Depression + Depressive Disorders Flashcards
Major depression is characterised by disturbances of mood, speech, energy and ideas.
What are the characteristic features of depression?
Include: => Mood => Speech => Energy => Ideas => Cognition => Physical => Behaviour => Hallucinations
Mood : depressed, miserable or irritable
Speech : impoverished, slow, monotonous
Energy : reduced, lethargic, lacking motivation
Ideas : feelings of futility, guilt, self-reproach, unworthiness, hypochondriacal, preoccupation, worrying, suicidal thoughts, delusions of guilt, nihilism, persecution
Cognition : impaired learning, pseudo-dementia in elderly patients
Physical : insomnia (esp. waking up early), poor appetite, weight loss, constipation, loss of libido, erectile dysfunction, body pain
Behaviour : retardation or agitation, poverty of movement and expression
Hallucinations : auditory - hostile and critical
Patients often describe their symptoms in physical terms.
What are the symptoms patients experience?
Marked fatigue + headache => 2 most common physical symptoms
Describe the world as ‘grey’
Describe themselves as ‘lacking interest for living’, ‘devoid of pleasure’ (anhedonia)
Anxiety and panic attacks common
*Symptoms should last at least 2 weeks and cause significant incapacity i.e. trouble working or relating to others to be classed as an illness
What symptoms are seen in severe depression?
Diurnal variation in mood i.e. feeling worse in the morning after waking up feeling apprehensive
Suicidal ideas : more frequent, prolonged, intrusive
Delusions of guilt, persecution
Negative auditory hallucinations
In severe depression in the elderly, concentration and memory can be affected => pseudo dementia
=> Elderly also experience nihilism
Suicide risk higher in those with depression
How common is depression?
Who does depression affect?
5% of depression at one point in time ; 3% dysthymia
Women > men
Depression doesn’t increase with age
No difference in ethnicity, social economic group
Higher rates (2-3x) in those separated or divorced
Depression is becoming more common and frequently found in the presence of:
=> Physical disease i.e. chronic, stigmatising, painful, excessive alcohol use
=> Social stresses i.e. loss events including separation, redundancy, bereavement
=> Lack of social support - no one to confide in
=> Depressed people with physical disorder view themselves as more disabled and sick
INFO CARD
What is dysthymia?
Dysthymia is a mild or moderate chronic depressive illness that lasts intermittently for 2 years or more
Characterised by: => tiredness => low mood => lack of pleasure => low self-esteem
Mood relapses and remits with several weeks of feeling well followed by feeling unwell
What is seasonal affective disorder?
Recurrent episodes of depression occurring during winter months in the northern hemisphere
Symptoms: => hypersomnia => increased appetite with carbohydrate craving => weight gain => profound fatigue
Peurperal affective disorders:
- Baby blues : brief episodes of emotional irritability, tearfulness in 50% of women 2-3 days after postpartum, resolves spontaneously
- Post-partum psychosis : within first 2 weeks of delivery. Patients experience disorientation and confusion.
=> severely depressed patients have delusional ideas that their child is deformed or evil
=> lead to thoughts of killing the child or committing suicide - Non-psychotic postnatal depressive disorders :
=> 1st postpartum years in 10% of mothers
=> risk factors i.e. first pregnancy, poor relationship with partner, poor bonding with baby
What are the differential diagnosis for depression?
Other psychiatric disorders: => Alcohol misuse => Borderline personality disorder => Dementia => Delirium => Schizophrenia => Normal and pathological grief
Organic (secondary) affective illness : Physical causes that are necessary and sufficient as a cause => Cushing's syndrome => Thyroid disease => Hyperparathyroidism => Corticosteroid treatment => Brain tumour
How do you investigate depressive disorders?
A detailed history is very important => helps to exclude differentials to i.e. alcohol misuse, relationship with partner
Investigations: => FBC, U&E, serum creatinine, eGFR => LFT inc. glutamyl transpeptidase => Serum calcium => ESR / CRP => Thyroid function test
Other tests: => Serum cortisol (morning and evening ) => Antinuclear antibody => Chest x-ray => EEG or brain scan
What is the pathology underlying depression?
- Monoamine deficiency
=> Chronic + ongoing depletion of monoamine due to raised activity of monoamine oxidase - Serotonin neurotransmitter system is down regulated
- Genetic link?
=> Risk of unipolar depression 3x higher in first degree relative - Exogenous steroids + Cushing’s syndrome assoc. with depressive symptoms
How is sleep affected in depression?
Reduced time between onset of sleep and REM sleep (shortened REM latency) and reduced slow-wave sleep seen in depression
What is the physical, psychological and social treatment overview for depression?
Physical:
=> Cessation of depressive drugs (alcohol, steroids)
=> Regular exercise (good for mild to moderate depression)
=> Antidepressants
=> Adjunctive i.e. lithium if no response to 2 different antidepressants
=> Electroconvulsive therapy if (resistant) depression is life threatening or non-responsive
Psychological:
=> Education & regular follow up by the same HCP
=> Cognitive behaviour therapy
=> Other psychotherapies i.e. couple, family, interpersonal
Social:
=> Financial i.e. eligible for benefits, debt counselling
=> Employment i.e. acquiring or chaining a job or career
=> Housing i.e. adequate, secure tenancy, safe, social neighbourhoods
=> Young children i.e. child support
CBT is recognised to be as effective in mild-moderate depression as anti-depressants => should be offered as first choice treatment.
CBT is also effective in preventing a relapse
How does CBT work?
=> Individual CBT more effective than group CBT
CBT aims to reverse the negative cognitive triad the patient has about:
- themselves
- their situation
- their futures
CBT tries to identify negative thoughts that maintain the negative perception.
This includes:
=> Catastrophizing e.g. making a mountain from a mole hill
=> Over-generalising e.g. I failed an exam therefore I am a failure
=> Categorical thinking e.g. all or nothing - my work is either good or very bad
CBT then tries to test logic of these thoughts by:
=> Looking at the evidence in therapy i.e. did you pass the other exams you took?
OR
=> Behavioural experiments i.e. showing the “very bad work” to a colleague and asking their opinion
Other psychotherapies:
- Interpersonal psychotherapy : focuses on interpersonal relationships involved in or affected by the patient’s illness using problem solving techniques to help find solutions
- Couple therapy : effective if it is the relationship resulting in depression
- Family therapy : effective in helping family solve problems but also supporting family in helping the patient get better
INFO CARD
How do selective serotonin reuptake inhibitor (SSRI) work?
SSRI selectively inhibit reuptake of monoamine serotonin (5HT) within the synapse.
Examples: => citalopram => fluoxetine => paroxetine => sertraline
SSRI have fewer adverse affect than tricyclic antidepressants
What are the most common side effects of SSRI?
Nausea & vomiting
Headache
Diarrhoea
Dry mouth
Erectile dysfunction / loss of libido
Insomnia & paradoxical agitation can occur when first starting drugs
Adolescents may develop suicidal thoughts
Risk of bleeding (due to inhibitor of serotonin uptake by platelets during aggregation)
Restless leg syndrome
Hyponatraemia
What is serotonin syndrome?
Toxic hyper-serotonergic state caused by indigestion of 2 or more drugs that increase serotonin levels e.g. SSRI combined with monoamine oxidase inhibitor
What is serotonin syndrome?
Toxic hyper-serotonergic state caused by indigestion of 2 or more drugs that increase serotonin levels e.g. SSRI combined with monoamine oxidase inhibitor or a tricyclic antidepressant
Symptoms: hyperthermia, agitation, confusion, tremor, diarrhoea, tachycardia and hypertension
=> Medical Emergency
What are tricyclic antidepressants?
Tricyclic antidepressants potentiate the action of monoamines, noradrenaline and serotonin by inhibiting their reuptake into nerve terminals.
E.g. amitriptyline, nortriptyline, dosulepin, imipramine most commonly used TCAs
TCA now rarely used for depression due to side effects ; more commonly used in chronic pain
What are the adverse effects of tricyclic antidepressants?
Antimuscarinic effects: => Dry mouth => Constipation => Tremor => Blurred vision => Urinary retention
Cardiovascular effects:
=> QT prolongation
=> Arrhythmias
=> Postural hypotension
Convulsants activity:
=> Lowered seizure threshold
Other effects:
=> Weight gain
=> Sedation
=> Mania (rare)
How do serotonin and noradrenergic antidepressants work?
SNRI block different neurotransmitters.
=> Dual acting agents (serotonin and noradrenaline reuptake inhibitors - SNRI) i.e. Duloxetine ; Venlafaxine (less potent SNRI)
=> Mirtazapine is a noradrenaline and selective serotonin antagonist. Side effects sedation and weight gain. No sexual adverse effects and can be given at night to help with sleep
How do monoamine oxidase inhibitor work?
Monoamine oxidase inhibitors act by irreversibly inhibiting intracellular enzymes monoamine oxidase A and B => increase of noradrenaline, dopamine and serotonin in the brain.
Antidepressants can take 1-3 weeks to show effects.
Regular follow up, especially in weeks 1-6 should accompany prescription of antidepressants to increase adherence
SSRI => 1st line treatment
Alternative agent should be conserved at week 4 in absence of any response
If you stop antidepressant therapy immediately => relapse
If 2 antidepressants trials have failed, adding a 2nd antidepressants or drug i.e. lithium may be beneficial
CBT + antidepressants => additive beneficial effect
INFO CARD
When is electroconvulsive therapy used?
Electroconvulsive therapy (ECT) is used in severe, life-threatening depressive illness, especially if psychotic symptoms are present
=> used if patient is suicidal, refusing to eat or drink or when rapid resolution is needed
=> ECT performed under general anaesthetic
What is the prognosis of depression?
=> Depression produces greater disability than angina, arthritis, asthma and diabetes
=> Most patients recover by 6 months in primary care and 12 months in secondary care
What are the two screening questions for depression?
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
A ‘yes’ to either of the above should prompt a more in depth assessment.
Hospital Anxiety and Depression (HAD) scale
=> Consists of 14 questions - 7 for anxiety and 7 for depression.
=> Each item is scored from 0-3 and produces a score out of 21 for both anxiety and depression
=> Severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Patient Health Questionnaire (PHQ-9)
=> Asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
=> 9 items which can then be scored 0-3 includes items asking about thoughts of self-harm
=> Depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
NICE use the DSM-IV criteria to grade depression:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
- Mild depression:
Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
- Symptoms or functional impairment are between ‘mild’ and ‘severe’
- Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms
