Trastorno Depresivo Flashcards
7.1.
What is the most common symptom reported by patients with
depression?
A. Difficulty sleeping
B. Decreased energy
C. Poor appetite
D. Poor concentration
E. Suicidal ideation
7.1. B. Decreased energy
The most common complaint of patients with depression is reduced
energy (97%). About 80% report difficulty sleeping. Eighty-four
percent report poor concentration. Many patients have decreased
appetite. About 66% have suicidal ideation
7.2.
A 25-year-old man returns to the mental health center after
having been prescribed a selective serotonin reuptake inhibitor
(SSRI) for the past 6 weeks. He states that he is now able to
focus much better in his law school classes. His mood has
improved to the point that he does not “feel like there’s always
a dark cloud over my head.” He reports increased energy,
which he attributes to getting 7 hours of sleep a night “for the
first time in years,” and to “finally being hungry enough to eat
as much as everyone else.” He ends by saying “I thought
everyone felt the same way I did. I didn’t realize I could feel
good most of the time. I had just felt so bad for so long.” What
is the most likely diagnosis?
A. Persistent depressive disorder
B. Major depressive disorder
C. Bipolar disorder
D. Generalized anxiety disorder
E. Cyclothymia
7.2. A. Persistent depressive disorder
Though this patient is reporting being happy, it is in the context of
not feeling as sad, as opposed to grandiosity. There is no history of
mania, so bipolar disorder and cyclothymia would not be diagnosed.
Though generalized anxiety disorder can present with difficulty
concentrating and difficulty sleeping, he does not mention anxiety.
He reports feeling depressed almost all of the time, which is more
consistent with persistent depressive disorder than major depressive
disorder, which has discrete episodes
7.3.
A 70-year-old woman presents to the primary care physician
with complaints of difficulty concentrating over the last 4
weeks. “My brain is in a fog. I’m having trouble remembering
things as well.” She worries that she is showing signs of
Alzheimer dementia, “like my father did before he died.” She
states that she used to do crossword puzzles daily to stay sharp,
“but now I can’t even finish one, so I’ve lost interest.” She
reports difficulty getting to sleep, which she attributes to
anxiety about “forgetting things and losing my mind.” She
notes that she has lost about 4 pounds over the last month due
to decreased appetite. She has no chronic medical illnesses and
takes no medications. Vital signs are within normal limits.
Physical examination reveals no abnormalities. Urinalysis,
urine drug screen, complete blood count, and comprehensive
metabolic panel are all within normal limits. What is the most
likely diagnosis?
A. Dementia of the Alzheimer type
B. Generalized anxiety disorder
C. Major depressive disorder
D. Vascular dementia
E. Normal aging
7.3. C. Major depressive disorder
Given the patient’s relatively sudden and acute onset of cognitive
difficulties, it is unlikely that she has Alzheimer dementia, or that
this is normal aging, both of which would be much more gradual. She
has some symptoms of generalized anxiety disorder, such as
difficulty with concentration and poor sleep, attributed to worrying.
However, it would be uncommon, though not impossible, for it to
present for the first time in the eighth decade (median age is in the
30s). Vascular dementia could present with acute problems in
cognition, but is less likely as she has no history of cardiac or other
health problems. Another explanation for her symptoms of poor
concentration, loss of interest in crossword puzzles, difficulty
sleeping, and decreased appetite is major depressive disorder. If
depression profoundly affects cognition in the elderly, it is
sometimes referred to as “pseudodementia.” Once the depression is
treated, prior cognitive functioning should return
7.4.
Patients with depression are most likely to abuse what
substance?
A. Alcohol
B. Benzodiazepines
C. Cocaine
D. Cannabis
E. Amphetamines
7.4. A. Alcohol
While patients with a depressive disorder at times turn to stimulants
such as cocaine and amphetamines, or to cannabis for relief of
depression, alcohol use disorder frequently coexists in both major
depressive disorder and bipolar I disorder, with a stronger
association with depression in women than in men. People also
sometimes use alcohol in a futile attempt to relieve depression.
7.5.
A 70-year-old man presents to the primary care physician with
a complaint of weight loss. He lost his wife of 45 years 5
months ago, “and I haven’t been the same since. I can’t stop
crying and thinking about her. The only thing that helps is
knowing that when the good Lord calls me home, we’ll be
together in heaven.” He lives alone and has no children or
immediate family nearby. He states that during the day he is
either in the bed sleeping or watching television, “but I just
have it on. I’m not paying attention to it. It can’t keep my
attention anymore.” He goes out to get groceries occasionally,
“but I’m not hungry.” He notes that his pants are now too big.
He used to talk with some friends, “but I don’t feel like doing
that anymore. It takes too much out of me.” Physical
examination reveals an emaciated man who looks older than
his stated age. The electronic medical record shows that he last
lost 30 pounds since his visit 1 year ago, and that his BMI is
now 16, down from 21. What is the most appropriate
management?
A. Referral to a psychiatrist
B. Starting antidepressant therapy
C. Referral to a grief counselor
D. Inpatient hospitalization
E. A social work consult
7.5. D. Inpatient hospitalization
Though the death of his wife was likely the cause of his current
symptoms, he still meets criteria for major depressive disorder. The
most concerning aspect is his nutritional status. Though he does not
appear suicidal, he is in medical danger due to self-neglect from lack
of appetite, confirmed by subjective report and objective measures of
his weight and clothes. He needs to be hospitalized to begin
treatment and refeeding. During hospitalization, the other measures,
such as a psychiatric and social work referral and grief counseling,
can be initiated.
7.6.
A 34-year-old woman is diagnosed with major depressive
disorder for the first time and started on an SSRI. After 8
weeks on a medium dosage of the medication, she states that
she feels “about 50% better. I’m going to work every day, but
it’s still hard to concentrate and I feel a little ‘blah’.” Prior to
starting treatment, she was in danger of losing her job because
she stayed at home in bed for 3 weeks. She is on no other
medications and has no other illnesses. What is the most
appropriate next step in treatment?
A. Continue current management
B. Augment with an antidepressant of a different mechanism
C. Increase the dose of the current medication
D. Begin ketamine treatment
E. Change medication to another antidepressant
7.6. C. Increase the dose of the current medication
The goal in treatment of major depressive disorder is remission, not
reduction of symptoms. As this patient has been on the same dose of
the SSRI for 8 weeks, it is unlikely that she will experience significant
further improvement. The next step is to increase the dosage of the
medication, as it has been somewhat helpful. If the dose increase
yields no further improvement, then augmentation with another
antidepressant of a different mechanism, such as a norepinephrine
dopamine reuptake inhibitor, as opposed to changing medications,
would be indicated given that she has some proven benefit from the
current medication. Ketamine is used for treatment-resistant
depression. Given that this is the patient’s first medication trial, she
should not yet be considered treatment resistant.
7.7.
A 25-year-old woman who has been treated with
antidepressant therapy as an outpatient for the last 3 months
now reports that she is “back to myself.” She states that her
mood is usually an “8 or 9 out of 10, like I was before I got
depressed.” She denies difficulty with energy, concentration,
sleep, or appetite, all of which were impaired during the major
depressive episode, her first, which lasted for 2 months before
she began treatment. She denies ever having suicidal ideation.
Now that she feels better, she wishes to stop the medication.
What is the most appropriate next step in treatment?
A. Start a 1- to 2-week taper now
B. Begin a 1- to 2-week taper in 6 months
C. Taper the mediation over the next 6 months
D. Continue the medication at a lower dose for 6 months, then
reassess
E. Begin a 1- to 2-week taper in 12 months
7.7. B. Begin a 1- to 2-week taper in 6 months
Given that the patient has experienced only one episode of major
depression, which did not warrant inpatient hospitalization or did
not involve suicidal ideation, she is a candidate for an attempt at
medication discontinuation. An antidepressant that has led to
complete remission of symptoms should be maintained for at least 6
months after remission, after which it can be tapered over 1 to 2
weeks, depending on the half-life of the medication. If she were on
her second or more episode of major depression, or this episode was
severe, then maintenance dosing should be considered
7.8.
During a therapy session for a 19-year-old man with major
depressive disorder, he recalls a time 2 years ago in which his
mother told him that she was disappointed in his grades at
school. “Since then, I’ve felt that I always let everyone down
and that I’m a failure at everything.” The therapist challenges
the patient’s belief that he is no good at anything, and helps
him develop a more realistic view of his abilities. This is an
example of what type of psychosocial therapy?
A. Cognitive behavioral
B. Behavior
C. Interpersonal
D. Psychoanalytically oriented
E. Family
7.8. A. Cognitive behavioral
A cognitive behavioral therapist examines a person’s automatic
thoughts (“I’m no good at anything”), cognitive distortions
(generalization), and other maladaptive beliefs and helps them
develop more realistic attributions and ways of thinking. Behavior
therapy usually involves operant conditioning, such as
punishment
and reinforcement, to shape patient responses and interactions.
Behavior therapy does not have many studies supporting its use in
major depressive disorder. Interpersonal therapy focuses intently on
relationships and how dysfunctional relationships can perpetuate
depression. Though the patient talks about his mother in this
example, his distress is centered on his feelings of failure, as opposed
to his relationship with her. Psychoanalytically oriented therapy
focuses on the relationship between therapist and patient, with the
goal of bringing about change in the patient’s personality structure.
Family therapy involves working with multiple family members, as
opposed to just mentioning a family member during a session
7.9.
Studies have consistently shown that a substantial minority of
patients with depression have an increase in what physiologic
chemical?
A. GABA
B. Cortisol
C. Brain-derived neurotrophic factor (BDNF)
D. Prolactin
E. Growth hormone
7.9. B. Cortisol
Several decades of testing of cortisol levels in depressed patients
have shown a hyperactive hypothalamic–pituitary–adrenal axis,
which leads to increased plasma, salivary, and urinary free cortisol
levels, likely due to increased neurons in the hypothalamus. GABA,
BDNF, and growth hormone are all decreased in major depression. A
change in prolactin level has not been found
7.10.
Structural image studies show reduced volume in what brain
structure in elderly patients with depressive disorders?
A. Hippocampus
B. Thalamus
C. Basal ganglia
D. Periventricular areas
E. Hypothalamus
7.10. A. Hippocampus
The increased cortisol, which occurs due to increased corticotrophinreleasing
hormone from the hypothalamus, damages the
hippocampus, which normally inhibits hypothalamic–pituitary–
adrenal (HPA) axis activity. Therefore, in contrast to an increased
number of neurons in the hypothalamus in an individual under
stress, there is a resultant decrease in hippocampal volume in image
studies. This then can set up a feedback loop in which the HPA axis is
further activated, which propagates the neuronal hippocampal loss
due to the increased amount of cortisol. The basal ganglia and
periventricular regions, like the thalamus, also show hyper- versus
hypointensities in structural images
7.11.
What life stressor is most often associated with the
development of depression?
A. Loss of a job
B. Sexual abuse
C. Loss of a parent or spouse
D. Chronic homelessness
E. Divorce
7.11. C. Loss of a parent or spouse
The life event most associated with the development of depression or
the onset of a depressive episode is the loss of a parent before age 11
or the loss of a spouse, respectively. Unemployed persons are more
likely to report depression than persons who are employed.
7.12.
A 44-year-old woman during her first therapy session for
depression recounts that at age 7, she was removed from her
parents and placed in foster care due to their drug use. At age
16, she was doing well in school and at home until her foster
mother died. When she was 35, she lost her job of 10 years due
to the company’s financial problems and resultant bankruptcy.
A month ago, she lost her job of 8 years due to a global
economic downturn. “Why even try? No matter what I do, I
keep getting knocked down.” According to the learned
helplessness theory of depression, what should be the goal of
treatment for this patient?
A. Working through feelings of abandonment by her birth and
foster mothers
B. Helping her develop a more positive sense of self
C. Examining cognitive distortions about the likelihood of
future untoward events
D. Helping her see that her depression is adaptive to the
environmental stressors
E. Assisting her with learning a sense of control and mastery
of the environment
7.12. E. Assisting her with learning a sense of control and
mastery of the environment
The psychosocial theory that best fits this patient’s circumstances is
that of learned helplessness. She has been buffeted by several events
out of her control and therefore, according to learned helplessness
behaviorists, needs to learn that she has some environmental control
in order to alleviate her symptoms of depression. Working through
abandonment feelings and developing a more positive sense of self
would be in line with a psychodynamic theory of depression.
Examining cognitive distortions would be a goal of treatment from a
cognitive theory, and seeing depression as adaptive would be
expected from a therapist subscribing to evolutionary theory
