Depression Flashcards
What is the definition of Mood/Affective disorders?
a change in affect/mood to depression (with or without associated anxiety) or to elation
(usually accompanied by a change in the overall level of activity)
What is the DSM-5 criteria for a depressive episode?
- 2+ weeks of a depressed mood
- 4/8 of the qualities on the DSM-5 criteria
What is on the DSM-5 criteria?
- sleep alterations (insomnia or hypersomnia)
- appetite alterations
- anhedonia
- decreased concentration
- low energy
- guilt
- psychomotor changes (agitation or retardation)
- suicidal thoughts
What does a dignosis of Major Depressive Disorder mean?
- no manic or hypomanic episodes in the past
- diagnosis of a current depressive episode
What are the DSM-5 subtypes of Major Depressive Disorder?
- atypical features
- melancholic features
- psychotic features
What does it mean to have the atypical subtype (DSM-5) of MDD?
- increased sleep and appetite
- heightened mood reactivity
What defines the melancholic subtype (DSM) of MDD?
- no mood reactivity
- marked psychomotor retardation
- anhedonia
What defines the psychotic subtype (DSM) of MDD?
- presence of delusions/hallucinations
How does DSM-5 classify a manic episode?
- euphoric or irritable mood
- 3/7 of the manic criteria
What is on the DSM-5 manic criteria?
- decreased need for sleep with increased energy
- distractibility
- grandiosity or inflated self esteem
- flight of ideas or racing thoughts
- increased talkativeness or pressured speech
increased goal-directed activities or psychomotor agitation - impulsive behaviour
What is required for a manic episode diagnosis?
- minimum 1 week
- notable functional impairment
- leads to type 1 bipolar disorder
What is required for a hypomanic episode?
- minimum 4 days
- NO functional impairment
What would lead to a diagnosis of type II bipolar disorder?
- no manic episodes
- only hypomanic episodes
- at least one major depressive episode
What happens if none of the requirements for a manic or hypomanic diagnosis?
DSM-5 diagnosis is:
Unspecified Bipolar Disorder
What is the differentiating characteristic between manic and hypomanic episodes?
- psychotic features (delusions/hallucinations)
- hospitalisation
- both are a noticeable functional impairment
What happens if a manic/hypomanic episode is caused by anti-depressants?
the diagnosis of bipolar disorder is made with DSM-5
Why are anti-depressant induced manic/hypomanic episodes no longer excluded?
shown that it occurs almost exclusively in those with bipolar, noty unipolar depression
What are the most consistent clinical features?
psychomotor changes
How common is relapsing following recovery from a mood episode?
50-60%
What does more than 4 relapses (mood cycles) mean?
rapid cycling
How would you differentiate type 1 and type 2 bipolar disorder?
type I: equally experience mania and depression (large amplitude on mood cycles)
type 2: experience little/no mania but largely depression
What is cyclothymia?
less extreme version of type I bipolar
What type of episode is most likely to be first with type I bipolar?
- 85% have depressive
- 10% manic
- 3-5% mixed
(90-100% will develop more episodes)
What does bipolar disease mean long term?
- symptomatic 47% of the time
- 80% of episodes are depressive
- 20% are manic or mixed
How often does anxiety accompany bipolar disorder?
- 30-70% of bipolar patients
- worst prognosis and outcomes
- DSM-5: Anxious Distress Specifier
When is MDD most often diagnosed?
children
Which treatments can be used for both mania and depression?
- neuroleptic agents
- lithium
What is the main difference between uni and bipolar depression?
insight is preserved in depression, impaired in mania
most impaired in hypomania, and severe mania
What was thought to be different about unipolar and bipolar depression?
- age of onset
- duration of episodes
- recurrent course
- genetic specificity
- differential treatment
How is depression characterised by biases?
maintaining/shifting attention
difficult to disengage from negative material
What are the neurofunctional abnormalities seen in depression?
(amygdala dysfunction and ACC activation)
- sustained amygdala response to negative stimuli
- anterior cingulate cortex appears to mediate negative attention biases
- increase lateral inferior frontal cortex action impairs the ability to divert attention from irrelevant negative information
How does an fMRI work?
detects changes in blood oxygenation and flow that occurs in response to neural activity (more active, more oxygen consumed, more blood flow to the area)
What impact does depression have on memory?
preferential recall of negative compared to positive material
(reduced recognition of all emotions except sadness)
What was the impact of an acute single dose of antidepressants on reaction to negative stimuli?
- noradrenergic antidepressants: increased recognition of happy faces
- serotonergic antidepressants, mirtazapine: decreased recognition of fearful faces
citalopram: mixed results
What was the impact of 7 day treatment of antidepressants on reaction to negative stimuli?
- noradrenergic and serotonergic antidepressants: reduced recognition of anger and fear
What does an early change in positive processing predict?
a good long term response?
Why is the clinical response to escitalopram after 6 weeks good?
early changes (first week) in: amygdala, thalamus, ACC, + insula in response to scared faces
What does an elevated baseline ACC activity in depressed patients predict?
a positive response to treatment
What do clinically useful antidepressants do?
increase synaptic monoamine concentrations (serotonin(5-HT), norepinephrine, dopamine)
What is indirect evidence of the role of 5-HT in depression?
- depletion causes depression
- suicides have reduced levels
- increase monoamine oxidase A in MDD
- low levels of 5-HT1A and 5-HT4 receptors
What is used to investigate brain pharmacology?
PET imaging
- invasive
- less optimal temporal and spatial resolution
- injected tracer (ligand)
How do we now measure 5-HT release?
- 5-HT2A agonist PET tracer
11C-CIMBI-36
What is the difference in HT release in healthy or MDD patients?
- measurable in healthy
- unmeasurable in MDD
What are the risks of using psychedelics to treat MDD?
- dysphoria
- anxiety
- nausea
- headache
What are the advantages of using psychedelics to treat MDD?
- non-addictive
- low physiological and brian toxicity
- good therapeutic index
How to psychedelics act?
stimulate serotonin 2A receptors at the synapse
What are the key features of a mental state examination?
- appearance and behaviour
- speech
- mood/affect
- thought
- perceptions
- cognition
- insight
What are the 2 different types of insight?
- objective (as seen by the practitioner)
- subjective (as reported by the patient
What should be included in a past psychiatric history?
- previous episodes?
- has there been treatment needed before?
- history of other mental illness
- previous admissions?
- collateral history?
What should be included in a family history?
- any mental illnesses?
- who?
- what are the family relationships like?
What should be included in a medication history?
- antidepressants
- antipsychotics
- mood stabilisers
- side effects
- how long?
- exact medication + dose?
- well tolerated?
- effective?
What should be included in a risk assessment?
to self - current plans - past attempts - self harm - self neglect to others - more rare from others - vulnerability?
What are the differentials for depression?
- bipolar?
- boderline personality disorder
- schizophrenia
- attention deficit disorder
Why is it important to differentiate between unipolar and bipolar MDD?
antidepressants
- ineffective in acute bipolar depression + prophylaxis
- can cause acute manic/hypomanic episodes (in bipolar)
- worsens long term course of bipolar (esp. rapid cycling), more mood episodes
What is the definition of a personality disorder?
maladaptive patterns of behaviour, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual’s culture. Develop early, inflexible and are associated with significant distress or disability
Which personality disorders can be difficult to differentiate from bipolar?
- antisocial
- borderline
- narcissistic
What is antisocial personality disorder?
pervasive pattern of:
- disregard for and violation of the rights of others
- lack of empathy
- bloated self-image
- manipulative and impulsive behaviour
What is borderline personality disorder?
pervasive pattern of:
- abrupt mood swings
- instability in relationships
- self-image, identity, behaviour and affect
- often leading to self-harm and impulsivity
What is narcissistic personality behaviour?
pervasive pattern of grandiosity, need for admiration, and a perceived or real lack of empathy
What is common between bipolar affective disorder and borderline personality disorder?
- rapid mood swings
- unstable interpersonal relationships
- impulsive sexual behaviour
- suicidality
What are common features of borderline personality disorder that aren’t features of bipolar affective disorder?
- poor self image
- fear of abandonment
- feelings of emptiness
What are common features of bipolar affective disorder that aren’t features of borderline personality disorder?
- high heritability
- grandiosity
- mood states less affected by the environment
What features are common between bipolar affective disorder and schizophrenia?
- hallucinations (50% of mania, 10% of depression)
- cognitive impairment
- depression, apathy, lack of affect, low energy and social isolation
- schizo affective shares features of both BPAD and schizophrenia
What is the main difference between schizophrenia and bipolar affective disorder?
BPAD has episodic delusions/hallucinations where as in schizophrenia they are chronic
What are the common features of bipolar affective disorder and attention deficit disorder?
- impaired concentration
- impairment of executive function
- abnormal working and short term memory
What are the main differences between ADD and BPAD?
BPAD has:
- high heritability
- recurrent depressive episodes
- mania worsened by amphetamines
What is post stroke depression?
(sometimes presistant)
- retardation in thinking and behaviour
- lesions in the left frontal lobe or basal banglia
In which areas of the brain do lesions tend to cause seizures?
- left frontal lobe
- basal ganglia
- more frontal the lesion, the more severe the symptoms
What is vascular depression?
- sub cortical dementia
- common in late life depression
What is vascular depression associated with?
white matter hyper intensities
- impacts cognitive function
- increased vulnerability to stressors
How do you manage/prevent/treat vascular depression
treat vascular risk factors:
- diabetes
- hypertension
- smoking + alcohol cessation
What possible endocrine causes can present like depression?
- hyper + hypothyroidism
- hyper + hypoparathyroidism
- hyper + hypoadreno-corticism
- hypoglycaemia
- Cushing’s syndrome
- Addison’s disease
What systemic diseases/infections can present with depression-like symptoms?
- viral
- systemic lupus erythematosus
- HIV
- pancreatic cancer
Why do systemic diseases/infections can present with depression-like symptoms?
cytokines manifested are considered to be the cause
What vitamin deficiencies can cause depression-like symptoms?
- vit B12
- folic acid
What neurological conditions can cause depression-like symptoms?
- MS
- Alzheimer’s
- Parkinsons
What medications can cause depression-like presentation?
- beta-blockers
- anti-Parkinson’s
- anti-cholinergics
- some antibiotics (ciproflaxin)
- statins
- oestrogen
- opiate pain killers
- acne medications
