Depressive disorder Flashcards
What are the 3 key symptoms of depression?
- Low mood
- Low energy
- Anhedonia - like a glass screen where nothing makes anything better.
How big of a problem is depression?
WHO when ranked diseases by contribution to the global burden of disease in terms of its impact on normal life (disability-adjusted life-years; DALYs), unipolar major depression came second after ischeamic heart disease
How common is depression? What is the median age of onset?
- The 1-year prevalence of major depression in the general population is 5.3% and lifetime prevalence is 13%.
- Mean age of onset of depression is 30 years.
Up to 30% of primary care patients have depressive symptoms (6–10% satisfy criteria for major depressive disorder)
What are the sex differences in incidence of depression?
Women have a higher prevalence, incidence and morbidity associated with depressive disorders compared with men.
Incidence 2:1 F>M
Approx 1 in 4 women and 1in 10 men develop depression severe enough to require treatment at some point in life.
What are the risk factors for depression?
- Female sex
- PH of depression or other MH problems
- Significant physical illness
- Afro-Caribbean, Asian, refugee and asylum seeker communities
- Social factors
What is the pathophysiology of depression?
Monoamine theory of depression
Predicts that pathophysiology of depression is a depletion in the levels of serotonin, norepinephrine, and/or dopamine in the central nervous system.
Ascending and descending tracts
What is the rol of 5HT and NA in mental and physical illness? Give a list of examples.
- Depression
- Anxiety
- Pain perception
- Vasoconstriction
- Urethral sphincter contraction
- Bladder wall relaxation
- Pilomotor contraction
What are the (non-psychiatric) differential diagnoses for depression? List 10.
Medications - antihypertensives (BB, methyldopa, CCB), steroids, H2 blockers, sedatives, muscle relaxants, retinoids, chemotherapy agents, sex hormones like oestrogen, psychiatric medications
Substance misuse - alcohol, benzo, opiates, cannabis, cocaine, amphetamines
Neurological - dementia, Parkinson’s disease, tumours, stroke
Endocrine - hyper/hypothyroidism, Addison’s, Cushing’s disease, menopause, hyperparathyroidism
Metabolic - hypoglycaemia, hypercalcaemia, porphyria
Others - anaemia, infection (syphilis, Lyme disease, HIV, encephalopathy), sleep apnoea
What psychiatric conditions can mimic depression? Name 5.
- bipolar disorder
- dysthymia
- anxiety disorder
- schizoaffective disorder
- schizophrenia (negative symptoms)
- personality disorder
What investigations are used to exclude physical illness in depression?
Blood tests:
- BM
- U&E
- LFTs
- TFTs
- Calcium levels
- FBC
- Other inflammatory markers
- Magnesium levels
- HIV/syphilis serology
- Drug testing
Imaging - only done in atypical presentation when suspicion of intracranial lesion e.g. unexplained headache or personality change.
What two common screening tools are used for depression?
PHQ-9 - Patient health questionnaire - 9 questions to diagnose and assess severity of depression (3 mins). 1-4 is minimal, 5-9 is mild, 10-14 is moderate, 15-19 is moderately severe and 20-27 is severe depression.
HADS - Hospital anxiety and depression scale - assesses for both anxiety and depression and takes 5 min. 0-7 is normal, 8-10 is mild, 11-14 is moderate, and 15-21 is severe
What is the ICD-10 criteria for depression?
Must last for at least 2 weeks and represent a change from normal AND must not be secondary to other causes (e.g. drugs, alcohol misuse, medication)
Core symptoms of depression:
- Low mood
- Anhedonia
- Reuced energy or fatigue
Other symptoms:
- Sleep disturbance
- Diminished appetite
- Lack of libido
- Sleep disturbance
- Reduced concentraton and attention
- Reduced self esteem/self confidence
- Bleak pessimistic views of the future
- Reduced concentraton and attention
- Ideas of guild and worthlessness
- Ideas or acts of self harm or suicide
- Ideas of guild and worthlessness
(this is just a grouping ^ for revision purposes)
Are people with depression always mood congruent?
No, can sometimes be mood incongruent with psychotic symptoms.
List 3 groups of psychotic symptoms that can occur in depression.
Delusions - usually mood congruent
Hallucinations - 2nd person usually
Catatonic symptoms - e.g. psychomotor retardation aka depressive stupor
What kind of delusions may be present in depression?
Mood congruent usually and therefore usually:
- nihilistic
- poverty
- overbearing guilt for misdeeds
- responsible for world events
- deserving of punishment
What kind of hallucinations can occur in depression?
Range of modalities but usually 2nd person auditory hallucinations
Auditory - derogatory voices, cries for help or screaming
Olfactory - usually bad smells such as rotting flesh and faeces
Visual - demons, the devil, torturers, dead bodies etc
What catatonic symptoms occur in depression?
Catatonic symptoms are marked psychomotor retardation aka depressive stupor:
- paucity of movement,
- including immobility,
- staring,
- mutism,
- rigidity,
- withdrawal
- refusal to eat
How many symptoms must you have to be diagnosed with severe vs mild depression?
Mild - 2 core, 2 other
Moderate - 2 core, 3+ other
Severe - 3 core, 4+ other
Severe with psychosis - severe + psychosis (delusions+/- hallucinations)
What type of insomnia is seen in depression?
Early morning wakening
(Anxiety causes problems falling asleep)
What types of affect exist?
Reactive - this is when someone reacts as expected to something
Incongruent - reacting in the opposite way of what you imagine
Flattened - completely, restricted or reactive
What is the management of mild-to-moderate depression?
- Watchful waiting + assess again within 2 weeks
- Consider low intensity psychosocial interventions e.g. self-help based on CBT, computerised CBT, relaxation therapy, or 6-8 sessions of brief CBT/counselling/problem solving therapy
NB: risk:benefit ratio of antidepressants is poor for mild depression
What is the management of moderate-to-severe depression?
If suicidal thoughts/risk then urgent psychiatric referral e.g. Crisis team
1.Antidepressants - NNT is 4-5
AND
2. High intensity psychological treatment (CBT or interpersonal therapy)
3. ECT - fast and short improvement of severe symptoms and if all other treatment options have failed or when life-threatening situation
4. Consider admission in the following cases:
- Risk to self - neglect or risk of suicide/self-harm, poor insight, treatment resistant depression, psychotic symptoms
- Risk to others
- Poor social support
What is atypical depression?
Subtype of depression with slightly different symptoms
How common is atypical depression and who is most at risk?
- F>M
- Onset usually in late teens and early 20s
- FH of affective disorders
- Usually have comorbid anxiety, somatisation or alcohol/drug misuse
What are the clinical features of atypical depression?
- Mood - depressed but remains active (no anhedonia)
- Fatigue - extreme
- Reversed duirnal variation in mood
- Hypersomnia - >10 hrs a day at least 3 days/week for 3 months
- Hyperphagia - with weight gain >3kg in 3 months
- Interpersonal rejection sensitivity
- Laeden paralysis - heaviness of limbs for 1hr/day for at least 3days/week for 3 months
What is laeden paralysis?
Feelings of heaviness of the limbs for 1hr/day for at least 3 days/week over 3 months
May occur in atypical depression
What is dysthymia?
Chronci low grade depressive symptoms which are usually long lasting (over years) but the person did feel ‘well’ before.
How common is dysthymia in the UK?
5% UK prevalence
Higher in females (2:1)
What are the clinical features of dysthymia?
- Depressed mood (>2 years)
- Reduced energy and fatigue
- Appetite may be increased/reduced
- Insomnia/hypersomnia
- Low self esteem
- Poor concentration
- Difficulties making decisions
- Thoughts of hopelessness
What is the prognosis with dysthymia?
Usually less severe than depression but more chronic
Low spontaneous remission rate, on average lasting ~5 years
Only 10% achieve remission within a year of treatment
25% suffer chronic symptoms
What are the clinical features of SAD (seasonal affective disorder)? What is the pathophysiology?
- Low mood occurs with change of season i.e. depression in winter with remission in spring
- There is an increase in appetite including ‘carbohydrate craving’
Pathophysiology: Likely related to melatonin synthesis, sunlight hits the pineal gland with decreases melatonin synthesis (increasing 5HT synthesis)
What is the mangement of SAD?
- Simple measures like light therapy (specialised SAD lights)
- Medication - antidepressants, propranolol
What are the general treatment phases of depression?
- Acute phase
- Continuation phase
- Maintenance phase
Remission, recovery (remission for significant time) and relapse can occur throughout
Which of the following is a core symptom of depression according to the ICD criteria?
- A. Sleep disturbance
- B. Diminished appetite
- C. Reduced self confidence
- D. Ideas or acts of self harm or suicide
- E. Reduced energy or fatigue
E
Which of the following is correct?
- A. Moderate Depression = 2 core symptoms + 3 other symptoms
- B. Mild Depression = 3 core symptoms + 1 other symptoms
- C. Moderate Depression = 3 core symptoms + 2 other symptoms
- D. Severe Depression = 2 core symptoms + 4 other symptoms
- E. Mild Depression = 2 core symptoms + 3 other symptoms
A
A 35 year old woman presents to her GP asking for a sick note. She has been struggling at work as a teaching assistant for the last 2 months ; she struggles to concentrate for long periods and has no energy to run around after the children. She feels guilty as a result and thinks she is no good as a teacher or a human. She comes home from work and cannot face going to her jazzercise class or for dinner with friends. She tells the GP that she had similar symptoms a year ago, and also for the two years preceding this, always during the Christmas term at school.
- Seasonal Affective Disorder
- Depression secondary to hypothyroidism
- Dysthymia
- Bipolar Affective Disorder Type I
- Atypical Depression
SAD
What kind of questions are importnat to ask in depression?
How do you ask about suicidal thoughts in depression?
Do not be afraid to ask as it does not make them more suicidal
Remember to link it in with the question
Must ask in depth questions including why/how/why not yet
What else should you ask about self harm/suicide attempt?
Get as much detail as possible
- Was it planned/spur of moment
- What happened during the incident?
- What kind of preparation did you go through?
- What exactly did you take do? Was there anyone around? Any alcohol? What did you do afterwards?
Then ask the most important questions: (1) what they thought would happen and (2) how they feel now
What difficult question may need to be asked in depression?
What biological symptoms are seen in depression?
- reduced sleep
- appetite
- energy
- concentration
- libido
What negative cognitions are seen in depression?
- hopelessness
- worthlessness
- guilt
