Mood Disorders Flashcards
What is depression?
Depression is a common mental health disorder characterised by persistent feelings of sadness, hopelessness and loss of interst in activities that were once enjoyable. There are several types of depression such MDD, persistent depressive disorder and SAD
What is the epidemiology of depression?
- Lifetime risk of 15%
- Affects 1 in 4 women and 1 in 10 men to the point of requiring treatment at some time in their lives
- Leading cause of death and disablity in adults under 44
- Affect 300 million globally
- Peak incidence 40-50 years
What are the risk factors for depression?
Heritability of depression is significantly lower than other mental illness.
- Biological factors
* Genetic predisposition
* Chronic medical conditions
* Neurochemical changes - altered HPA axis - Psychological factors
* Childhood trauma e.g. loss of a parent, abuse
* Neurotic personality traits - Social factors
* Traumatic life events
* Unemployment
What is the pathophysiology of depression?
Depression is thought to be related to dysfunction of neurotransmitter systems including serotonin and noradrenaline in conjunction with altered HPA axis function.
Structural brain changes associated with increased risk of depression include:
* Focal lesions of subcortical white matter
* Reduction of glial cells in the prefrontal cortex
* Atrophy of the hippocampus
What is the clinical presentation of depression?
To diagnose depression symptoms must be present for 2 weeks or more and must cause clinically significant distress and/or impairment. They should not be due to an organic cause.
Core symptoms include:
1. Persitent low mood - sadness, emptiness, hopelessness for majority of the day nearly every day.
2. Low energy/fatigue - physically drained after minimal exertion. Sluggishness in thought and physical movements
3. Anhedonia - loss of interest or pleasure in almost all activities once enjoyed. Diminished interest in hobbies, social interactions, sexual activity and other sources of enjoyments.
Additional features include:
1. Cognitive changes - difficulty in concentrating and decision-making. Feelings of guilt/worthlessness
2. Sleep disturbance - Insomnia, difficulty falling asleep or maintaining sleep. or Hypersomnia - excess sleeping.
3. Appetite changes - significant weight loss when not dieting, weight gain, decreased appetite particularly in younger patients, increased appetite among those with atypical depression
4. Psychomotor agitation/retardation - restlessness such as pacing up and down. Alternatively may be significant slowing down of thought and reduction of physical movement
5. Suicidal ideation - recurrent thoughts of death, suicidal ideation or attempts
What are the diagnostic criteria for depression?
MDD DSM-5 Criteria:
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.:
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
The following must also apply:
* The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
* The episode is not attributable to the physiological effects of a substance or to another medical condition.
* The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
* There has never been a manic episode or a hypomanic episode. (This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.)
How is the severity of depression classified?
According to DSM-V:
* Subthreshold - <5 symptoms
* Mild - 5 symptoms (at least one core) with symptoms only resulting in minor functional impairment
* Moderate - symptoms of functional impairment are between mild and severe
* Severe - most symptoms present and the symptoms markedly interfere with normal function +/- psychotic symptoms
What are the subtype of depressive disorder?
- Dysthymia
* Chronic but mild symptoms of depression. Can be associated with physical illness or other psychiatric disorders - Psychotic depression
* Most severe form of depression where patients can present with delusions e.g. that they are dead (Cotard’s syndrome) or experience derogatory auditory hallucinations
* Suicide risk is high and can also present with psychomotor retardation which may require ECT - Atypical depression
* Occurs with symptoms opposite to those expected i.e. increased sleep, increased appetite - Mixed anxiety and depressive disorder
* Symptoms of anxiety and depression of co-existent but do not individually meet the criteria for a diagnosis of a mood or anxiety disorder
What differentials should be considered in the diagnosis of depression?
- Psychiatric conditions
* Bipolar disorder - episodes of mania and depression. Antidepressant treatment can precipitate a manic episode
* Dysthymia - chronic less severe mood disturbance
* Adjustment disorder - depressive symptoms in response to a significant life change or stressor, generally rersolving within a few months after the stressor has ceased
* Anxiety disorders - excessive worry, fear or panic
* Dementia - Medical conditions
* Thyroid disorder - hypothyroidism can present with fatigue, weight gain and mood changes
* Neurological disorders - conditions such as Parkinson’s disease and MS can have depressive symptoms as a feature or a reaction to the diagnosis
* Chronic pain syndromes - cause and a consequence of chronic pain
* Nutritional deficiency - particularly B12, folate and vitamin D
* Endocrine disorders - Cushing’s syndrome, Addison’s disease can affect hormone levels and lead to mood disturbances - Substance-Induced Mood Disorders
* Alcohol and drugs - substance abuse can cause depressive symptoms during intoxication or withdrawal
* Medication-Induced Depression - various medications including beta blockers, corticosteroids, isotretinoin can induce depression
What screening questions can be asked for depression?
During the past month have you felt low, depressed or hopeless?
During the past month have you had little interest or pleasure in doing things?
How is depression classified in the NICE guidelines?
Less severe depression - a PHQ-9 score of <16
More severe depression - a pHQ-9 score of >16
How is less severe depression managed?
A number of possible first-line treatments with emphasis on discussion with patients to reach shared decision. The least intrusive and least resource intensive treatments should be tried first and antidepressant medication should not be routinely offered as first-line
Treatment options typically via referral to IAPT include:
* Guided self help
* Group CBT
* Group behavioural activation
* Individual CBT
* Individual BA
* Group exercise
* Group mindfulness and meditation
* Interpersonal psychotherapy
* SSRIs
* Counselling
* Short-term psychodynamic psychotherapy
What is management of more severe depression?
A shared decision with patient is recommended.
Treatment options in order of preference by NICE:
* Combination of individual CBT and an antidepressant
* Individual CBT
* Individual BA
* Antidepressant medication - SSRI or SNRI or another antidepressant if indicated based on previous clinical and treatment history
* Individual problem solving
* Counselling
* Short-term psychodynamic psychotherapy
* Interpersonal psychotherapy
* Guided self-help
* Group exercise
What counselling should be given to patients started on an SSRI?
SSRIs e.g. Citalopram, sertraline, paroxetine, fluoxetine.
* Side effects - nausea, abdominal discomfort, diarrhoea, insomnia, sexual dysfunction, upper GI bleeding, hyponatraemia, increased suicidal risk
* Withdrawal - symptoms include insomnial, nausea, dizziness, agitations. withdraw over a few weeks
* Overdose - rarely fatal
* Cautions - increased seizure frequency in epilepsy. Co-administration with other serotinin increasing drugs can increase risk of serotonin syndrome (tachycardia, shivering, sweating, hyperthermia, hyperreflexia, organ failure)
* Potential 2-4 week delay in effect on symptoms
* Potential increased risk of bleeding with SSRIs
* Patients should be followed up within 1 week of starting SSRIs if <30 y/o or at increased risk of suicide. Or every 2-4 weeks in first 3 months
* After symptoms improve treatment should continue for at least 6 months before dose is tapered to prevent withdrawal symptoms and relapse
If no response to first line treatment can try a different SSRI or switch to an SNRI such venlafaxine
What are the criteria for referral to secondary care in depression?
- Patient not responding adequately to treatment
- Risk of harm to self or others
- Patient is severely unwell
- Uncertain diagnosis
