Depression ☺️ Flashcards
Describe the epidemiology of depression
Affects women more than men
Roughly 20% of adults will require treatment for a mood disorder during their lives
18-44, leading cause of disability and premature death
What is the aetiology of depression
Biopsychosocial factors Biological -neurotransmitter dysfunction -comorbidities, medications -family history -birth complications, disability
Psychological
- personality traits
- low self esteem
Social -familial conflict, divorce unemployment, poverty -poor social networks -trauma, adverse childhood events
Describe the theory of the HPA axis
Describe the theory of neurotransmitters
HPA
- CRF => ACTH => cortisol, -ve feedback loop
- dysfunctional in depression => excess cortisol
Neurotransmitters
- dopamine regulates motivation, pleasure
- seretonin regulates mood, sleep, cognition
- noradrenaline regulates energy
- deficiency => depression
What are the symptoms
- core symptoms
- associated symptoms
Core symptoms
- feeling down, depressed, hopeless over the last month
- little interest, pleasure in activities
Associated symptoms
- disturbed sleep, appetite, weight changes
- fatigue
- agitation/slow movements
- poor concentration, indecisiveness
- worthlessness, excess guilt
- suicidal thoughts, ideations
What are the psychiatric differentials
Grief reaction => symptoms relate to a specific cause, self worth maintained, guilt and regret linked to specific events
Anxiety => often accompanies depression
Bipolar => depressive and manic/hypomanic episodes
Premenstrual dysphoric disorder => symptoms before menstruations, resolve after menstruation
What are the neurological differentials
Parkinsons => can coexist with depression. Pill rolling tremor, rigidity, bradykinesia
MS => can coexist with depression. Autonomic, visual, motor, sensory problems
Dementia => progresses at a slower rate
What are the endocrine differentials
Hypothyroidism => weight gain, constipation, fatigue
What are the drug differentials
Substance misuse, medications => may cause similar symptoms
What are the signs of depression
No definitive signs, may have a depressed affect, downcast, furrowed brow
May speak slowly
Watch out for evidence of self harm.
What diagnostic criteria would you use?
DSM-5
At least 5 of the following during the same 2 week period where 1 is a depressed mood or loss of pleasure
-depressed mood most of the day, nearly everyday
-decreased pleasure in all/most activities most of the day, nearly everyday
-significant changes in appetite/weight
-significant changes in sleep nearly everyday
-fatigue/loss of energy nearly everyday
-feeling worthless/excess guilt
-decreased ability to concentrate nearly everyday
-recurrent thoughts of death, suicidal ideation without a specific plan
How could you assess the severity
PHQ-9
BDI-II
Both use DSM-5 criteria
What investigations would you order
why?
FBC => fatigue may be due to anemia or infection
U&E, creatinine => kidney diseases can also present with depressive symptoms. Dysfunctional kidneys are unable to metabolize antidepressants properly
LFT => liver diseases can also present with depressive symptoms. Dysfunctional livers are unable to metabolize antidepressants properly
TFT => high TSH, hypothyroidism
Calcium => rare but hypocalcemia can present with depressive symptoms with muscle cramps and tingling in extremities
Folate. B12 => fatigue caused by pernicious anemia
How would you manage depression
-assessing suicide risk
Ask if the patient has ever had thought, attempted or has a family history of suicide
If yes => ask about their method, plans and preparations
Ask about protective factors
Identify risk factors
previous attempts at suicide, self harm or exposure to such behavior
family history of mental health problems, suicide, self harm
male
unmarried, alone
drug/alcohol dependence
If there is a risk, assess if they have adequate social support and signpost to sources of help
Consider hospitalization if the risk to themselves or other people is great.
Encourage them to go voluntarily but compulsory admission may be organized under the Mental Health Act
How would you manage depression
-psychological interventions
CBT => can be done via written materials, online, in-person or in groups
Interpersonal psychotherapy => IPT focuses on feelings whereas CBT focuses on cognitions. Aims to help improve interpersonal and interpersonal communication skills within relationships.
Behavioral activation => focuses on combating low mood by helping patients to engage in pleasurable activities more often and build their problem solving abilities
How would you manage depression
-pharmacological interventions
For a new diagnosis => SSRI’s such as citalopram and fluoxetine
For recurrence => an antidepressant that the patient responds well to
Choice of antidepressant will be influenced by polypharmacy and chronic physical health problems
