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Y4 Psychiatry: Conditions > Depressive Disorder > Flashcards

Depressive Disorder Flashcards

1
Q

What is depressive disorder?

A

Depressive disorder is an affective mood disorder characterized by a persistent low mood , loss of pleasure and/or lack of energy accompanied by emotional, cognitive and biological symptoms.

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2
Q

What is the heritability of depression?

A

Monozygotic twin studies show the heritability of depression as 40– 50% , and it is likely that multiple genes are involved.

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3
Q

Briefly describe the monoamine hypothesis

A

The monoamine hypothesis states that a deficiency of monoamines (noradrenaline , serotonin and dopamine) causes depression; this is supported by the fact that antidepressants which increase the concentration of these neurotransmitters in the synaptic cleft, improve the clinical features of depression.

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4
Q

How does the HPA axis affect depression?

A

Over-activity of the hypothalamic– pituitary– adrenal (HPA) axis has been linked to depression.

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5
Q

What are the predisposing factors for depression?

Note: biological, psychological and social

A

Biological

  • Female gender (2:1)
  • Postnatal period
  • Genetics: 40– 50% monozygotic concordance rates, family history
  • Neurochemical: ↓ serotonin, ↓ noradrenaline, ↓ dopamine
  • Endocrine: ↑ activity of HPA axis
  • Physical co-morbidities
  • Past history of depression

Psychological

  • Personality type
  • Failure of effective stress control mechanisms
  • Poor coping strategies
  • Other mental health co-morbidities (e.g. dementia)

Social

  • Stressful life events
  • Lack of social support
  • More common in asylum seeker and refugee population
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6
Q

What are the precipitating factors for depression?

Note: biological, psychological and social

A

Biological

  • Poor compliance with medication
  • Corticosteroids

Psychological

  • Acute stressful life events (e.g. personal injury, loss of loved one, bankruptcy)

Social

  • Unemployment
  • Poverty
  • Divorce
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7
Q

What are the perpetuating factors for depression?

Note: biological, psychological and social

A

Biological

  • Chronic health problems (e.g. diabetes, CCF, COPD and chest pain syndromes)

Psychological

  • Poor insight
  • Negative thoughts about self, the world and the future (Beck’s Triad)

Social

  • Alcohol and substance misuse
  • Poor social support
  • ↓ Social status
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8
Q

What are the risk factors for depression?

Note: FF, AA, PP, SS

A
  • Female
  • Family history
  • Alcohol
  • Adverse events
  • Past depression
  • Physical co-morbidities
  • ↓ Social support
  • ↓ Socioeconomic status
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9
Q

Globally, how many people in the world are thought to have depression?

A

350 million.

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10
Q

What age is onset of depression most common?

A

Men: 40s.

Women: 30s.

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11
Q

What are the core symptoms of depression?

A
  1. Anhedonia (lack of interest in things which were previously enjoyable to the patient)
  2. Low mood (present for at least 2 weeks)
  3. Lack of energy
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12
Q

What are the cognitive symptoms of depression?

A
  • Lack of concentration
  • negative thoughts
  • Excessive guilt (feelings of worthlessness or excessive of inapproapriate guilt, nearly every day)
  • Suicidal ideation
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13
Q

What are the biological symptoms of depression?

A
  • Diurnal variation in mood (DVM)
    • The patient’s low mood is more pronoucned during certain tiems of the day, usually in the morning
  • Early morning wakening (EMW)
    • Waking up to 2 hours earlier than they usually would premorbidly
    • In atypical depression there may be hypersomnia (excessive sleep)
  • Loss of libido
  • Psychomotor retardation (slow speech and movement)
  • Weight loss and loss of appetite
    • In atypical depression weight gain and increased appetite may occur
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14
Q

What are the psychotic symptoms of depression?

A
  • Hallucinations
    • Normally second person auditory hallucinations
  • Delsuoins
    • They are usaully hypochondrical guilt, nilhilistic or persecutory in nature
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15
Q

What are the main symptoms of depression?

Note: DEAD SWAMP

A
  • Depressed mood
  • Energy loss
  • Anhedonia
  • Death thoughts
  • Sleep disturbance
  • Worthlessness or guilt
  • Appetite of weight change
  • Mentation (concentration) reduced
  • Psychomotor retardation
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16
Q

Briefly describe Beck’s congnitive triad

A

Beck’s cognitive triad represents three types of negtive thought. The triad invovles negative thoughts about:

  1. Self
  2. World/ environment
  3. Future
17
Q

Briefly describe the ICD-10 Classification of depression

Note: mild, moderate, severe and severe with psychosis

A

Mild depression = 2 core symptoms + 2 other symptoms

Moderate depression = 2 core symptoms + 3– 4 other symptoms

Severe depression = 3 core symptoms + ≥4 other symptoms

Severe depression with psychosis = 3 core symptoms + ≥4 other symptoms + psychosis

18
Q

Briefly describe the MSE for depression

A

Appearance: signs of self-neglect, thin, unkempt, depressed facial expression and tearful.

Behaviour: poor eye contact, tearful, psychomotor retardation, slow movements, slow responses, may sometimes present with psychomotor agitation.

Speech: may be slow, non-spontaneous, reduced volume and tone.

Mood: low (subjectively) and depressed (objectively).

Thought: pessimistic, guilty, worthless, helpless, suicide and delusions (if psychotic).

Perception: second person auditory hallucination (often derogatory).

Cognition: imparied concentration.

Insight: usually good.

19
Q

What are the investigations for depression?

A

Investigations are used to exclude organic causes for depression. They are not mandatory and should be used according to clinical judgement:

  • Diagnostic questionnaires: e.g. PHQ-9 , HADS and Beck’s depression inventory.
  • Blood tests: FBC (e.g. to check for anaemia), TFTs (e.g. to test for hypothyroidism), U&Es , LFTs , calcium levels (biochemical abnormalities may cause physical symptoms which can mimic some depressive symptoms), glucose (diabetes can cause anergia).
  • Imaging: MRI or CT scan may be required where presentation or examination is atypical or where there are features suspicious of an intracranial lesion e.g. unexplained headache or personality change.
20
Q

Give examples of other depressive disorders

A
  • Recurrent depressive episode
  • Seasonal affective disorder
  • Masked depression
  • Atypical depression
  • Dysthymia
  • Cyclothymia
  • Baby blues
  • Postnatal depression
21
Q

What is recurrent depressive disorder?

A

A recurrent depressive episode refers to when a patient has another depressive episode after their first.

22
Q

What is seasonal affective disorder?

A

Characterised by depressive episodes recurring annually at the same time each year, usually during the winter months.

23
Q

What is masked depression?

A

A state in which depressed mood is not particularly prominent, but other deatures of depressive disorder are e.g. sleep disturbance and diurnal variation in mood.

24
Q

What is atypical depression?

A

This typically occurs with mild-moderate depression with reversal of symptoms e.g. overeating, weight gain and hypersomnia. There is a relationship between atypical depression and seasonal affective disorder.

25
Q

What is dysthymia?

A

Depressive state for at least 2 years, which does not meet the criteria for a mild, moderate or severe depressive disorder and is not the result of a partially-treated depressive illness.

26
Q

What is cyclothymia?

A

Chronic mood fluctuation over at leat a 2-year period with episodes of elation and of depression which are insufficient to meet the criteria for a hypomania or depressive disorder.

27
Q

What are the ‘baby blues’?

A

Seen in around 60-70% of women, typically 3-7 days following birth. and is more common in primiparae. Mothers are anxious, tearful and irritable. Reassurance and support is all that is required.

28
Q

What is postnatal depression?

A

Affects approximately 10% of women. Most cases start within a month and typically peak at 3 months. Clinical features are similar to depression seen in other circumstances.

29
Q

Briefly describe the bio-psycho-social approach to treating depression

A

Biological

  • Antidepressants
  • Adjuvants e.g. antipsychotics
  • ECT

Psychological

  • Psychotherapies
  • Self-help programmes
  • Physical activitiy

Social

  • Social support groups
30
Q

Briefly describe the treatment of mild-moderate depression

A
  • Watchful waiting
  • Antidepressants are not recommended as first-line unless certain criteria are met
  • Self-help programmes
  • Computerised CBT
  • Physical activity programme
  • Psychotherapies- if all options above fail
31
Q

What is watchful waiting in mild-moderate depression?

A

Watchful waiting should be considered and reassess the patient again in 2 weeks.

32
Q

When are antidepressants recommended in mild-moderate depression?

A

Not recommended as a first-line therapy for mild depression unless:

  1. Depression has lasted a long time
  2. Past history of moderate– severe depression
  3. Failure of other interventions
  4. Depression complicates the care of other physical health problems
33
Q

Briefly describe the management of moderate-severe depression

A
  • Suicide risk assessment
  • Psychiatry referral may be indicated
  • Mental Health Act
  • Antidepressants
    • +/- Adjuvants
  • Psychtherapy e.g. CBT or IPT
  • Social support
  • ECT
34
Q

When is a psychiatry referral needed in moderate-severe depression?

A

Indicated if:

  1. Suicide risk is high
  2. Depression is severe
  3. Recurrent depression
  4. Unresponsive to initial treatment
35
Q

What antidepressants are used in moderate-severe depression? And what advise is given to patients regarding how long they should be taken for?

A

First-line antidepressants are selective serotonin reuptake inhibitors (SSRIs) e.g. citalopram.

Other antidepressants include tricyclic antidepressants (TCAs) , serotonin noradrenaline reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs can only be prescribed by specialists).

Should be continued for 6 months after resolution of symptoms for first depressive episode, 2 years after resolution of second episode, and long term in individuals who have had multiple severe episodes.

36
Q

What adjuvants can be used to treat moderate-severe depression?

A

Lithium or antipsychotics.

37
Q

When is ECT indicated in treating depression?

A

Indications specific to depression include:

  1. Acute treatment of severe depression which is life-threatening
  2. Rapid response required
  3. Depression with psychotic features
  4. Severe psychomotor retardation or stupor
  5. Failure of other treatments
38
Q

What psychotherapies can be used to treat depression?

Explain each: CBT, IPT, behavioural activation, counselling and psychodynamic therapy

A

CBT

Depression causes negative thoughts, which can lead to negative behaviours. CBT allows people to identify and tackle negative thoughts; conducted in groups or individually.

IPT

Helps to identify and solve relationship problems, whether it is with family, partners or friends.

Behavioural activation

Encourages depressed patients to develop more positive behaviour or activities that they would usually avoid.

Counselling

Enables patients to explore their problems and symptoms. Counsellors offer support and guide patients to help themselves for a particular focus, e.g. bereavement or relationship counselling.

Psychodynamic therapy

Aim is to explore and understand the dynamics and difficulties of a patient’s life, which may have begun in childhood.

39
Q

What differentials should be considered for depression?

A
  • Other mood disorders e.g. bipolar affective disorder, other depressive disorders
  • Secondary to physical condition e.g. hypothyroidism
  • Secondary to psychoactive substance abuse
  • Secondary to other psychiatric disorders e.g. psychotic disorders, anxiety disorders, adjustment disorder, personality disorder, eating disorders and dementia
  • Normal bereavement

Y4 Psychiatry: Conditions (23 decks)

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