Depression and Bipolar Related Disorders Flashcards
What is the diagnostic criteria for major depressive disorder? Include amount of time and number of symptoms? READ ALL OF THESE
5 or more of the following symptoms over greater than 2 weeks:
At least one must be: Depressed mood or loss of interest / pleasure (anhedonia)
At least four must come from: SIGECAPS (minus I which is interest)
Sleep -> increased or decreased
Interest
Guilt -> feeling excessively guilty or worthless
Energy -> decreased energy
Concentration -> impairment of concentration / decision making
Appetite -> increased or decreased
Psychomotor retardation -> moving robotically or slowly, agitated in rare instances
Suicidality -> recurrent thoughts or attempted
For MDD, how often must these symptoms be present?
The criteria must be present EVERYDAY for longer than 2 weeks and represent a significant impairment in function (except for weight gain and suicidality)
What will the speech of a depressed person often be like?
Slow, monotonous, and delayed in production (sleep latency) -> thinking slow and have no emotion
What is the typical thought process in MDD? What is the most dangerous thought content?
Typical -> poverty of ideation - slowed thinking and low or no thoughts, often with negative ruminations and hopelessness / helplessness Most dangerous: psychotic depression with perceptual disturbances / command hallucinations = “you should kill your wife then yourself”
How do you distinguish between bereavement and depression? Think in respect to time course, thought content, suicidality, and self-esteem
Time course: in grief - you may still have positive emotions, and the sadness tends to come in waves, decreasing in intensity overtime In depression - persistent depression / anhedonia Thought content: Grief = thinking of the deceased. Depression = self-critical / pessimistic ruminations / guilt Suicidality: possible in both, but grief tends to be more related to joining loved ones later Self esteem: preserved in grief, though may express regret due to failing the deceased. Depression it is severely reduced.
What medical condition is depression a risk factor for?
Cardiac events / CAD in patients with pre-existing heart condition -> increased morbidity and mortality in co-occurring medical conditions -> same risk for MI as LV dysfunction
True or False, depression is responsible for over half of suicides.
True -> 2/3 of patients will contemplate suicide, 15% will complete
What is the logic with regards to keeping an MDD patient on longterm therapy?
Kind of like drug half lives to steady state: 1 previous episode: 50% chance of recurrence 2 previous episodes: 75% chance of recurrence 3 previous episodes: 90% chance After 1 episode, can try weaning off. If a second episode occurs, depending on severity, can try to wean again. 3 episodes and it’s maintenance for life.
What sleep abnormalities are present in MDD?
Increased sleep latency Decreased REM latency and greater proportion of REM sleep
How does the dexamethasone suppression test for MDD work?
Give dexamethasone -> in non-depressed people, coristol production is suppressed -> in depression, cortisol production is unchanged (increased cortisol levels in depression)
What does a positive dexamethasone test indicate?
That person with positive test + diagnosed depression is more likely to have melancholia, psychotic features, and at greater risk for suicide
Is there any clinically useful test for diagnosis of depression?
NO - sleep abnormalities and dexamethasone suppression are not specific enough lab tests
Why is Parkinson’s a risk factor for depression? How could this be treated?
By the monoamine hypothesis of depression, depletion of dopamine (a monoamine) will lead to increased depression risks -> Bupropion (NDRI) and amphetamines could be used to treat this depresion
What is the monoamine / receptor hypothesis of depression? Where in the brain does this affect?
Monoamine -> deficiency or malfunctioning in monoamines in the brain leads to depression Receptor hypothesis -> upregulation of postsynaptic neurotransmitter receptors in the setting of deficiency leads to depression -> both lack significant clinical evidence This affects just about everywhere in the brain
What are two hormonal axes changes that have been linked to depression?
Adrenal axis -> 50% have increased cortisol (think dexamethasone test) Thyroid axis -> good percentage have hypothyroidism or decreased response to TRH
What are the nonspecific brain findings in MDD? With regards to size
Increased ventricle:brain ratio with smaller whole brain volume Smaller hippocampal volume
What are the nonspecific brain findings in MDD? With regards to activity
Reduced activity in dorsolateral prefrontal cortex -> seat of reasoning = associated cognitive decline Increased activity in amygdala and ventromedial prefrontal cortex -> leads to depressed mood and anxiety -> hypoactivity of the cortex overall on PET scan
What psychological factor has the most compelling data that it causes depression? How?
Death of a parent prior to age 11 Stress alters neurotransmitters in brain, leads to neuronal loss / decrease in synapses
What is an important factor in early life which can lead to depression?
Maternal / parental neglect -> animals deprived of attachment bonds have greater chance of depression + lifetime stress overactivity
What are two cognitive / thought patterns which predispose to depression?
Cognitive distortions -> how you interpret life events / personal significance to things. Can include giving an external locus of control -> feeling powerless to change things. Learned helplessness -> helplessness and entrapment thoughts can seed depression -> nothing you do will make a difference -> i.e. infants in orphanages who stop crying
What personality factors predispose to depression? How does this relate to chronicity of MDEs?
No single factor, but personality disorders can increase risk by changing stress response to favor depression -> personality disorders and substance use increase likelihood of chronicity
Why are women thought to be more susceptible to depression?
Reproductive cycling influences hormones, and greater susceptibility to hypothyroidism
How do genetic factors relate to treatment of depression?
Polymorphisms of 5-HT receptor expression associated with response to SSRIs, or NET blockade polymorphisms associated with response to tricyclic antidepressants
Why do we treat to full remission and not just response?
For those who only achieve partial remission, there is a greater likelihood of developing additional depressive episodes
How is full remission defined for MDD?
A return to patient’s baseline level of symptom severity and functioning, which correlates with a HAMD score of <7.
What is the criteria for an MDE to be a separate episode?
>2 month separation between when MDD criteria are not met.
What is the acute phase of depression defined as? How often is the patient seen?
The time period from diagnosis until initial reduction of symptoms (typically 6-8 weeks) -> reduction in symptoms defined by >50% reduction in symptom severity, where patient no longer meets criteria for MDD -> better than 50% will respond to their first antidepressant, up to 20% will be intolerant and need a change Patient should be seen twice a month in this period
What are indications for hospitalization in the acute phase of depression and how long is the normal stay?
Suicide/homicide risk, lack of ability to care for self, rapid symptom progression, lack of social support system 5-7 days is usual
