Depressive disorder

Question 1

ICD-10 classification system’s 3 core symptoms:

Answer 1

1. Depressed mood, little variation from day to day, unreactive to circumstances.
2. Partial/complete anhedonia
3. Anergia

Question 2

Biological Sx

Answer 2

1. Early morning wakening(at least 2h before)
2. Mood worse in morning
3. Appetite and W loss(5% body W over 1 month)
   - overeating and oversleeping considered atypical depressive symptoms
   - Psychomotor retardation and agitation
   * when severe, unresponsive, akinesis, near total mutism
   - loss of libido

Question 3

Cognitive Sx

Answer 3

1. Reduced attention and memory
2. Suicide ideation and self harm
3. Low self-esteem
4. Hopelessness
5. Guilt(out of proportion)

Question 4

Psychotic Sx

Answer 4

Delusions and hallucinations, usually mood congruent

Question 5

DDx

Answer 5

1. Mood disorders:
   - Recurrent depressive disorder
   - depressive episode
   - dysthymia
   - bipolar affective disorder
   - cyclothymia
2. Schizoaffective disorder
3. Secondary to general medical condition
4. Psychoactive substance
5. Secondary to other psychiatric disorders:
   - Psychotic disorders
   - anxiety disorders
   - adjustment disorder
   - eating disorder
   - personality disorder
   - dementia

Question 6

ICD-10 criteria for depressive episode

Answer 6

1. Sx for at least 2w AND
2. At least 2 core Sx. AND
3. At least 2 of biological/cognitive Sx.
4. Severity:
   a) Mild: ≥4 Sx, most normal activities cont.
   b) Moderate: ≥5 Sx. great difficulty cont normal activities
   c) Severe: ≥7 Sx w all 3 core Sx. unable to cont normal activities
   d) Severe w psychotic Sx: w delusions, hallucinations, psychomotor retardation.

Question 7

Assessment

Answer 7

1. History:
   - Ask abt core Sx.
   - Biological Sx.
   - Cognitive Sx.
2. Examination:
   - Full neurological and endocrine.
3. Inv:
   a) Social: Collateral info, consider home visit, interviewing immediate family.
   b) Psychological:
   - self reported inventory, mood diary
   c) Physical:
   - FBC: anaemia, infection, high MCV(alcohol)
   - U&E
   - LFT: w GGT(alcohol)
   - TFT and Calcium
   - If indicated: CRP/ESR, vit B12 and folate, urine drug screen, ECG, EEG, CT brain

Question 8

Aetiology:

1. Genetics
2. Early life experience
3. Personality
4. Acute stress
5. Chronic stress
6. Neurobiology and neurochemistry

Answer 8

1. 40-50% heritability, may need environmental trigger.
2. Parental divorce, Postnatal depression
3. Neuroticism, personality disorders
4. Poor social support, unemployment, chronic illness

Question 9

MANAGEMENT:

• most treated successfully in primary care/outpatient psychiatry
  1. Admission if:
  2. Lifestyle advice
  3. Mild depression/persistent sub-threshold Sx.(minimal fn. impairment)
  4. Moderate to severe depression(mild to marked fn. impairment) OR step 2 of mild depression
  5. Pharmacological Tx.
  6. ECT

Answer 9

1. • psychotic phenomena
     - active suicide ideation, planning, risk f.
     - extreme self-neglect

• detention under MHA considerations
  2. Alcohol, substance use. healthy diet, exercise, good sleep hygiene, exercise groups.

3. a) Psychosocial Interventions:
   - self-help CBT
   - structured group physical acitivity
   - sleep hygiene
   b) Consider Pharmacological treatment if:
   - past Hx of moderate/severe depression
   - mild depression complicates management of physical health problem
   - persistent subthreshold depressive ≥2y
   - unresponsive to first-line treatments
4. High intensity psychosocial interventions:
   - Individual CBT
   -Individual IPT
   AND
   Antidepressants.
5. SSRIs(first line)
   - continued at full dose for ≥6/12 after remission.
   - longer/lifelong if recurrent
   - MAOI for atypical depression(hypersomnia, overeating, anxiety)
   - antipsychotics can be augmenting agents(psychiatrist only)

• TCA cardiotoxic.
• Drug tx failure when tx dose prescribed for 6-8w without response

6. • Prev good response to ECT
     - Antidepressants X work/intolerant
     - Severe self-neglect
     - Psychotic features, severe psychomotor retardation.
     - Depression with severe suicidal ideation

Question 10

Course and prognosis

Answer 10

• single episode generally remit within 6 months
• 80% further depressive episode
• 20x incresed suicide risk

Question 11

SWITCHING ANTIDEPRESSANTS:
1. From citalopram, escitalopram, sertraline, or paroxetine to another SSRI

2. From citalopram, escitalopram, sertraline or paroxetine to venlafaxine
3. From fluoxetine to another SSRI
4. From fluoxetine to vanlafaxine
5. From fluoxetine to TCA
6. From SSRI to a TCA

Answer 11

1. Withdraw gradually, stop then start alternative SSRI.
2. Cross-taper cautiously, start venlafaxine at 37.5 mg daily then increase gradually.
3. Withdraw, leave gap of 4-7d then start low dose of alternative SSRI
4. Withdraw then start venlafaxine at 37.5 mg daily and increase slowly
5. Withdraw before starting TCA
6. Cross-taper gradually

Question 12

INITIATING ANTIDEPRESSANTS

Answer 12

1. After starting, review at 2w.
   - review at 1w for<30y
2. If good response, continue for ≥6/12 after remission to reduce risk of relapse

Question 13

OLDER ADULTS:

1. Specific clinical features
2. Medication

Answer 13

1. a) Severe psychomotor agitation/retardation
   b) Cognitive impairment(depressive pseudodementia)
   c) Poor concentration
   d) Generalised anxiety
   e) Hypochondriasis
   f) When psychotic, likely to have hypochondriacal delusions, delusions of poverty and nihilistic delusions.
2. • 1/2 usual dose of antidepressants
     - Slower response to antidepressants, 6-8w. Continue with dose that got patient better.
     - Continue for ≥1-2y/indefinitely
     - Avoid TCAs
     - ECT very effective so consider for severe depression, suicidal ideation, severe psychomotor retardation, failure to respond/tolerate medication, previous good response to ECT
     - Lower Lithium dose for augmentation