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
