Depression Flashcards
Requirements for diagnosis to be depression
- Present for at least 2 weeks
- Not secondary to effects of drugs/alcohol, medication, medical disorder or bereavement
- May cause significant distress of impairment of social, occupational or general functioning
Core symptoms
- Depressed mood
- Anhedonia (reduced interest)
- Weight change
- Disturbed sleep
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Reduced libido
- Feelings of worthlessness or inappropriate guilt
- Low concentration/indecisiveness
- Recurrent thoughts of death/suicide
Somatic symptoms
- Loss of emotional reactivity
- Diurenal mood variation
- Anhedonia
- Early morning wakening
- Psychomotor retardation or agitation
- Loss of appetite and weight
- Loss of libido
Psychotic symptoms/features
- Delusions
- Hallucinations
- Catatonic symptoms or marked psychomotor retardation (depressive stupor)
Delusions in depression
- Poverty
- Personal inadequacy
- Guilt over presumed misdeeds
- Responsibility for world events
- Deserving of punishment
- Other nihilistic delusions
Hallucinations in depression
- Auditory
- Defamatory or accustory voices, cries for help or screaming
- Olfactory
- Bad smells such as rotting food, faeces, decomposing flesh
- Visula
- Tormentors, demons, the Devil, dead bodies, scenes of death or torture
Mood incongruent delusions/hallucinations are also possible
Diagnostic criteria/classification
- Mild
- 2 typical and 2 other core symptoms
- Moderate
- 2 typical and 3 other core symptoms
- Severe
- 3 typical and 4 other core symptoms
Can be with or without psychotic features
Core symptoms
- 3 core symptoms
- Depressed mood
- Anhedonia
- Fatigue
Epidemiology - prevalence
Around 5%
Epidemiology - sex ratio
M:F 1:2
Risk factors
- Genetics
- Childhood experiences
- Loss of parent, lack of parental care, parental alcholism, sexual abuse
- Personality
- Anxiety, impulsivity, obsessionality
- Social
- Divorced
- Lack of employment
- Adverse life events
- Loss
Aetiology
- Not well known but biopsychomodel exists (attach image from page 245)
- Early adverse experience
- Personality factors
- Psychological factors
- Gender
- Social factors
- Brain pathology
- Neurotransmitter abnormalities
- Thyroid abnormalities
- Changes in sleep pattern
Aetiology - early adverse experience
Foetal environment and later social environment has effect on HPA axis
Aetiology - personality factors
- Mediates level of response to sensory experience which can increase vulnerability due to
- Autonomic hyperarousal
- Lability (unpredictable responses to emotional stimuli)
- Negative basis in attention, processing and memory for emotional material
Aetiology - psychological factors
- Disruption of normal social, martial, parental or familial relationship correlated with high rates depression
- Adverse childhood events may increase susceptability to high response to later stressful events
- Low-self esteem vulnerability factor
Aetiology - social factors
- Low income greater risk
- Social causation (stress associated with problems leads to depression)
- Social selection (predisposed people fall down social ladders or fail to rise them)
Aetiology - brain pathology
- Ventricular enlargement and sulcal prominence
- Increased white matter lesions
- Hypoperfusion in frontal, temporal and parietal areas, and hyperperfusion in frontal and cingulate cortex
Aetiology - neurotransmitter abnormalities
- Monoamine theory of depression
- Reduced monoamine function (5-HT, NE, DA) caused depression
Aetiology - thyroid abnormalities
- Abnormalities in thyrotopin (TSH) respone to TRH, both blunting and enhancement, despite normal thyroid hormone levels
Aetiology - changes in sleep pattern
- Early monrning wakening, reduced total SWS and shortened REM latency
Differential diagnosis
- Psychiatric
- Stress related disorders, bipolar disorder, schizoaffective disorders, personality disorders
- Neurological
- PD, Huntington’s disease, MS, stroke, epilepsy, tumours, head injury
- Endocrine
- Addisons, Cushings, hyper/hypothyroidism, menopause symptoms, premenstrual syndrome, prolactinaemia, hyperparathyroidism, hypopituitarm
- Metabolic
- Hypoglycaemia, hypercalcaemia
- Haematological
- Anaemia
- Inflammatory
- SLE
- Infections
- Syphillis, Lyme disease, HIV encephalopathy
- Sleep disorders
- Sleep apnoea
- Medication
- Anti-hypertensives
- Substance misuse
Investigations
- None to diagnose, done to exclude differentials
- Standard
- FBC, ESR, B12/folate, U&Es, LFT, TFT, glucose, Ca
- Focused
Prognosis - chronic course
10-20% patients
Prognosis - reccurence
30% at 10 years
60% at 20 years
Prognosis - mortality
Suicide rate 13%
Prognosis - good outcome factors
- Acute onset
- Earlier age onset
Prognosis - poor outcome factors
- Insidious onset
- Elderly
- Low self-confidence
- Comorbidity
- Lack of social support
Reasons for hospital admission
- Risk of suicide
- Risk to harm others
- Severe depressive episode
- Severe self-neglect
- Severe psychotic symptoms
- Initiation of ECT
- Treatment resistent depression
Treatment - first line
- Antideppresant
- For mild/moderate episodes or if contraindication to antideppresants
- CBT or other psychotherapies
- In severe cases
- ECG
Treatment - choosing antideppresant
- Patient factors
- Age, sex, comorbid physical illness, previous response
- Issues of tolerability
- Symptomatology
- Sleep problems - more sedative
- Lack of energy/hypersomnia - stimulatory
- With anxiety/panic - SSRI/imipramine
- OCD - chlomipramine/SSRI
- Risk of suicide - avoid TCAs
Treatment - adequate trial
At least 4 weeks of highest tolerated dose (up to BNF maximum)
Treatment - first line with sleep problems
More sedative agent
Treatment
First line with lack of energy/hypersomnia
More stimulatory agent
Treatment
First line with anxiety/panic
SSRI/imipramine
Treatment
First line with OCD symptoms
Clomipramine/SSRI
Treatment
First line to avoid when suicide risk
Avoid TCAs
Treatment
Suicide risk
Can be increased with initial treatment with antidepressant
TREATMENT
Second line
Alternative agent from different class of antidepressant or from the same class but with different side effect profile
TREATMENT
Partial repsonders
May benefit from addition of lithium (observed for 2 weeks)
TREATMENT
ECG indications
- First line when severe biologic features (weight loss) or marked psychomotor retardation
- Patient high risk of harming themselves (clear evidence of repeated suicide attempt)
- Second or third line in failed pharmacological therapy
TREATMENT
Maintenance therapy - first episode
- Emphasise compliance, continue for at least 6 months to 1 year after remission
- Discontinuation should be gradual
- Patient can continue medication long term, no evidence says this causes harm
TREATMENT
Maintanence therapy - recurrent episodes
- If periods between episodes < 3 years or severe episodes
- Prophylactic treatment maintained for at least 5 years
- Otherwise treat as first episode
TREATMENT
Depressive episode with psychotic features
- ECG considered for first line, evidence supports better than pharmacology
- Combination therapy - antideppresant plus antipsychotic
- Lower dose of antipsychotic when symptoms better
TREATMENT
Treatment resistent depression
- Review diagnostic formulation
- Check patient compliance
- Continue therapy at highest safe dose
- Consider change of antidepressant to different class
- Consider combination of antideppresants from different classes
- Consider use of ECT
