Depressive disorders Flashcards
Define depression disorder
An affective mood disorder characterised by persistent low mood, loss of pleasure and/or lack of energy accompanied by emotional, cognitive and biological Sx’s
Epidemiology depressive disorder
- W>M
- Incidence (per year): 1/20 adults (5%)
- Lifetime risk: 10% M < 25% W
Risk factors depressive disorder
FFAAPPSS
• Female + FHx
• Alcohol + Adverse events
• Past depression + Physical co-morbidity
• ↓ Social support + ↓ Socioeconomic status
Biological - depressive disorder
- Predisposing
- Precipitating
- Perpetuating
Predisposing
- Female
- post-natal period
- genetics/FHx
- neurochemical (↓ serotonin/NAd/D), endocrine (^ activity of HPA axis), physical comorbidities
- PMH of depression
Precipitating
- Poor medication compliance
- steroids
Perpetuating
- Chronic health problems (DM, COPD, CCF, chronic pain syndromes…)
Psychological - depressive disorder
Predisposing
- Precipitating
- Perpetuating
Predisposing:
- Personality type
- failure of effective stress control mechanisms
- poor coping strategies, other mental health co-morbidities
Preciiatating:
- Acute stressful events (bankruptcy, loss of loved one…)
Perpetuating:
- Poor insight
- negative thoughts about self/world/future (Beck’s triad)
Depressive disorder
CFs - typical symptoms
- Depressed/low mood
- Anhedonia: reduced interest or pleasure in all activities
- Low energy/fatigue
Other core symptoms of depressive disorder
- Loss of weight
- Loss of appetite
- Disturbed sleep: early morning waking (insomnia – waking 2-3hrs earlier) or hypersomnia (atypical presentation)
- Psychomotor agitation: unintentional + purposeless movements) e.g. pacing around room
- Psychomotor retardation: slowing of movement/speech
- Decreased libido
- Feeling of worthlessness, hopelessness
- Excessive/inappropriate guilt (can be delusional)
Biological (somatic) symptoms of depressive disorder
- Poor concentration
- Loss of emotional reactivity
- Diurnal mood variation (DVM): pt’s mood is more pronounced at certain point in the day (usually morning)
- Anhedonia
- Early morning waking (EMW)
- Psychomotor agitation or retardation
- Loss of appetite + weight
- Loss of libido
- Suicidal ideation (recurrent thoughts of death/suicide)
Psychotic features of depressive disorder
• Mood congruent (usually)
o Delusions: poverty, personal inadequacy, responsible for world events, deserving punishment, nihilistic delusions (mood congruent delusions of self-blame, hypochondriacal ideas, guilt)
o Hallucinations:
• Auditory – usually 2nd person
• Olfactory – bad smells (rotting, faeces…)
• Visual – tormentors, dead bodies…
• Mood incongruent
o Thought insertion/withdrawal, delusions of control
• Catatonic symptoms (or marked psychomotor retardation): unusual movements, inability to move…
MSE findings
Appearance Self-neglect, thin, unkempt, depressed facial expression, tearful
Behaviour Poor eye contact, psychomotor retardation, tearful, slow movements, slow responses, psychomotor agitation
Speech Slow, non-spontaneous, reduced volume + tone
Mood Low + depressed
Thought Pessimistic, guilty, worthless, helpless, suicidal, delusions (psychotic)
Perception Second person auditory hallucinations (derogatory)
Cognition Impaired conc.
Insight Good
DDx
- Neurological: PD, HD, space occupying lesion, head trauma (CT head), dementia, MS, stroke,
- Haematological: anaemia
- Metabolic: hypoglycaemia
- Endocrine: thyroid (both hyper and hypo), Cushing’s, Addison’s, perimenstrual Sx’s, menopausal Sx’s, prolactinoma, hyperparathyroidism (^ Ca2+), hypopituitarism
- Rheumatological: SLE
- Infections: Syphilis, HIV encephalopathy, Lyme disease
- Medication related: beta blockers, CCBs, steroids, H2 blockers (e.g. ranitidine), sedatives, CTx agents, muscle relaxants, medications affecting sex hormones (pill + GnRH inhibitors), statins, anti-psychotics…
- Substance misuse: ALCOHOL, BDZs, opiates, marijuana, cocane, amphetamines…
Other psychiatric disorders
• Dysthymia, stress-related disorders, bipolar disorder, anxiety disorders (OCD, panic disorder, phobias), schizoaffective disorders, schizophrenia (negative symptoms), BPD, eating disorders…
ICD 10 classification of severity depressive disorder
- Mild: 2/3 typical Sx’s + 2 other core Sx’s (4)
- Moderate: 2/3 typical Sx’s + 3 other core Sx’s (5-6 total)
- Severe: 3/3 typical Sx’s + ≥4 other core Sx’s
- (Severe w/ psychosis: 3/3 core Sx’s + ≥4 other Sx’s + psychosis)
Subtypes – may be in SBA therefore learn/look out for symptoms
- Depression w/out somatic symptoms
- Depression w/ somatic symptoms
- Depression w/ psychotic symptoms
Diagnostic questionaire
- Patient rating scale: e.g. PATIENT HEALTH QUESTIONNAIRE-9 PHQ-9 (assesses low mood) → 3 mark question in phase 4 EXAM
- Hospital Anxiety and Depression Score HADS
- Beck’s depression inventory
How would you rule out treatable causes - i.e. what ix would you do?
Rule out organic/treatable causes (see DDx)
• Standard tests: FBC (anaemia), TFTs, U+Es, B12/folate, LFTs, glucose, Ca2+ (remember: Ca2+ is separate test from U+Es)
• If indicated:
o Urine + blood toxicology
o Breath or blood alcohol
o ABG
o Serology: Thyroid Ab’s, anti-nuclear/dsDNA Ab
o Syphilis serology
o Additional electrolytes: e.g. phosphate, Mg
o Dexamethasone suppression test (Cushing’s)
o Short-synacthen test + cosynotropin stimulation test (Addison’s)
o LP: Lyme’s Ab, protein…etc
o CT, MRI, EEG
Remember it is important to do a risk assessment to assess risk to self + others
