PSYCH - Depression & medical illness Flashcards
What is major depression?
- 4 features
Abnormal sadness or clinical depression
– PERSISTENT lowering of the mood
–interfere with the person’s ability to function (socially and in work or study or other duties)
–and/or leads to substantial distress
–at least 2 weeks lowered mood for most of the day on most days the minimum duration (DSM-IV and ICD-10)
2 melancholic features of major depression
–Anhedonia: loss of pleasure or reactivity in almost all activities
–Worse in morning; Early morning wakening (2hrs or more); psychomotor retardation/agitation, significant weight loss/anorexia, excessive guilt, distinct quality to depressed mood
What lab findings are associated with major depression?
- Dexamethasone nonsuppression
- elevated cortisol
- alterations of sleep EEG profiles, (tyramine challenge tests)
- asymmetry on dichotic listening tests)
9 questions to elicit symptoms of major depression & its scoring system
- Low energy?
- Loss of interest?
- Lost confidence in yourself?
- Felt hopeless? (If ‘YES’ to any ONE of the above, go on to:)
- Unable to concentrate?
- Lost weight? (due to poor appetite)
- Early waking?
- Felt slowed up?
- Felt worse in mornings?
1 point for each positive answer.
Score of greater than 3 suggests Major Depression
Discuss the DSM-IV criteria for major depressive episode
- criteria for positive result
- chronology of symptoms
- 9 symptoms
At least 5 of the following symptoms (must include either 1. or 2.)
Symptoms present on most days for most of the day, over at least 2 weeks
- Depressed mood
- Markedly diminished interest or pleasure in all or most activities
- Significant weight/appetite loss or gain,
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feeling worthless or excessively guilty
- Diminished concentration or ability to think clearly
- Recurrent thoughts of death (not just fear of dying), suicidal ideas or plans
How (not what) do you perform a mental state examination?
- Begins when the patient enters the room
- Concludes when the patient leaves the room
- Objective and empathic
- Process intermingles with history taking
- Passive observation, active exploration
- Equivalent in psychiatry to the physical examination in internal medicine and surgery
(5) Similarities & (2) differences b/w MSE & physical examination
Similarities:
•Most objective part of the clinical assessment
•Based on clinician’s own direct observations rather than patient’s (or relatives’) report of their symptoms and behaviour
•Occurs at a particular point in time and should be documented as such
•Is reported in a conventional format under headings, in a conventional order of findings, no abnormality is also reported where relevant to the case
•Can be used as part of diagnostic process and also to monitor clinical progress and/or response to treatment
Differences:
•Occurs throughout the clinical encounter (not at a particular point like the physical examination)
•Some mental state clinical “signs” can be directly observed (eg agitated fidgeting, responding to hallucinations) but some must be inferred from what the patient says in the interview
8 components of mental state examination
- Appearance
- Behaviour and Attitude to Interview e.g. downcast demeanour furrowed brow, stooped posture, slowed activity, reduced spontaneity of movement and gesture , tearfulness
- Speech and Language*: e.g. monotone voice, slow responses
- Mood and Affect: e.g. little modulation of affect, flattened affect if severe
- Thought Process and Thought Content: e.g. negative and pessimistic themes suicidal ideas or plans, c/o poor concentration, lack of motivation, guilt, burden, hopeless helpless, worthlessness
- Perception
- Cognition*
- Insight
NOTE: important not to ascribe neurological deficits (*) to MSE
What is major depressive episode an independent risk factor for?
AMI
Cardiovascular risk of mental illness
- (3) direct effects
- (4) indirect effects
–Equivalent to smoking, raised cholesterol or hypertension
–Evidence that it impacts of recovery
–Increased risk further heart related incidents, AMI, and sudden death
Due to: Direct effects: -Changes in cortisol -Increased platelet aggregation -Heart rate variability
Indirect effects:
- Reduced motivation
- Increased smoking
- Poor adherence to diet, exercise
- Avoidance
Describe the complex causal directions of psychiatric disorders and medical conditions
- Medical conditions can cause symptoms of Major Depression and Anxiety Disorders
- Substance Abuse can directly lead to medical conditions
- Mood and Anxiety Disorders can present with physical symptoms resembling medical conditions (eg Panic Attacks may resemble cardiac event)
Describe major depression in the physically ill
•Common
•Just because its understandable doesn’t mean it shouldn’t be treated
•Yet diagnostic framework less helpful
•Harder to interpret symptoms in a severely medically ill inpatient
–Anorexia, weight loss, insomnia, fatigue, reduced concentration
–may be due to physical illness and unfamiliar hospital environment
What are some medical conditions associated with depression symptoms
- Stroke
- Parkinson’s Disease
- Hypothyroidism
- Hypomagnesaemia
- Cushing’s Syndrome
- Addison’s Disease
- Hypocalcaemia
- Viral infections
- Delirium in apathetic form
- Dementias
- Vitamin B group deficiencies
Describe anxiety
- define
- Cognitive symptoms
- physical symptoms
- behavioural symptoms
- Diffuse, unpleasant, vague sense of apprehension
- Physical Discomfort
- Adaptive: fight or flight
Cognitive Sx: fear, embarrassment, impending doom, doubt. Panic attacks, generalised anxiety disorder
Physical Sx: increased HR, RR, tremor, sweating
Behavioural Sx: avoidance
What are some questions to elicit generalised anxiety disorder?
- Have you felt keyed-up, and on edge?
- Have you been worrying a lot?
- Have you been irritable?
- Have you had difficulty relaxing?
If Yes to any 2 of the above, go on to:
- Have you been sleeping poorly?
- Have you had headaches (or neckaches; or tightness in head)?
- Dizzy; trembly; sweating; diarrhoea; frequency; tingling etc. (automatic anxiety)?
- Been worried about health?
- Difficulty falling asleep?
Anxiety states usually score at least 5
