Depression Flashcards
prevalence
10-20% lifetime
12month 2-5%
mean age of onset
27
gender distribution
M:F 1:2
equal out with older age over 55yrs
urban vs rural
more urban
types of depressive episode
mil or moderate +/- somatic syndrome
severe +/- pyschotic symptoms
ICD 10 criteria for dx depression
Major:
- low mood most days most of the time for >2wks
- loss of interest in activities previously found enjoyable
- low energy
Minor:
- loss of confidence, low self esteem
- inappropriate guilt
- thoughts of death or suicide
- poor concentration/indecisive
- psychomotor change
- poor appetite
- sleep problems
what is mild depression
2 major + 2 minor criteria
what is moderate depression?
2 major + 4 minor criteria
what is a severe depressive episode?
3 major + five minor criteria
somatic always present
+/- psychosis
what is somatic syndrome in unipolar depression
four + of the below:
- anhedonia
- lack of reaction to enjoyable events
- early morning waking
- depressed mood with diurnal variation
- psychomotor change
- appetite loss, wt loss
- loss of libido
causes of depression
- genetics
2. structural brain changes
genetics of depression
relatives: 9.1% risk
MZ concordance 40-50%
serotonin transporter gene
Structural brain changes in depression
reduced volume in hippocampus and caudate nuclei
blood flow in brain in depression
altered in
- prefrontal cortex
- anterior cingulate gyrus
- amygdala
- basal ganglia
what is the monoamine theory?
depression due to probs with serotonin, dopamine and NA levels in brain
evidence for serotonin theory?
- decreased tryptophan (serotonin precursor) foundin depressed patients
- tryptophan low diet - depression like syndrome
- antidepressants work on serotonin
- low serotonin and precursors in autopsy depressed patients
- platelet serotonin binding is decreased in depression§
evidence for NA involvement depression?
- depression in people who are given NA depleting agents
evidence for dopamine involvement
- in animals antidepressants increase dopamine
2. dopamine metabolites low in depressed patients
where is dopamine increased with antidepressants?
nucleus accumbens
aside from monoamines/genetics - biological causes of depression?
- endocrine - HPA axis -50% with cushings are depressed + 50% depressed are non suppressed on dexa test
- thyroid - 25% depressed patients have blunted TSH response to TRH
Aside from biological causes - causes of depression?
- social
2. psychological
social theories depression?
- brown + harris
- marriage
- life events
brown + harris?
increased depression in women who:
- > 3 kids under age of 14
- no confiding relationships
- not working outside home
marriage + depression?
lower rates
life events and depression?
6x increase in life events 6 months before depressive episode - loss events. Threat events = anxiety
psychological theories of depression?
- psychodynamic
- cognitive
- seligman
psychodynamic theories of depression?
freud, bowlby + klein
link w/ loss + interpersonal problems in childhood
cognitive theories of depression?
Beck (developer of CBT) says latent dysfunctional assumptions learned through early experiences activate events which lead to cycle of negative thinking and depressed mood
seligman theory depression
learned helplessness
treatment for depression is guided by?
NICE guidelines for stepped care
tx for all presentations?
Assess
Support
Psychoeducate
active monitoring and refer for any further interventions
tx for mild depression
Guided self-help
CBT
Activity scheduling
Medication trial if no work
tx for moderate and severe depression?
SSRI 1st line
increase dose
Use in combo with treatment like CBT/IPT
resistant depression tx?
- Change antidepressant class eg SNRI, TCA, MAOI
- augmentation strategies
- ECT
depression + psychosis tx?
antidepressant + antipsychotic
ECT
what are the augmentation strategies
- lithium - effective in 50%
- antipsychotics -olanzapine, risperidone, quetiapine
- T3 - well tolerated
- antidepressant - SSRI + mirtazapine
ECT indications?
- treatment resistant depression
- emergency relief of depressive symptoms eg post partum/refusing oral intake
- antidepressant meds c/i
how likely to relapse?
if one episode - 50-85% chance of another
if 2 then 80-90% chance 3rd
how long stay on meds after 1st episode?
6-9 months from remission of symtpoms
how long stay on meds if >2 episodes in recent past?
at least 2 years
how long do episodes last?
average 6 months
25% >1yr
10-20% chronic relapsing remitting course
px of depressive episode?
average no of epsiodes over 25 years = 5
25% will have 5 years no symptoms
80% risk recurrence
suicide risk depression?
- 15% completed rate
- x12 than general population
- higher risk earlier in disease
- all cause mortality is x2 general public
risk factors for future episodes?
- previous episodes
- incomplete remission
- bipolar
- poor social support
- poor physical health
- substances
- personality disorder
- unemployment
- poor compliance
what is dysthymia?
- chronic low mood but subthreshold for depression
2. may feel well for periods but chronic brooding, tiredness, sleep probs and insecurity
prevalence of dysthymia?
lifetime 6%
treatment dysthymia?
guided selfhelp
CBT
group actiity programmes
Treat with SSRIs if persistent
px dysthymia?
poor with ongoing symptoms
what is seasonal affective disorder?
controversial
- recurrent depressive episodes with seasonal pattern related to length of daylight
- possibly linked to melatonin abnormalities
tx for seasonal affective disorder?
light therapy in winter time
specific light box with sunlight wavelength light - not tanning beds!
What is atypical depression?
- depression sub-type
- depressed mood which is reactive
- hypersomnia (>10 hours)
- hyperphagia
tx atypical depression?
similar to depression
possibly better response to MAOIs than others
