Depression

Question 1

What are some risk factors for depression?

Answer 1

Genetic susceptibility
Life factors (social situation eg single parent)
Alcohol/drug dependence
Abuse
Unemployment
Previous psychiatric illness
Chronic disease
Lack of a confiding relationship
Urban population
Post natal period

Question 2

What is the definition of depression?

Answer 2

Refers to both negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities).

Question 3

What are some subtypes of depression?

Answer 3

Psychotic depression
Cotard’s syndrome
Somatic syndrome
Atypical depression
Late onset depression

Question 4

What is psychotic depression?

Answer 4

Occasionally paranoid, typically ‘mood-congruent’ or hypochondriacal

Question 5

What is Cotard’s syndrome?

Answer 5

Nihilistic delusions (eg bowels turning to dust)
More common in elderly

Question 6

What is somatic syndrome?

Answer 6

Four of the following symptoms should be present:

• Marked loss of interest or pleasure in activities
• Lack of emotional reactions to events or activities
• Waking in the morning 2 hours or more earlier than usual
• Depression worse in the morning
• Objective evidence of marked psychomotor retardation or agitation (reported by other people)
• Marked loss of appetite
• Weight loss (5% or more of body weight in the past month)
• Marked loss of libido

Question 7

What is atypical depression?

Answer 7

Mood reactivity (mood brightens in response to positive events)

Two (or more) of the following:
- Significant weight gain or increase in appetite
- Hypersomnia
- Leaden paralysis (heavy, leaden feelings in arms or legs)
- Long-standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment

Question 8

What is late onset depression?

Answer 8

Depression that occurs for the first time in later life
Slower response to antidepressants

Question 9

What is the classic triad of depression symptoms?

Answer 9

Anhedonia
Anergia
Amotivation

Question 10

What are some other symptoms of depression other than the classic triad?

Answer 10

Diurnal variation
Early morning wakening (at least 2 hours)
Symptoms present for at least 2 weeks

Question 11

What are some potential appearance signs of depression on MSE?

Answer 11

Signs of personal neglect

Question 12

What are some potential behaviour signs of depression on MSE?

Answer 12

Difficult to establish rapport
Reduced eye contact
Reduced facial expression
Furrowed brow
Limited gesturing
Psychomotor retardation

Question 13

What are some potential speech signs of depression on MSE?

Answer 13

Reduced rate of speech
Lower in pitch
Reduced volume
Reduced intonation
Increased speech latencies
Limited content

Question 14

What are some potential mood signs of depression on MSE?

Answer 14

‘Low’, ‘down’, ‘miserable’, ‘unhappy’, ‘sad’
‘Flat’
‘Empty’, ‘black’, ‘numb’

Question 15

What are some potential affect signs of depression on MSE?

Answer 15

Depressed (ie low)
Reduced range
Limited reactivity
May report emotional paralysis

Question 16

What are some potential thought signs of depression on MSE?

Answer 16

Form: typically normal
Flow: slow, pondering, almost absent
Content: negative, self-accusatory, failure, guilt, low self-esteem, pessimism, delusions, suicidal

Question 17

What are some potential perception signs of depression on MSE?

Answer 17

Most people no perceptual disturbance
Increased self-referential thinking in some
Hallucinations can occur (almost always auditory and usually usually second person and derogatory)

Question 18

What are some potential cognition signs of depression on MSE?

Answer 18

Slow with complaints of poor memory
‘Pseudo-dementia’
Deficits in working memory, attention, planning

Question 19

What are some potential insight signs of depression on MSE?

Answer 19

Typically preserved
Usually aware of symptoms but attribution can be affected by illness (eg blaming symptoms on sins, personal failing, weakness)

Question 20

What are the core diagnostic features of depression?

Answer 20

At least 2/3 of the following:

• Depressed mood to a degree that is definitely abnormal, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks
• Loss of interest or pleasure in activities that are normally pleasurable
• Decreased energy or increased fatiguability

Question 21

What are some additional diagnostic features of depression?

Answer 21

An additional symptom/symptoms from the following to make a total of 4:

• Loss of confidence/self-esteem
• Unreasonable feeling of self-reproach or excessive and unreasonable guilt
• Recurrent thoughts of death/suicide
• Diminished ability to think or concentrate, such as indecisiveness or vacillation
• Change in psychomotor activity (agitation or retardation)
• Sleep disturbance
• Change in appetite (increase or decrease) with corresponding weight change

Question 22

How can the severity of depression be assessed?

Answer 22

Rating scales: HRSD, MADRS
Number of symptoms:
- Moderate = 2 core plus 4 others
- Severe = 3 core + 5 others

Question 23

What is the management of mild depression?

Answer 23

Watchful waiting and assess within 2 weeks
Consider offering low intensity psychosocial interventions (CBT)
Antidepressants not recommended

Question 24

What is the management of moderate-severe depression?

Answer 24

Antidepressant with high-intensity psychological treatment (CBT or IPT)
- First line: SSRI (eg escitalopram, sertraline, mirtazapine)
- Second line: switch SSRI
- Third line: switch class (eg SNRI, tricyclic, MAOi)
Urgent psychiatric referral if active suicidal intentions, putting themselves or others at risk of harm, psychotic, severely agitated, self-neglecting
ECT reserved for most severe inpatient cases

Question 25

What is the treatment of mild depression in young people?

Answer 25

Watchful waiting 2 weeks
Group IPT/CBT, non-directive supportive therapy for 2-3 weeks

Question 26

What is the treatment of unresponsive or moderate-severe depression in young people?

Answer 26

1) Individual CBT/IPT/family therapy/psychodynamic psychotherapy 4-6 sessions
2) Fluoxetine
3) Sertraline or citalopram