Depressive Illness

Question 1

What is depression

Answer 1

A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.
• Depression can occur in all age groups but less common in children under 12.

Question 2

Depressive disorders are very common
• Globally more than 264million people of all ages suffer from depression
(WHO)
• 5 – 10% in primary care settings
• Symptoms may be as high as 30% in the general population
• More common in women than in men (2:1)
• Depression is a leading cause of disability worldwide and a major contributor to the overall global burden of disease.
• Depression can lead to suicide
• Suicide is the second leading cause of death in persons aged 20 – 35yrs
and depressive disorders contributes about 50% of these deaths.

True or false

Answer 2

True

Question 3

Why does depression often go undiagnosed and untreated

Depression contributes to higher morbidity and mortality when associated with other physical disorders and it’s successful diagnosis and treatment shown to improve outcomes. True or false

Depression is also associated with
• high rates of comorbid alcohol and substance misuse,
• And has a considerable social impact on relationships, families, and productivity (through time off work) true or false

Name five risk factors of depression

Answer 3

Depression often goes undiagnosed and untreated because patients and physicians often regard symptoms as being understandable given social circumstances and/or background.

True

True

Genetics
Childhood experiences 
Personality traits
Physical illness
Social circumstances

Question 4

Explain the risk factors of depression

COMORBIDITY – About two-thirds of patients will also meet criteria for another psychiatric disorder (e.g. anxiety disorders, substance misuse, alcohol dependency, personality disorders) true or false

Answer 4

Genetic: Heritability range between 17 – 75% and families also have high rates of anxiety disorders and neuroticism.
• Childhood experiences: Loss of a parent, lack of parental care, parental alcoholism/antisocial traits, Childhood sexual abuse.
• Personality Traits: Anxiety, impulsivity, obsessionality (i.e. high neuroticism scores)
• Physical Illness: Especially if chronic, severe, or painful. Neurological disorders (e.g. Parkinson’s, MS, Stroke, Epilepsy) have higher risk. Higher rates also noted in post – MI, diabetic, and cancer patients.

• Social Circumstances:
• Marital status – men have low rates associated with marriage, high rates
with separation or divorce.
• For women, having 3 or more children below age 11, lack of paid employment, and lack of confiding relationships.
• Adverse life events – particularly ‘loss’ events (increased risk 2-3mths after event) in vulnerable individuals.

True

Question 5

The aetiology of depression has yet to be fully understood, however it is likely to be due to the interplay of which factors?

Explain how psychosocial stressors cause depression

Answer 5

biological, psychological , and social factors in the lifespan of an individual.
•

Psychosocial stressors may play a role both as precipitating and perpetuating factors, increasing the risk of chronicity and recurrence; while individuals with established depression are at higher risk of further stressors of many kinds.

Question 6

Name four structural Brain changes in brain pathology that cause severe depression

Answer 6

ventricular enlargement and sulcal prominence.
• Increased rate of white matter lesions in older patients (perhaps related to vascular disease)
• Refractory cases associated reduced grey matter in left hippocampus (correlating with verbal memory), basal ganglia and thalamus.
• Reduced cortical volumes in the left parietal and frontal association areas.

Question 7

Name four things from functional

Imaging studies reports that cause depression

Answer 7

Functional Imaging studies report
• Hypoperfusion in frontal, temporal, and parietal areas (esp. older patients) and increased perfusion in frontal and cingulate cortex (in younger patients, associated with good treatment response)
• Studies point to 2 functionally segregated areas of the prefrontal cortex as being critical neural substrates for depression:
• the ventromedial prefrontal cortex (vmPFC) associated with negative affect, physiological symptoms, self awareness/insight;
• and the dorsolateral prefrontal cortex (dlPFC) associated with cognitive/executive functioning, (re)-appraisal of affect states, suppression of emotional responses.

Question 8

Explain neurotransmitter abnormalities as a cause of depression

What is the key hormone responsible for stabilizing mood, feelings of wellbeing, and happiness and also helps with sleeping, eating and digestion?
Low levels and high levels of this hormone can cause?
Name four severe symptoms of serotonin

Answer 8

Neurotransmitter Abnormalities
• The discovery that all antidepressants increase monoamine (i.e. 5-HT, NA, DA) release and/or reduce their reuptake in the synaptic cleft, led to development of the monoamine theory of depression, which suggests that reduced monoamine function may cause depression.
• Blunted neuroendocrine responses and symptom induction by tryptophan depletion (5-HT precursor) suggest an important role for 5-HT.

Serotonin

Low levels of serotonin can lead to depression, anxiety, suicidal behaviour, and obsessive compulsive disorder.
• High levels of serotonin causes mild symptoms such as shivering, heavy sweating, confusion, restlessness, headaches, high blood pressure, twitching muscles, diarrhoea. Severe symptoms include high fever, unconsciousness, seizures, or irregular heartbeats.

Question 9

Explain endocrine abnormalities as a cause of depression

Answer 9

Endocrine Abnormalities
• Endocrine changes in depression are evident across the life span, but some are unique to aging. Women with a previous history of depression are at higher risk of developing depression during menopause, although oestrogen replacement does not relieve depression.
• Low testosterone levels have been associated with depression in older men.

Question 10

Explain how an overactive thyroid will cause depression

Answer 10

Hyperthyroidism (Overactive Thyroid) • Enlarged thyroid gland
• Heat Intolerance
• Infrequent, scanty menstrual periods • Irritability or nervousness
• Palpitations
• Muscle weakness or tremors
• Sleep disturbances
• More frequent bowel movements
• Weight loss

Question 11

Explain how an underactive thyroid will cause depression

Answer 11

Hypothyroidism (Underactive Thyroid) • Dry, coarse skin and hair
• Fatigue
• Forgetfulness
• Irregular menstrual periods
• Hoarse voice
• Inability to tolerate cold
• Weight gain
• Enlargement of the thyroid gland

Question 12

What is the general criteria of diagnosing depression

Depression may be?

Answer 12

General Criteria - (ICD-10)
• Depressive episode should last for at least 2 weeks.
• There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode at any time in the individual’s life.
• The episode is not attributable to psychoactive substance use or to any organic mental disorder.

Depression may be mild, moderate or severe

Question 13

What are the general symptoms of depression

Answer 13

• Somatic/Vital/Endogenomorphic/Melancholic/ Biological Symptoms • Loss of emotional reactivity
• Diurnal mood variation (depression worse in the morning)
• Anhedonia
• Early morning wakening (about 2hrs or more before usual time)
• Psychomotor agitation or retardation
• Loss of appetite and weight (about 5% or more of body weight in past month)
• Loss of libido

Question 14

What are the core symptoms A of depression

Answer 14

Core Symptoms A (ICD-10)
• At least 2 of the following 3 symptoms must be
present:
• Depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost everyday, largely uninfluenced by circumstances, and sustained for at least 2 weeks.
• Anhedonia(inability to feel pleasure in normally pleasurable activities.)
• Decreased energy or increased fatiguability

Question 15

What are the core symptoms B of depression

• A fifth character may be used to specify the presence or absence of “ the somatic syndrome” true or false

Answer 15

Core Symptoms B (ICD-10)
• Loss of confidence and self esteem
• Unreasonable feelings of self-reproach or excessive and inappropriate guilt
• Recurrent thoughts of death or suicide, or any suicidal behaviour
• Complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation
• Change in psychomotor activity, with agitation or retardation (either subjective or objective)
• Sleep disturbance of any type
• Change in appetite (decrease or increase) with corresponding weight change

Question 16

How is mild ,moderate,severe depression diagnosed

Note: If important symptoms such as agitation or retardation are marked, the patient may be unwilling or unable to describe many symptoms in detail. An overall grading of severe episode may still be justified in such a case. True or false

Answer 16

MILD DEPRESSION
• The diagnosis requires
• At least 2 of the core symptoms A
• An additional symptom or symptoms from core symptoms B, to give a total of at least 4

MODERATE DEPRESSION
• The diagnosis requires
• At least 2 of the core symptoms A
• Additional symptoms from core symptoms B, to give a total of at least 6

SEVERE DEPRESSION
• The diagnosis requires
• All 3 of the core symptoms A
• Additional symptoms from core symptoms B, to give a total of at least 8

Question 17

What are the psychotic symptoms in severe depression

A fifth character may be used to specify whether the psychotic symptoms are mood congruent or mood incongruent. Name some mood congruent psychotic symptoms and mood incongruent psychotic symptoms

Answer 17

SEVERE DEPRESSION WITH PSYCHOSIS
• Psychotic Symptoms in Severe Depression (ICD-10)
• Delusions or hallucinations other than those listed as typically schizophrenic (i.e. delusions other than those that are completely impossible or culturally inappropriate and hallucinations that are not in third person or giving a running commentary); the commonest examples are those with depressive, guilty, hypochondriacal(characterized by the delusional belief that one is afflicted with a medical disorder of defect. ), nihilistic( rejecting all religious and moral principles in the belief that life is meaningless. ),self-referential, or persecutory content.
• Depressive stupor:

Catatonic depression is one of the severe kinds of depression that can put people into a stupor. This depression is characterized by the affected person being speechless and motionless for a long period of time. Here the person does not respond to his or her surrounding environment.

With mood-congruent psychotic symptoms
• (i.e. delusions of guilt, worthlessness, bodily disease, or impending disaster, derisive or condemnatory auditory hallucinations)
• With mood-incongruent psychotic symptoms
• (i.e. persecutory or self-referential delusions and hallucinations without an affective content)

Mood congruence is the consistency between a person’s emotional state with the broader situations and circumstances being experienced by the persons at that time. By contrast, mood incongruence occurs when the individual’s reactions or emotional state appear to be in conflict with the situation.

Question 18

How is recurrent depressive disorder diagnosed

Answer 18

RECURRENT DEPRESSIVE DISORDER/EPISODES
• There has been at least one previous episode, mild, moderate, or severe, lasting a minimum of 2 weeks and separated from the current episode by at least 2 months free from any significant mood symptoms.
• At no time in the past has there been an episode meeting the criteria for hypomanic or manic episode.
• Most commonly used exclusion criteria: the episode is not attributable to psychoactive substance use or any organic mental disorder.
• It is recommended to specify the predominant type of previous episodes (mild, moderate, severe, uncertain).

Question 19

What is dysthymia

None, or very few, of the individual episodes of depression within such a two-year period are severe enough, or last long enough, to meet the criteria for recurrent mild depressive disorder. True or false

How is dysthymia diagnosed

Answer 19

period of at least two years of constant or constantly recurring depressed mood.
• Intervening periods of normal mood rarely last for longer than a few weeks and there are no episodes of hypomania

During at least some of the periods of depression at least three of the following should be present:

(1) A reduction in energy or activity;
(2) Insomnia;
(3) Loss of self-confidence or feelings of inadequacy;
(4) Difficulty concentrating;
(5) Often in tears;
(6) Loss of interest or enjoyment in sex and other pleasurable activities;
(7) Feeling of hopelessness or despair;
(8) A perceived inability to cope with the routine responsibilities of everyday life;
(9) Pessimistic about the future or brooding over the past;
(10) Social withdrawal;
(11) Less talkative than normal.

Question 20

How can depression present indirectly

Answer 20

DEPRESSION: INDIRECT PRESENTATIONS
• Insomnia, fatigue, or other somatic complaints (e.g. headache, GI upset, change in weight).
• Elderly persons presenting with agitation, confusion, or a decline in normal functioning (pseudodementia)
• Children presenting with symptoms such as irritability, decline in school performance, or social withdrawal

Question 21

How is mild,moderate,severe depression managed

Answer 21

DEPRESSION: MANAGEMENT
• In Mild Depression of recent onset and no previous history of a more severe mood disorder, guidelines include
• Psychotherapy (Mainly CBT,cognitive behavioral therapy)
• Refraining from antidepressant use • Close, active monitoring of patient
• In Moderate and Severe Depression
• A combination of Antidepressants and Psychotherapy
• Admission mandatory for severe cases and patients with suicidality

Question 22

Im which trimesters will subclinical mild anxiety or mood disturbance get worse?

10% risk of clinical depression in the first trimester associated with past history of ?

In which trimester should you avoid medication

Always ask about thoughts of self-harm or harming the baby
• Psychiatric admission and completed suicide are less common in pregnancy than at other times.

Answer 22

•
• There may be subclinical mild anxiety or mood disturbance, worse in the third and first trimesters.
• depression, previous abortion, previous intrauterine loss, unwanted pregnancy.
• Third trimester depression may persist as post-partum depression. • Avoid drug treatment in the first trimester.

True

Question 23

Name some depressive disorders related to childbirth

Explain baby blues
How is it managed?
There is weak evidence that it may be related to post-partum reductions in levels of which hormones?

Answer 23

BABY BLUES
• Up to 3⁄4 of new mothers will experience a short-lived period of tearfulness and emotional lability starting 2 or 3 days after giving birth and lasting 1 – 2 days.
• Requires only reassurance and observation towards resolution.
• oestrogen, progesterone, and prolactin (which do occur around 72hrs after the birth)

POSTNATAL DEPRESSION (PND)

Question 24

What is PNd

The clinical features are similar to other depressive episodes, although thought content may include:
• Worries about the baby’s health or
• Her ability to cope adequately with the baby
• There may be a significant anxiety component
• 90% of cases last less than 1month; 4% last more than 1year
True or false

State six risk factors of PND

Answer 24

A significant depressive episode, temporarily related to childbirth, occurring in 10 – 15% of women within 6months post partum (3 – 4 weeks).

True

Personal or family history of depression • Older age
• Single mother
• Poor relationship with own mother
• Ambivalence towards or unwanted pregnancy • Poor social support
• Significant other psycho-social stressors
• Severe ‘baby blues’
• Previous post partum psychosis

Question 25

How is PNd managed

Answer 25

POSTNATAL DEPRESSION (PND): MANAGEMENT
• Early identification and close monitoring of ‘at risk’ groups (use of Edinburgh Postnatal Depression Scale)
• Prevention by education, support, and appropriate pharmacological intervention
• Depressive episode treated with antidepressants and/or brief CBT
• If severe or associated with thoughts of self-harm or harm to baby, may require hospital admission.