HNNS Case 5: Depression

Question 1

Describe roles of Monoamines in the regulation of bodily function

Answer 1

Monoamine: 1 amino group + 1 aromatic group + 2 carbon chain

NE: Alertness, Concentration, Energy
Dopamine: Pleasure, Reward, Motivation
Serotonin: Obsessions + Compulsions, Memory

Question 2

Neuroanatomical / Neurochemical abnormalities of depressive disorders

Answer 2

See lecture

1. Neurotrophic hypothesis
2. Monoamine hypothesis

Question 3

Understand the multifactorial etiology of depressive disorders

Answer 3

1. Genes
2. Brain chemistry / hormones
3. Stress
4. Personality

Question 4

Pharmacological basis underlying therapeutic efficacy of antidepressant medications

Answer 4

See lecture

Question 5

Recognise psychopathology specific to depressive disorders

Answer 5

See lecture

Question 6

Formulate a list of DDx of depressive disorders by integrating clinical information and investigations

Answer 6

Diagnosis of depression:

1. Diagnostic and Statistical Manual of Mental Disorder (DSM4)
2. Hamilton Depression Rating Scale
   - 21 items
   - Total score 50
   - Normal 0-1; Mild 8-16; Moderate 17-23; Severe >24

Classification of depression:

1. Major depression disorder
2. Minor depression disorder
3. Dysthymic disorder

Organic causes of depression:

1. ***Stroke
2. ***Infection / Inflammation
3. Neoplasm
4. ***Iatrogenic
   - Prednisone
   - Beta-blockers
   - Antidepressants
   - Benzodiazepine
5. ***Endocrine
   - Hypothyroidism (Cognitive dysfunction) / Hyperthyroidism
   - Menopause —> mood swing
6. Alcohol / Drug abuse

Investigation:

1. History taking
2. Other symptoms of mental illness e.g. Delusion
3. Past medical / drug history
4. Blood test —> hormones / drugs
5. Neuroimaging —> brain lesion

Distinguishing between mental illness and other medical causes:
NO medical test
—> exclude other DDx
—> use diagnostic and statistics tools to diagnose different mental illness

Question 7

Rationale and Pharmacological mechanisms of use of Antidepressants

Answer 7

See lecture

Question 8

Types of psychotherapy effective in alleviating depressive symptoms

Answer 8

1. Antidepressants
2. Talk therapies
   - CBT
   - Interpersonal therapy
3. Deep brain stimulation
4. Art therapy
5. Mindfulness

Question 9

Prevalence of depressive disorders

Answer 9

• Most common in HK: Mixed Anxiety and Depressive Disorder (MADD)
• Female > Male
• Suicide 2nd leading cause of death in 15-29 yo

Question 10

Disability associated with depressive disorders

Answer 10

1. Decreased interest in ADL
2. Appetite disturbance
3. Sleep disturbance
4. Difficulty concentrating / thinking
5. Slowing of physical movement / reactions e.g. speech
6. Difficulty adapting / managing oneself
7. Difficulty interacting with others

Question 11

Recognise mortality associated with depressive disorder

Answer 11

• Suicide 2nd leading cause of death in 15-29 yo

Question 12

Rationale for compulsory psychiatric admission and its related application procedures

Answer 12

Mental Health Ordinance (Cap. 136) (MHO)

• Can apply voluntarily
• Aims: ensure safety and health of patient + others
  —> High suicidal risk / High risk to harm others
  —> Requested by: Family members, Registered doctors, Certified social workers

Procedures:
Form 1: Signed by relatives / public officer
Form 2: Mental state examination by health professional
Form 3: Risk and protective factor by District judge / magistrate
Form 4: 2 Medical professional —> 21 days
Form 7: 2 Medical professional —> detain abnormally aggressive / seriously irresponsible patients for further detention

Duration: Generally 7 days (Form 1-3), Can be extended up to 21 days (Form 4)

Suicide risk assessment:

1. Patient Health Questionnaire (PHQ)
2. Ask Suicide-Screening Questions screening tool (ASQ)
3. Suicide assessment five-step evaluation and triages (SAFE-T)
4. Modified SAD PERSONS scale