Mood disorders + Depression Flashcards
What is the definition of affect?
Refers to the transient flow of emotion in response to a particular stimulus. The
assessment of mood and affect are described in the Mental state examination, Section 2.2.
Fluctuations in mood are a normal part of human experience. It is only when a disturbance of
mood is severe enough to cause impairment in the activities of daily living (ADL), that it is
considered as a mood disorder
What is the definition of mood?
Refers to a patient’s sustained, experienced emotional state over a period of time. It may
be reported subjectively (in the patient’s own words) or objectively as dysthymic (low), euthymic
(normal) or elated (elevated)
Definition of mood disorder?
Otherwise known as an ‘affective disorder’, is any condition characterized by
distorted, excessive or inappropriate moods or emotions for a sustained period of time.
ICD-10 Classification of affective disorders?
- Manic episode: including hypomania, mania without psychotic symptoms and mania with
psychotic symptoms. - Bipolar affective disorder.
- Depressive episode: including mild, moderate, severe and severe with psychotic symptoms.
- Recurrent depressive disorder.
- Persistent mood disorders: cyclothymia, dysthymia.
- Other mood disorders.
- Unspecified mood disorder.
What is a primary mood disorder?
a mood disorder that does not result from another medical or psychiatric
condition. Broadly speaking, a primary mood disorder is either unipolar (depressive disorder,
dysthymia) or bipolar (bipolar affective disorder, cyclothymia).
What is a secondary mood disorder?
: a mood disorder that results from another medical or psychiatric
condition.
What is the definition of depression/ depressive disorder?
Depressive disorder is an affective mood disorder characterized by a persistent low mood, loss of
pleasure and/or lack of energy accompanied by emotional, cognitive and biological symptoms.
What is the pathophysiology/ aetiology of depression?
Depression is a highly complex multifactorial disorder influenced by a number of biopsychosocial factors (see Table 3.2.1).
Monozygotic twin studies show the heritability of depression as 40–50%, and it is likely that
multiple genes are involved.
The monoamine hypothesis states that a deficiency of monoamines (noradrenaline, serotonin
and dopamine) causes depression; this is supported by the fact that antidepressants which
increase the concentration of these neurotransmitters in the synaptic cleft, improve the clinical
features of depression.
Over-activity of the hypothalamic–pituitary–adrenal (HPA) axis has been linked to depression.
Psychosocial factors such as personality type, stressful life events and failure of effective stress
control mechanisms increase the likelihood of developing depression.
What are some predisposing aetiological factors of depression?
Biological: Female gender (2:1)
Postnatal period
Genetics: 40–50%
monozygotic
concordance rates,
family history
Neurochemical: ↓
serotonin, ↓
noradrenaline, ↓
dopamine
Endocrine: ↑ activity of
HPA axis
Physical co-morbidities
Past history of
depression
Psychological: Personality type
Failure of effective
stress control
mechanisms
Poor coping
strategies
Other mental health
co-morbidities (e.g.
dementia)
Social: Stressful life
events
Lack of social
support
More common
in asylum
seeker and
refugee
population
What are some precipitating aetiological factors of depression?
Biological: Poor compliance with
medication
Corticosteroids
Psychological: Acute stressful life
events (e.g. personal injury, bereavement, bankruptcy_
Social:
Unemployment
Poverty
Divorce
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Perpetuating aetiology of depression?
Psychological: Chronic health
problems (e.g.
diabetes, COPD, CCF
and chronic pain
syndromes)
Biological: Poor insight
Negative thoughts
about self, the world
and the future (Beck’s
triad)
Social: Alcohol and
substance
misuse
Poor social
support
↓ Social status
Epidemiology and RFs for depression?
Depressive disorders are among the leading causes of disability worldwide. Globally >350 million
people suffer from depression.
In General Practice in the UK, each year, about 1 in 20 adults experience an episode of
depression.
Onset is most commonly in the 40s (in ♂) and 30s (in ♀).
RF mnemonic for depression?
FF, AA, PP, SS’
Female/Family history
Alcohol/Adverse events
Past depression/Physical co-morbidities
↓ Social support/↓ Socioeconomic status
Core symptoms of depression
Anhedonia Lack of interest in things which were previously enjoyable to the patient.
Low mood Present for at least 2 weeks.
Lack of energy Also known as anergia.
Persistent sadness or low mood
Loss of interest or enjoyment
Fatigue or Low Energy
Cognitive symptoms of depression
Lack of
concentration
Diminished ability to think or concentrate, nearly every day.
Negative
thoughts
Excessive guilt
Suicidal
ideation
Biological symptoms of depression
Diurnal
variation in
mood (DVM)
The patient’s low mood is more pronounced during certain times of the day,
usually in the morning.
Early morning
wakening
(EMW)
Waking up to 2 hours earlier than they usually would premorbidly. In atypical
depression, there may be hypersomnia (excessive sleep).
Loss of libido Reduced sexual drive.
Psychomotor
retardation
Refers to slow speech as well as slow movement.
Weight loss
and loss of
appetite
Significant weight loss when not dieting, or decrease in appetite nearly every
day. Weight gain and increased appetite may occur in atypical depression
Psychotic symptoms of depression
Hallucinations These are usually second person auditory hallucinations.
Delusions These are usually hypochondriacal, guilt, nihilistic or persecutory in nature
Beck’s cognitive triad of depression?
Negative views about oneself
Negative views of the world
Negative views of the future
What is a useful pneumonic for the main symptoms of depression?
Depressed mood
Energy loss (anergia)
Anhedonia
Death thoughts (suicide)
Sleep disturbance
Worthlessness or guilt
Appetite or weight change
Mentation (concentration) reduced
Psychomotor retardation
Associated symptoms of depression
Poor or increased sleep
Poor or increased appetite
Poor concentration or indecisiveness
Low self confidence
Agitation or slowing of movements
Guilt or self blame
Incidence of depression in younger people
2.7% 11- 16 year olds
0.3% 5 -10 year olds
25% detected and treated
Causes of depression and protective factors in children
School
Bullying
Learning Difficulties
Friendships
Family
Abuse/Neglect
Domestic Violence
Family Support
Drugs and alcohol
Alcohol is a depressant
Speed leads to depression
Phx
Genetic -family history
Thyroid Disorder
Steroids
Chronic Physical Illness
ICD-10 classification of depression?
Mild depression = 2 core symptoms + 2 other symptoms
Moderate depression = 2 core symptoms + 3–4 other symptoms
Severe depression = 3 core symptoms + ≥4 other symptoms
Severe depression with psychosis = 3 core symptoms + ≥4 other symptoms + psychosis
History to find depression?
Explore the core symptoms: ‘How has your mood been recently?’ (low mood), ‘Do you
still enjoy the things that you used to?’ (anhedonia), ‘Do you find yourself feeling tired
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more easily or more worn out?’ (anergia)
Explore the cognitive symptoms ‘Are you able to concentrate on activities, for example,
watching a television programme?’ (lack of concentration), ‘How do you see things
unfolding in the future?’ (negative thoughts), ‘Do you feel life is worth living?’, ‘Have
you had any thoughts of taking your own life?’ (suicidal)*
Explore the biological symptoms: ‘Do you find your mood particularly worse during
certain times of the day?’ (DVM), ‘What time did you used to wake up before you felt
low in mood?’, ‘What time do you wake up now?’ (EMW), ‘Has anyone around you
mentioned that you seem low or restless?’ (psychomotor retardation), ‘When people
feel down, sometimes their sexual drive also goes down, has this happened to you?’
(loss of libido)
If patients suggests suicidal ideation/ activity what should you do?
*If the patient suggests that they are actively suicidal, you must carry out a full risk
assessment
MSE for depression
Appearance Signs of self-neglect, thin, unkempt, depressed facial expression, tearful.
Behaviour Poor eye contact, tearful, psychomotor retardation, slow movements, slow
responses, may sometimes present with psychomotor agitation.
Speech May be slow, non-spontaneous, reduced volume and tone.
Mood Low (subjectively) and depressed (objectively).
Thought Pessimistic, guilty, worthless, helpless, suicidal, delusions (if psychotic).
Perception Second person auditory hallucinations (often derogatory).
Cognition Impaired concentration.
Insight Usually good.
Investigations for depression?
Diagnostic questionnaires: e.g. PHQ-9, HADS and Beck’s depression inventory.
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Blood tests: FBC (e.g. to check for anaemia), TFTs (e.g. to test for hypothyroidis
m), U&Es, LFTs, calcium levels (biochemical abnormalities may cause physical
symptoms which can mimic some depressive symptoms), glucose (diabetes can cause
anergia).
Imaging: MRI or CT scan may be required where presentation or examination is
atypical or where there are features suspicious of an intracranial lesion e.g.
unexplained headache or personality change.
DDs for depression?
Other mood disorders: Bipolar affective disorder, other depressive disorders
(see Key facts 1).
Secondary to physical condition e.g. hypothyroidism (see Overview of mood disorders,
Section 3.1).
Secondary to psychoactive substance abuse.
Secondary to other psychiatric disorders: Psychotic disorders, anxiety disorders,
adjustment disorder, personality disorder, eating disorders, dementia.
Normal bereavement.
Grief
Acute reaction to life event eg bullying
Anxiety – affects sleep, concentration, can cause fatigue
PTSD- affects sleep, concentration, can lead to loss of interest
Co-morbidity ( often associated with Depression)
Post traumatic Stress disorder
Eating disorder
Anxiety Disorder
Drugs and Alcohol misuse
What is recurrent depressive disorder seasonal affective disorder, masked depression, atypical depress?
Recurrent depressive disorder: A recurrent depressive episode refers to when a patient has
another depressive episode after their first.
Seasonal affective disorder: Characterized by depressive episodes recurring annually at the
same time each year, usually during the winter months.
Masked depression: A state in which depressed mood is not particularly prominent, but other
features of a depressive disorder are, e.g. sleep disturbance, diurnal variation in mood.
Atypical depression: This typically occurs with mild–moderate depression with reversal of
symptoms e.g. overeating, weight gain and hypersomnia. There is a relationship between
atypical depression and seasonal affective disorder.
What is dysthymia, cyclothymia, baby blues, postnatal depression?
Dysthymia: Depressive state for at least 2 years, which does not meet the criteria for a mild,
moderate or severe depressive disorder and is not the result of a partially-treated depressive
illness.
Cyclothymia: Chronic mood fluctuation over at least a 2-year period with episodes of elation
and of depression which are insufficient to meet the criteria for a hypomanic or a depressive
disorder.
Baby blues: Seen in around 60–70% of women, typically 3–7 days following birth, and is more
common in primiparae. Mothers are anxious, tearful and irritable. Reassurance and support is
all that is required.
Postnatal depression: Affects approximately 10% of women. Most cases start within a month
and typically peak at 3 months. Clinical features are similar to depression seen in other
circumstances.
What is the management of mild-moderate depression?
Watchful waiting: Should be considered and reassess the patient again in 2 weeks.
Antidepressants: Not recommended as a first-line therapy for mild depression unless: (1)
depression has lasted a long time; (2) past history of moderate–severe depression; (3) failure of
other interventions; (4) or the depression complicates the care of other physical health problems.
Self-help programmes: Patient works through a self-help manual with a healthcare professional
providing support and checking progress.
Computerized cognitive behavioural therapy (CBT): Based on conventional CBT, involves a
computer programme educating them about depression and challenging negative thoughts.
Physical activity programme: Exercise has been shown to benefit mental health. Group exercise
class under the supervision of a qualified trainer may be recommended.
Psychotherapies (see Key facts 2): If the options above fail, psychotherapies can be tried.
