Depressive Disorders Flashcards
How are depressive disorders classified?
Specific symptoms: -major depression -persistent depressive disorder (dysthymia) -other specified / unspecified Dd/o Aetiology: -premenstrual dysphoric d/o -depressive d/o due to medical condition -substance/medication induced depressive d/o
Incidence depressive symptoms reported in primary care? Prevalence major depression?
Depressive symptoms: 30%
Major depression: 10%
Depression v demoralisation and grief?
-tied to thoughts / reminders inciting event
-resolve when circumstances / events imporve
-interspersed with periods of positive emotion and humour
-not accompanied by pervasive feelings of worthlessness and self loathing
-lasts days (cf wk - mo)
-suicidal thoughts and loss of function less likely
BUT CAN PRECIPITATE major depression
Aetiology depression?
- Unknown
- Genetic (~50%) and environmental contributions
- ?changes to NA/DA/5HT neurotransmission
- ?neuroendocrine dysregulation (HPA, HPT axes; growth hormone)
- Psychosocial fx (stress etc)
Theories as to why women at greater risk of depression?
- Greater exposure/response to stresses (+ response to adversity ==> ruminative v active)
- Higher MAO levels
- Higher incidence thyroid dx
- Endocrine changes with menstruation / menopause
- power / parity / marriage role
What is SAD?
- Sx in seasonal pattern
- usually Autumn / Winter
- usually climates with long / severe Winters
Which conditions are commonly accompanied by depression?
- Thyroid / adrenal d/o
- Benign and malignant brain tumours
- Stroke
- AIDS
- Parkinsons
- MS
Which drugs may precipitate depressive d/o?
- Corticosteroids
- Some B-blockers
- Interferon
- Reserpine
- Abuse of recreational drugs (EtOH, amphetamines)
Symptoms of depression?
- Cognitive, psychomotor and other dysfunction:
- -poor concentration
- -fatigue
- -loss of sexual desire
- -anhedonia
- -sleep disturbance
- -suicidal ideation
- -anxiety / panic attacks
Medical sequelae of depression?
- Reduce protective immune responses
- Increased risk CV d/o, MI and stroke
Why does depression have CV consequences?
?in depression cytokines and pro clotting factors are elevated, HR variability decreased (all potential RFx for CV d/o)
Appearance pt with major depression?
- Miserable with tearful eyes
- Furrowed brow
- Down turned corners of mouth
- Slumped posture
- Poor eye contact
- Lack of facial expression
- Little body movement
- Speech changes (soft voice, lack of prosody, monosyllabic)
- May neglect personal hygiene
Symptoms for Dx major depression?
≥ 5 present nearly every day in same 2-wk period, one must be depressed mood or anhedonia (loss of interest or pleasure):
- Depressed mood most of the day
- Markedly diminished interest or pleasure in all or almost all activities for most of the day (anhedonia)
- Significant (> 5%) weight gain or loss or decreased or increased appetite
- Insomnia (often terminal insomnia + EMW) or hypersomnia
- Psychomotor agitation or retardation observed by others (not self-reported)
- Fatigue or loss of energy
- Decreased libido
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate or indecisiveness; set shifting
- Recurrent thoughts of death or suicide, a suicide attempt, or a specific plan for committing suicide
What is persistent depressive disorder (PDD)?
-Depressive symptoms that persist for >2y w/o remission
Symptoms and signs of PDD
- Habitually gloomy, pessimistic
- Humorless
- Passive
- Lethargic
- Introverted
- Hypercritical of self and others
- Complaining
Dx symptoms of PDD?
Must have a depressed mood for most of the day for more days than not for ≥ 2 yr plus ≥ 2 of the following:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
What is anxious distress?
Patients feel tense and unusually restless; have difficulty concentrating as worry/fear something awful may happen or they will lose control of themselves
What is melancholia?
- Lost pleasure in nearly all activities
- Do not respond to pleasurable stimuli
- Despondent and despairing
- Excessive or inappropriate guilt
- Early morning awakenings
- Marked psychomotor retardation or agitation
- Significant anorexia or weight loss
Diagnosis of depression?
-Clinical criteria (DSM)
-FBE, UEC, TSH, B12, folate (r/o medical cause)
Severity determined by degree of pain and disability (physical, social, occupational) and duration.
DDx depression?
- Demoralisation and grief
- Anxiety d/o (mimics)
- Major depression must exclude BpD
- Dementia of depression
- Early dementia -> depression
- Physical/ medical d/o
Which main medical conditions are linked with depression?
- Hypothyroidism
- Parkinson disease
- Cushings
- Ca (pancreatic, SClung)
- MS
- HIV
Rx depression?
- Support
- Psychotherapy (CBT, IPT, couple therapy)
- Drugs
- Exercise
- Lifestyle (sleep, diet, reduce EtOH)
- Confiding in others
- ECT
Initial drug of choice?
SSRI
When is ECT required?
- melancholic
- psychotic
- puerperal
- bipolar depression or mania
- prominent suicidality
- poor oral intake
What are the neurovegetative (biological) symptoms of depression?
- sleep disturbance (terminal insomnia + EMW)
- appetite disturbance
- psychomotor retardation
- impaired concentration and set shifting, rumination
- working memory deficits
- libidinal changes
What are the cognitive-affective Sx of depression?
- anxiety
- helplessness / hopelesness
- loss of SE
- social withdrawal
- depersonalisation, derealisation
- guilt / shame
- nihilism
- rage
How many affected by post partum depression?
~10%; 1/2 severe
50% recurrence
When does post partum depression occur?
4-12 weeks post partum
Key features of depression in older adults?
- loss common precipitant
- organic d/o more common as precipitants
- somatic complaints prominent (pain, dec function)
- irritable more than sad
Which drugs may induce mood d/os?
- Monoamine depletion (reserpine, propranolol, alpha methyldopa)
- CSTs: >80pred
- GABAergics: benzos, vigabatrin, EtOH
- Chemo
- OC (rare)
- Interferon
What are common psych comorbidities?
- Substance abuse (treat 1st, or simultaneously)
- Anxiety d/o (treat concurrently)
- personality d/o (treat in parallel)
What are the childhood factors which predispose to depression?
- Parental loss with poor parenting after
- Chronic exposure to depressed mothers
- Insecure attachment
Protective factors depression in childhood?
- 1 good relationship
- higher IQ
Environmental factors contributing to depression (adult)?
- loss
- humiliation
- entrapment
- danger
Anaclitic/sociotropic predisposition to depression?
- exaggerated need for relatedness
- characterised by emptiness, desperation, diffuse affectivity
- personal slights significant
- Rx termination often hard
Introjective/ autonomous predisposition to depression?
- need for autonomy
- self critical
- failure to achieve goal significant
- may do well in Rx once engaged
What are psychotic symptoms of depression like?
-Usually mood congruent
-Hallucinations (10-20%)
-Delusions - almost invariable
80% response rate to ECT or APA + anti deep
How can depression in children present differently cf adults?
- MSE changes subtle
- Match behaviour / mood with age, gender, IQ peers
- Function in various environments important clues
- Utilise several sources
What is pseudo depression following damage to frontal convexity?
-apathy
-motor slowness
-poverty of speech
in damage to frontal convexity
What do orbital frontal lesions present with?
- Shallow jocularity
- disinhibition
How does nervous system structure and function differ in depressed pts?
- Smaller hippocampus
- Larger ventricles
- MAO, BDNF, NMDA cascade changes
- Cortisol changes
- HPA & sympathetic NS changes
What was Freud’s psychodynamic perspective of depression?
Mourning and internalised aggression
What was Shengold’s psychodynamic perspective of depression?
Avoiding murdeorus feelings towards parental introject
What was Pedder’s psychodynamic perspective of depression?
Inability to mourn, bring to mind
What was Jacobson’s psychodynamic perspective of depression?
Regression and gap between ego ideal and self representation
What was Winnicott’s psychodynamic perspective of depression?
terror Mother will not survive aggression (demands or separation) and or still love
Duration pharm Rx depression, 1st ep?
- 6-12 weeks full dose
- Maintain 6-12/12 post recovery
