Depression Flashcards
What is depression?
Refers to both negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities)
Def: Euthymic
Normal mood
Def: Hyperthymic
Elevated mood
Def: Cyclothymic
Variable mood
Def: Anhedonia
Loss of enjoyment/pleasure
Def: Anergia
Lack of energy
Def: Amotivation
Lack of motivation
Def: Diurnal variation
Varying over the course of the day
Def: Early morning wakening
Waking at least 2 hours before expected waking time
Def: Psychomotor retardation
Subjective or objective slowing of thoughts and/or movement
Def: Stupor
Absence of relational functions (E.g. Action and speech)
What are some risk factors for depression?
- Genetic susceptibility
- Life factors - i.e. social situation e.g. single mums
- Alcohol/drug dependence
- Abuse (sexual or not) - particularly in childhood
- Unemployed
- Previous psychiatricdiagnosis
- Chronic disease
- Lack of a confiding relationship
- Urban population
- Post natal period
What are some sub-types of depression?
Psychotic depression
Cotard’s syndrome (Nihilistic delusion)
Somatic syndrome
Atypical depression
Late-onset depression
What is meant by psychotic depression?
A form of depression in which there are psychoses, occasionally paranoid, which are typically hypochondriacal and are congruent with mood
What is Cotard’s syndrome
A syndrome of severe depression in which the person believes they are dead or they are an empty shell with rotting innards
Most common in the elderly
What are some somatic symptoms of depression
- Marked loss of interest or pleasure in activities that are normally pleasurable
- Lack of emotional reactions to events or activities that normally produce an emotional response
- Waking in the morning 2 hours or more before the usual time
- Depression worse in the morning
- Objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people)
- Marked loss of appetite
- Weight loss (5 % or more of body weight in the past month)
- Marked loss of libido
What are the features of atypical depression?
- Mood reactivity (that is, mood brightens in response to actual or potential positive events)
- Significant weight gain or increase in appetite
- Hypersomnia
- Leaden paralysis (heavy, leaden feelings in arms or legs)
- Long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
What is late-onset depression?
Depression occurring for the first time in later life (>65)
What are some risk factors for late-onset depression?
- Genetic susceptibility
- Life events (i.e. loss of spouse)
- Social factors (i.e. Loneliness, financial hardship)
- Poor physical health (especially vascular disease)
What are some symptoms of depression?
- Classic triad:
- Anhdonia - loss of enjoyment/pleasure
- Anergia - lack of energy
- Amotivation
- Diurnal variation - typically worse earleier in the day
- Early morning wakening - waking at least 2 hours before the expected/normal waking time
MSE - Depression - Appearance
May be signs of personal neglect
MSE - Depression - behaviour
- Rapport is often difficult to establish
- Reduced eye contact
- Reduced facial expression
- Brow is classically ‘furrowed’
- Limited gesturing - movements may be slowed, or absent
- Psychomotor retardation - subjective or objective slowing of thoughts and/or movements
MSE - Depression - Speech
- Reduced rate of speech
- Lower in pitch
- Reduced volume
- Reduced intonation
- Increased speech latencies
- Limited content
MSE - Depression - Mood
- ‘Low, ‘down’, ‘miserable’, ‘unhappy’, ‘sad’
- Can be described as ‘flat’
- Often ‘empty’, ‘black’, ‘numb’
MSE - Depression - Affect
- Depressed i.e. low
- Reduced range (stays low throughout)
- Limited reactivity - affect doesn’t respond or react to changes in subject, context, or emotion
- May report emotional paralysis
MSE - Depression - Thought
- Form: typically normal
- Flow: thoughts are slow, pondering, can be almost absent
- Content: negative, self-accusatory, failure, guilt, low self-esteem, pessimism, delisions, suicidal thinking
- Cotard’s syndrome (nihilistic delusions)
MSE - Depression - Perception
- In most cases there is no perceptual disturbance
- Some people report increased self-reference thinking (‘people are talking about me’
- Hallucinations can occur - almost always auditory, usually second person and derogatory (‘you are a bad person and deserve to die’)
MSE - Depression - Cognition
- Subjectively, cognition is slow with complaints of poor memory
- ‘Pseudo-dementia’
- Typical deficits involve working memory, attention, and planning
- Often compounded by anxiety
MSE - Depression - Insight
- Insight is typically preserved
- People are usually aware of their symptoms - recognition is commonly intact
- However, attribution can often be affected by the illness - symptoms may be blamed on sins, physical illness, personal failings, or weakness
What is the main diagnostic criteria used for depression in the UK and Europe?
ICD-11
What are the 4 main depressive disorders recognised by ICD-11?
- Single episode depressive disorders
- Recurrent depressive disorder
- Dysthymic disorder
- Mixed depressive and anxiety disorder
What are the 3 severity classifications for depression?
Mild
Moderate
Severe
What is the ICD-11 criteria for classification of a depressive episode
A period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least 2 weeks, accompanied by other symptoms such as:
- Loss of confidence or self-esteem
- Unreasonable feeling of self-reproach or excessive and unreasonable guilt
- Recurrent thoughts of death/suicide, or any suicidal behaviour
- Complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation
- Change in psychomotor activity - with agitation or retardation (either subjective or objective)
- Sleep disturbance of any type
- Change in appetite (increase or decrease) with corresponding weight change
Criteria for mild depression
- Patient is distressed by the symptoms
- Has some difficulty continuing to function in one or more domains (E.g. Social, occupational)
- No delusions or hallucinations
Criteria for moderate depression?
- Several symptoms to a marked degree OR
- A large number of symptoms to a lesser degree
- There is usually considerable difficult functioning in multiple domains (E.g. Social, occupational)
Criteria for severe depression
- Many or most symptoms to a marked degree OR
- A few symptoms to an intense degree
- Serious difficulty in most domains (E.g. Social, occupational)
Management of mild depression
No anti-depressants
Watchful waiting and assessment within 2 weeks
Possible low-intensity interventions such as CBT
Management options for moderate-severe depression
Anti-depressants (1st line)
High-intensity psychological treatment (CBT, interpersonal therapy)
Psychiatric referral (If required)
ECT (Severe)
1st line pharmacological management of depression
SSRI
2nd line pharmacological management of depression
Switch SSRI
3rd line pharmacological management of depression
Add or swap antidepressant (E.g. SNRI, Tricyclic, MAOI)
What is ECT?
Electroconvulsive therapy
Given under general anaesthetic twice a week
Very useful in severe depression
Management of mild depression in children
- Watchful waiting for 2 weeks
- Group IPT/CBT, non-directive supportive therapy for 2-3 weeks
Management of unresponsive or moderate-severe depression in children
- Individual CBT, IPT, family therapy, psychodynamic psychotherapy 4-6 sessions
- Fluoxetine
- Sertraline or citalopram
How is response to management in depression monitored?
There are 2 main symptomatology questionnaires used for monitoring response in depression treatment:
- IDS-30-SR (30 item patient-rated scale)
- QIDS (Quick version)
