Depression - General Flashcards
What are three points which are not stated in ICD criteria but must be the case for a diagnosis of depression to be made?
Symptoms must be clearly abnormal for the individual, they must persist and they must interfere with normal functioning to some degree.
What are the 2 general ICD-10 criteria which MUST be present for the patient to be diagnosed as having depression?
The depressive episode should last at least two weeks, and there should be no evidence of previous manic or hypomanic episodes.
What are the three features under ICD-10 criteria B (core features) for the diagnosis of depression? How many of these must be present for a diagnosis of depression to be made?
Low mood, anhedonia and lack of energy/fatigue. At least 2/3 of these features must be present for a diagnosis to be made.
In criteria B of the ICD-10 depression features, when should low mood be present?
Present for most of the day, almost every day, largely uninfluenced by circumstances.
What are the 7 features listed under criteria C for the ICD-10 diagnosis of depression?
Loss of confidence/self-esteem, unreasonable guilt, suicidal thoughts/behaviours, decreased concentration, psychomotor agitation/retardation, sleep disturbance, change in appetite.
What is the most common sleep disturbance to be seen in depression?
Early morning wakening
What are somatic symptoms?
Various bodily sensations that a depressed individual perceives as unpleasant or worrisome.
Briefly describe mild depression?
A few symptoms of depression are usually present. The patient is often distressed by these but will probably be able to continue with most activities.
How is mild depression usually managed?
Normally managed in primary care only, and often with no treatment as the episodes will get better by themselves.
According to ICD-10, what defines moderate depression?
2/3 of criteria B must be present, and some additional features from criteria C to make at least 6 features from criteria B and C together.
According to ICD-10, what defines severe depression?
3/3 of criteria B must be present, and some additional features from criteria C to make at least 8 features from criteria B and C together.
Severe depression can be further divided depending on the presence or absence of what?
Psychotic symptoms
Describe some features of a patient with psychotic depression?
These patients will typically be paranoid, have ‘mood congruent’ i.e. depressive, delusions or hallucinations and can sometimes by hypochondriacal.
What is Cotard’s syndrome? Who is it mostly seen in?
A subtype of psychotic depression where people deny their own existence or believe that a part of them does not exist. It is more common in the elderly.
How may the mood in depression be?
Depressed, miserable or irritable
How may a person with depression’s speech be?
Impoverished, slow, monotonous
How would you describe a person with depression’s energy?
Reduced, lethargic, lacking motivation
What are some ideas that a person with depression might have?
Feelings of futility/guilt/unworthiness, hypochondriacal preoccupations, suicidal thoughts
What are some cognitive features of depression?
Impaired learning and concentration, pseudodementia in older patients
What are some physical features of depression?
Insomnia, poor appetite and weight loss, constipation, sexual dysfunction, bodily pains
What are some behavioural features of depression?
Psychomotor retardation or agitation, poverty of movement and expression
In more severe forms of depression, diurnal variation can occur. What is the usual pattern of this?
Patients feel worse in the morning and gradually get a little better throughout the day
What type of hallucinations are most commonly seen in depression?
2nd person auditory (often insulting them or suggesting suicide)
What are the 3 main groups of people who are at an increased risk of depression?
Females, the unemployed and those who are separated/divorced
What are some social factors which often coincide with depression?
Physical illness, excessive/chronic alcohol use, loss events, interpersonal difficulties, lack of social support
What are some differential diagnoses of depression?
Other psychiatric disorders, Cushing’s disease or excessive steroid treatment, thyroid disease, hyperparathyroidism, brain tumour (rare)
What are some physical treatments for depression?
Stopping depressing drugs, regular exercise, anti-depressants and adjunctive drugs, ECT
When should ECT be used as a treatment for depression?
If the depression is life threatening (e.g. not eating or drinking) or non-responsive
What are are psychological treatments for depression?
Education and regular follow up, CBT, other psychotherapies e.g. couples, family, interpersonal
What are some social treatments for depression?
Sort finances, acquiring or changing job, good housing, child support
What is the most effective treatment (generally) for depression?
A mixture of CBT and an anti-depressant
How would you describe CBT?
It involves the identification of negative automatic thoughts that maintain the negative perceptions which feed depression. It then tests the logic of these thoughts
What are some examples of the negative automatic thoughts which occur in depression which get tested by CBT?
Catastrophising, over-generalising and categorical thinking
What is the evidence for CBT?
Good evidence that it is as effective as anti-depressants for the treatment of mild-moderate depression and should be offered as a 1st choice treatment. It is also effective at reducing the risk of relapses.
What is interpersonal therapy?
Focuses on interpersonal relationships involved in or affected by the depression and uses problem solving techniques to find solutions.
According to NICE, what is the management for mild-moderate depression?
Low intensity psychological interventions
According to NICE, if there is no response to low intensity psychological therapy OR there has been a past history of moderate-severe depression OR the depression has been present for more than two years, what are the next steps?
High intensity psychological interventions OR an anti-depressant (usually SSRI)
According to NICE, if high intensity psychological interventions OR an anti-depressant (usually SSRI) is tried to no effect, what is the next step?
Combine the two
According to NICE, what are the treatment options for a complex/severe depression?
ECT, augment with anti-psychotic, inpatient care
When should patients with depression be treated as inpatients?
When they are at risk of suicide, self-harm or neglect
If a medication for depression does not seem to be working, what could be some causes for this?
Non-concordance, incorrect diagnosis, substance misuse, physical illness, social factors need sorted first
If a medication is not working for a patient and you have addressed all likely causes and think the treatment needs to be altered, what are some options?
Increase dose, change drug, combine drugs, augment with anti-psychotic or lithium
What are the most common combinations of drugs to be used in depression?
SSRI or SNRI + mirtazapine
What are the 3 things which should be done before starting anti-depressants?
Get ratings of depressive symptoms so you can compare the effect later, warn patients about side effects and that they will likely be transient, arrange follow-up for 1-2 weeks later
What should you tell a patient about continuing their anti-depressant for the recommended length of time?
This will greatly reduce the risk of relapse and will not result in addiction
Why is it important to look out for elderly people with depression presenting with ‘dementia’?
This can just be caused by the depression or certain medications and is treatable
Cognitive impairment in depression occurs as a result of what?
Underlying brain dysfunction
What are some cognitive deficits which can be seen in depression?
Poor attention, poor memory, slowed reaction time, impairments in planning
What is the main neuroendocrine change in depression? What does this lead to?
Chronically raised cortisol levels which leads to disturbances in noradrenaline and serotonin transmission
What happens to hippocampal volume as depression continues?
It decreases
On mental state examination, what are some features of depression that you may list under ‘appearance and behaviour’?
Reduced facial expressions, furrowed brow, decreased eye contact, limited gesturing, difficult to establish rapport
On mental state examination, what are some features of depression that you may list under ‘speech’?
Reduced rate, pitch, volume and intonation, increased speech latencies, limited content
On mental state examination, what are some features of depression that you may list under ‘mood’?
Low/miserable/unhappy
On mental state examination, what are some features of depression that you may list under ‘affect’?
Depressed mood, limited reactivity, reduced range (i.e. stays low throughout)
On mental state examination, what are some features of depression that you may list under ‘thought’?
Normal form, can be slow and sometimes absent, can be of negative content (e.g. failure, guilt), delusions and paranoia can occur
What are some examples of self-referential thinking which can be seen in depression?
Increased sensitivity to criticism, self-conscious in busy places, feeling under scrutiny
On mental state examination, what is a feature which doesn’t always occur in depression but could be listed under ‘perception’?
Hallucinations
On mental state examination, what are some features of depression that you may list under ‘cognition’?
Typically slow, may complain of poor memory, planning and attention
What will a person with depression’s insight be like?
Typically preserved, but may attribute depression to other things e.g. sins, personal failings
