apathy, lack of affect, low energy, and social isolation)
Schizoaffective shares features of both BPAD and schizophrenia

BPAD =
Episodic delusions/hallucinations

SZ =
Chronic delusions/hallucinations

Question 18

What are the similarities and differences between Bipolar Affective Disorder (BPAD) and Attention Deficit Disorder (ADD)?

Answer 18

Similarities =
Impaired concentration
Impairment of executive function
Abnormal working and short term memory

BPAD =
Family history (heritability)
Recurrent depressive episodes
Amphetamines worsen mania

Question 19

What are some common psychiatric co-morbidities with Bipolar Affective Disorder?

Answer 19

Any anxiety disorder = 93% prevalence, 34.8% odds ratio

Any substance abuse disorder = 71.1% prevalence, 6.9% odd ratio

Question 20

What are the possible organic / iatrogenic causes of depression?

Answer 20

Endocrine = (Hyper- and) hypothyroidism, hyper- and hypoparathyroidism, hyper- and hypoadreno-corticism, hypoglycemia, Cushing’s syndrome, Addison’s disease

Other systemic conditions incl infections = viral infections, systemic lupus erythematosus, HIV infection, pancreatic (and other) cancer. [Cytokines manifested in systemic diseases are considered to be a cause of depression]

Deficiencies incl. of = vit B12 or folic acid.

Neurological conditions, incl. = multiple Sclerosis, Alzheimers, Parkinsons

Medications = incl Beta-blockers, steroids, anti-Parkinsons, anti-cholinergics (e.g. for irritable bowel syndrome (IBS) with such as dicyclomine), some antibiotics (incl ciprofloxacin), statins, estrogen, opiate pain killers, acne medications

Question 21

What are some other organic differentials that can result in depression-like symptoms?

Answer 21

Vascular Depressionor early sub-cortical dementia = late life depression

Vascular depression =white matter hyperintensities, more vulnerable to stressors. so important to treat vascular risk factors e.g. diabetes, hypertension

Poststroke depression = sometimes becomes persistent e.g. lesions in the left frontal lobe or basal ganglia are apt to cause depression, with the tendency that the more frontal the lesion, the more severe the symptoms