Psychiatry - Depression

Question 1

Depression?

What is it?

Answer 1

Pervasive low mood diagnosed via ICD-10/DSM-5:

• Symptoms must be present for at least 2 weeks with change from normal mood plus 2-3 core symptoms
• Change in mood not 2ndary to drug/alcohol misuse, medical condition, or adverse life event
• Impairment of social functioning

Question 2

Depression?

Symptoms?

Answer 2

Three broad categories:

Core symptoms:

• depressed mood,
• anergia,
• anhedonia

Negative thinking:

• thoughts of guilt,
• low esteem,
• thoughts of suicide & death,
• poor concentration

Somatic symptoms:

• Decreased weight
• Increased weight - atypical depression
• Sleep disturbance/Early morning waking
• Decreased libido
• Constipation
• Psychomotor retardation/agitation

Question 3

Depression?

Classification of Depression?

Answer 3

Mild(4-5 symptoms):

• Can still continue with daily tasks
• +/- somatic symptoms

Moderate(6-7 symptoms):

• Real difficulty in completing daily tasks
• +/- somatic symptoms

Severe(8-10 symptoms):

• Unable to complete daily tasks
• +/- psychotic tasks

Psychotic symptoms are mood congruent/incongruent:

Mood-Congruent:

• Delusions of poverty, guilt, punishment
• If patient holds delusion that they are dead - Cotard’s syndrome
• Hallucinations
  
  • Auditory: derogatory voices
  • Olfactory: rotting fruit/flesh
  • Visual: tormentors

Mood-Incongruent:

• Thought insertion (The delusion that thoughts are being placed into one’s mind by an outsider; often a symptom of schizophrenia)
• Thought withdrawal (the delusional belief that thoughts have been ‘taken out’ of the patient’s mind, and the patient has no power over this. It often accompanies thought blocking)

Question 4

Depression?

Investigations?

Answer 4

Ensure patient not suffering from organic disorder:

• Careful history
• Use of questionnaires: HADS, PHQ-9, GAD-7
• Assess suicide risk
• Bloods: FBC, U&E, LFTs (GGT & MCV for alcohol misuse), TFTs Hypothyroidism can cause low mood, ESR, glucose, Ca2+, B12, folate
• Specific tests if indicated by Hx & Examn
• Radiology: CT/MRI

Question 5

Depression?

Causes?

Answer 5

Complicated interaction between genetics/neurohormonal and psychosocial factors:

• Genetic: family history of depression
• Neurohormonal: monoamine hypothesis ie low serotonin, noradrenaline and dopamine. Maybe increased cortisol levels
• Psychosocial: Adverse life interests, negative childhood experiences, chronic illness, unemployment, lack of confiding

Question 6

Depression?

Treatment?

Answer 6

Depends on classification of depression?

Mild:

• Conservative therapy
• Exercise regime
• Alcohol and lifestyle advice
• Sleep hygiene
• Guided self-help

Moderate-Severe:

An exercise regime as above

Psychological therapies:

• CBT
• Counselling
• Interpersonal psychotherapy is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment(EST) that follows a highly structured and time-limited approach and is intended to be completed within 12–16 weeks.
• Dynamic therapy is a time-limited and structured psychotherapy, typically delivered over 16 weekly sessions. … DIT focuses mostly on relationship problems. When a person is able to deal with a relationship problem more effectively, his or her psychological symptoms often improve.

Medical Therapy:

• Anti-depressants
• Anti-psychotics
• Anti-epileptics
• ECT