Depression Flashcards
What is psychiatry?
medical speciality concerned with the diagnosis, treatment and prevention of mental health disorders
What is the different between a psychiatrist and a psychologist?
- psychiatrist = medical degree, assess, diagnose, treat
- psychologist = pyschology degree, postgrad clinical psycology, asses, formulate, treat
work together and very similar
what is the incidence of psychiatric conditions in the UK?
1 in 4 per year in UK
How many people worldwide are estimated to have a psychiatric condition?
500 million people globally
What is the diagnostic hierarchy in psychiatry?
the order in which disorders need to be excluded before reaching a diagnosis
- organic
- schizophrenia and related disorders
- bipolar spectrum disorders
- depressive disorders
- anxiety and somatoform disorders
- personality disorders
What is an organic disorder in psychiatry?
change in mental function that is secondary to physical processes rather than a psychiatric illness
Why are organic disorders assessed for first?
- mimic psychiatric disorders
- usually life-threatening that need immediate treatment
- usually reversible
How are anxiety disorders and personality disorders diagnosed?
- usually a diagnosis of exclusion
What is psychosis?
altered relationship with reality
What is a delusion?
- fixed false belief
- held despite evidence to the contrary
- outwith sociocultural norms
What is a hallucination?
sensory perception in the absence of external stimuli
What is an illusion?
misperception of real external stimuli
What is depression?
pathologically low mood that impacts on function
What is mood?
subject feeling of sustained emotion
patient will report
What is affect?
Objective immediate conveyance of emotion
What is euthymia?
Normal mood state
What is mania?
elevated mood
What is hypomania?
mildly elevated mood
What is subsyndromal depression?
mild depression
What is bipolar disorder?
more than 2 mood disturbances one of which is mania
What causes depression?
- biological
- psychological
- social
What are the biological causes of depression?
- Genetic link
- medical comorbidities (hypothyroid, heart failure, MS, CVA)
- psychiatric comorbidities (schizophrenia)
- medications (steroids in cushings)
- neurochemical ( low serotonin, noradrenalin, dopamine)
- neuroendocrine (low t3, tsh, high cortisol)
Describe the pathogenesis of depression from a biological point of view
neurochemical theory - monoamine hypothesis
+ serotonin cant be measured in the brain, but metabolites can be measured in the CSF = decreased
+ antidepressants work
+ neurochemical blockers induce depression
- antidepressants dont work immediately
- antidepressants dont always work
What are monoamines?
- serotonin
- dopamine
- neoradrenaline
What are the psychological causes of depression?
- personality traits (anxious, obsessive)
- personality disorders
- maladaptive coping skills
- adverse life events (losses)
What are the social causes of depression?
- poor social support
- socioeconomic disadvantage
- northernization = the more north of the equator, the more likely to be depressed
Describe the epidemiology of depression
- point prevelance = 4-6%
- lifetime incidence = 20%
- any age (mean 30)
- female:male = 2:1
5 mean episodes per lifetime
What are the clinical features of depression
Core symptoms:
= low mood +/- anhedonia +/- fatigue
every day for >2 weeks
How id depression diagnosed?
using guidelines = ICD-10 from WHO
What is anhedonia?
Loss of enjoyment/pleasure in things you used to enjoy
What are the associated symptoms of depression?
Biological:
- diurnal variation
- insomnia
- decreased appetite
- decreased weight
- decreased libido
- constipation
- amenorrhoea
(tend to apply in more severe forms of depression)
What are the cognitive features of depression?
- decreased concentration
- slow/negative thinking
- guilt
- loss of self esteem
- hopelessness
- suicidality
Beck’s cognitive triad (negative thinking about the world, the future and oneself)
What cognitive distortions are linked with depression?
- minimizing
- magnifying
- arbitrary
- inference
- selective abstraction
- personalization
- over-generalisation
- catastrophizing
What is psychotic depression?
If depression becomes severe enough it can tip over into psychosis
- delusions: mood congruent (‘nihilistic’ - match the mood of depression)
- guilt
- poverty
- hypochondriasis
- persecutory
- hallucinations: auditory second person “you’re stupid”
What is cotard’s syndrome?
self or part of self is dead
How is depression categorised?
mild: >2 core +/- 2 associated, function ok
moderate: >2 core +/- 4 associated, function decreased
severe: >2 core +/- 6 associated, function severely decreased
if psychosis present = severe
What are outcomes of depression?
- recurrent depressive disorder
- substance misuse
- anxiety
- suicide (attempted/completed)
- cardiovascular disease
What are the differentials of depression?
- dysthymia
- atypical depression (SAD)
- adjustment reaction
- grief
What is dysthymia?
mildly decreased mood more more than 2 years, but not enough to be classed as depression
What is cyclothymia?
alternating mild depression and mild mania, but not enough to be classed as bipolar
What is adjustment reaction?
- adaptation to stressor
- can include low mood
- onset <1 month from stress
- duration <6 months max
What is the Kubler-Ross model of grief?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Describe abnormal grief
- intense
- prolonged (> 6 months)
- delayed (2 weeks)
- absent (inhibited)
How is depression assessed?
- clinical history
- risk assessment
- MSE
- physical exam
- baseline bloods
How is life threatening depression treated?
(= suicidal, self neglect)
- may need hospitalisation
- if refusing treatment, may need to be detained under the mental health act
What is the biological treatment for depression?
Moderate depression: antidepressants
Severe: antidepressants + antipsychotics, ECT
Name examples of SSRIs?
(selective serotonin reuptake inhibitors)
- citalopram
- fluoxetine
- sertraline
[also: SNRI, SARI, NASSA, NRI, DRI, NRDI, SPARI]
Name examples of TCAs
(tricyclics)
- amitryptiline
- doxepine
- amoxapine
Name examples of MAOIs
(monoamine oxidase inhibitors)
- isocarboxid
- phenelzine
- moclobemide
Describe the normal role or serotonin
Seortonin is produced in the neurons of the central nervous system and is released from the presynaptic cell, crossing the synapse, attaches to a receptor to induce a messenger in the postsynaptic cell. Then it gets reabsorbed in the presynaptic cell.
How do SSRI’s work?
block the reuptake of serotonin, which increases the amount pr3esent in the synapse and magnifies its effects
Which antidepressent can be used to increase alertness in someone experiencing fatigue with depression?
Venlafaxine (SNRI)
Which antidepressent can be used to decrease alertness in someone experiencing insomnia with depression?
Mirtazepine (NASSA)
What are the side effects of SSRIs?
- nausea
- vomiting
- weight gain
- dizziness
- anxiety
- mania
- serotonin syndrome
- cardiac effects
be aware of discontinuation syndrome
What is the response rate of antidepressants?
- 33% will respond immediately
- 33% will respond after switching antidepressants
- 33% wont respond at all
What are first line antidepressants?
SSRIs
What are second line antidepressants?
TCAs
What are third line antidepressants?
MAOIs
How do TCA’s work?
block serotonin, noradrenaline reuptake
usually more potent than SSRIs but more adverse effects
What are the side effects of TCAs?
- antiadrenergic (decrease BP)
- anticholinergic (cant see, cant pee, cant shit, cant spit)
- more profound ECG changes (arrythmias, QTc prolonged)
How do MAOIs work?
monoamine oxidase = enzyme that breaks down serotonin, noradrenaline and dopamine in the CNS
MAOIs inhibit this enzyme
What are the side effects of MAOIs?
hypertensive crisis = ‘cheese reaction’
MAO-A also in GI tract that breaks down tyramine (found in cheese and other foods)
Using MAOIs can cause this - patients on strict avoidance diet
If blocked, increases BP
What is ECT?
electrotherapy
- controlled seizure and anaesthetic
- used in depression, mania, catatonia
- more effective than drugs
can promote healing of certain cells and increases neurotransmitters, redirects blood flow
What are the side effects of ECT?
- anaesthetic risks
- memory (confused)
- in rare cases - memory loss
What are the primary talking therapies used in the treatment of depression?
- CBT
- Psychotherapy
- Family therapy
What is CBT?
thoughts, feelings, behaviours and physical is interlinked
by working on thoughts, can improve other aspects of life
usually intensive ~12 weeks
teaches skills for life
What are the social treatments of depression?
- occupational therapy (activity scheduling)
- social workers (housing, financial)
- Employment
