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Year 5 - Psychiatry > Depressive disorder > Flashcards

Depressive disorder Flashcards

1
Q

What are the 3 key symptoms of depression?

A
  1. Low mood
  2. Low energy
  3. Anhedonia - like a glass screen where nothing makes anything better.
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2
Q

How big of a problem is depression?

A

WHO when ranked diseases by contribution to the global burden of disease in terms of its impact on normal life (disability-adjusted life-years; DALYs), unipolar major depression came second after ischeamic heart disease

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3
Q

How common is depression? What is the median age of onset?

A
  • The 1-year prevalence of major depression in the general population is 5.3% and lifetime prevalence is 13%.
  • Mean age of onset of depression is 30 years.

Up to 30% of primary care patients have depressive symptoms (6–10% satisfy criteria for major depressive disorder)

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4
Q

What are the sex differences in incidence of depression?

A

Women have a higher prevalence, incidence and morbidity associated with depressive disorders compared with men.

Incidence 2:1 F>M

Approx 1 in 4 women and 1in 10 men develop depression severe enough to require treatment at some point in life.

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5
Q

What are the risk factors for depression?

A
  • Female sex
  • PH of depression or other MH problems
  • Significant physical illness
  • Afro-Caribbean, Asian, refugee and asylum seeker communities
  • Social factors
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6
Q

What is the pathophysiology of depression?

A

Monoamine theory of depression

Predicts that pathophysiology of depression is a depletion in the levels of serotonin, norepinephrine, and/or dopamine in the central nervous system.

Ascending and descending tracts

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7
Q

What is the rol of 5HT and NA in mental and physical illness? Give a list of examples.

A
  • Depression
  • Anxiety
  • Pain perception
  • Vasoconstriction
  • Urethral sphincter contraction
  • Bladder wall relaxation
  • Pilomotor contraction
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8
Q

What are the (non-psychiatric) differential diagnoses for depression? List 10.

A

Medications - antihypertensives (BB, methyldopa, CCB), steroids, H2 blockers, sedatives, muscle relaxants, retinoids, chemotherapy agents, sex hormones like oestrogen, psychiatric medications

Substance misuse - alcohol, benzo, opiates, cannabis, cocaine, amphetamines

Neurological - dementia, Parkinson’s disease, tumours, stroke

Endocrine - hyper/hypothyroidism, Addison’s, Cushing’s disease, menopause, hyperparathyroidism

Metabolic - hypoglycaemia, hypercalcaemia, porphyria

Others - anaemia, infection (syphilis, Lyme disease, HIV, encephalopathy), sleep apnoea

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9
Q

What psychiatric conditions can mimic depression? Name 5.

A
  1. bipolar disorder
  2. dysthymia
  3. anxiety disorder
  4. schizoaffective disorder
  5. schizophrenia (negative symptoms)
  6. personality disorder
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10
Q

What investigations are used to exclude physical illness in depression?

A

Blood tests:

  • BM
  • U&E
  • LFTs
  • TFTs
  • Calcium levels
  • FBC
  • Other inflammatory markers
  • Magnesium levels
  • HIV/syphilis serology
  • Drug testing

Imaging - only done in atypical presentation when suspicion of intracranial lesion e.g. unexplained headache or personality change.

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11
Q

What two common screening tools are used for depression?

A

PHQ-9 - Patient health questionnaire - 9 questions to diagnose and assess severity of depression (3 mins). 1-4 is minimal, 5-9 is mild, 10-14 is moderate, 15-19 is moderately severe and 20-27 is severe depression.

HADS - Hospital anxiety and depression scale - assesses for both anxiety and depression and takes 5 min. 0-7 is normal, 8-10 is mild, 11-14 is moderate, and 15-21 is severe

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12
Q

What is the ICD-10 criteria for depression?

A

Must last for at least 2 weeks and represent a change from normal AND must not be secondary to other causes (e.g. drugs, alcohol misuse, medication)

Core symptoms of depression:

  • Low mood
  • Anhedonia
  • Reuced energy or fatigue

Other symptoms:

    • Sleep disturbance
      • Diminished appetite
      • Lack of libido
    • Reduced concentraton and attention
      • Reduced self esteem/self confidence
      • Bleak pessimistic views of the future
    • Ideas of guild and worthlessness
      • Ideas or acts of self harm or suicide

(this is just a grouping ^ for revision purposes)

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13
Q

Are people with depression always mood congruent?

A

No, can sometimes be mood incongruent with psychotic symptoms.

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14
Q

List 3 groups of psychotic symptoms that can occur in depression.

A

Delusions - usually mood congruent

Hallucinations - 2nd person usually

Catatonic symptoms - e.g. psychomotor retardation aka depressive stupor

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15
Q

What kind of delusions may be present in depression?

A

Mood congruent usually and therefore usually:

  • nihilistic
  • poverty
  • overbearing guilt for misdeeds
  • responsible for world events
  • deserving of punishment
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16
Q

What kind of hallucinations can occur in depression?

A

Range of modalities but usually 2nd person auditory hallucinations

Auditory - derogatory voices, cries for help or screaming

Olfactory - usually bad smells such as rotting flesh and faeces

Visual - demons, the devil, torturers, dead bodies etc

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17
Q

What catatonic symptoms occur in depression?

A

Catatonic symptoms are marked psychomotor retardation aka depressive stupor:

  • paucity of movement,
  • including immobility,
  • staring,
  • mutism,
  • rigidity,
  • withdrawal
  • refusal to eat
18
Q

How many symptoms must you have to be diagnosed with severe vs mild depression?

A

Mild - 2 core, 2 other

Moderate - 2 core, 3+ other

Severe - 3 core, 4+ other

Severe with psychosis - severe + psychosis (delusions+/- hallucinations)

19
Q

What type of insomnia is seen in depression?

A

Early morning wakening

(Anxiety causes problems falling asleep)

20
Q

What types of affect exist?

A

Reactive - this is when someone reacts as expected to something

Incongruent - reacting in the opposite way of what you imagine

Flattened - completely, restricted or reactive

21
Q

What is the management of mild-to-moderate depression?

A
  1. Watchful waiting + assess again within 2 weeks
  2. Consider low intensity psychosocial interventions e.g. self-help based on CBT, computerised CBT, relaxation therapy, or 6-8 sessions of brief CBT/counselling/problem solving therapy

NB: risk:benefit ratio of antidepressants is poor for mild depression

22
Q

What is the management of moderate-to-severe depression?

A

If suicidal thoughts/risk then urgent psychiatric referral e.g. Crisis team

1.Antidepressants - NNT is 4-5

AND

2. High intensity psychological treatment (CBT or interpersonal therapy)

3. ECT - fast and short improvement of severe symptoms and if all other treatment options have failed or when life-threatening situation

4. Consider admission in the following cases:

  • Risk to self - neglect or risk of suicide/self-harm, poor insight, treatment resistant depression, psychotic symptoms
  • Risk to others
  • Poor social support
23
Q

What is atypical depression?

A

Subtype of depression with slightly different symptoms

24
Q

How common is atypical depression and who is most at risk?

A
  • F>M
  • Onset usually in late teens and early 20s
  • FH of affective disorders
  • Usually have comorbid anxiety, somatisation or alcohol/drug misuse
25
Q

What are the clinical features of atypical depression?

A
  • Mood - depressed but remains active (no anhedonia)
  • Fatigue - extreme
  • Reversed duirnal variation in mood
  • Hypersomnia - >10 hrs a day at least 3 days/week for 3 months
  • Hyperphagia - with weight gain >3kg in 3 months
  • Interpersonal rejection sensitivity
  • Laeden paralysis - heaviness of limbs for 1hr/day for at least 3days/week for 3 months
26
Q

What is laeden paralysis?

A

Feelings of heaviness of the limbs for 1hr/day for at least 3 days/week over 3 months

May occur in atypical depression

27
Q

What is dysthymia?

A

Chronci low grade depressive symptoms which are usually long lasting (over years) but the person did feel ‘well’ before.

28
Q

How common is dysthymia in the UK?

A

5% UK prevalence

Higher in females (2:1)

29
Q

What are the clinical features of dysthymia?

A
  • Depressed mood (>2 years)
  • Reduced energy and fatigue
  • Appetite may be increased/reduced
  • Insomnia/hypersomnia
  • Low self esteem
  • Poor concentration
  • Difficulties making decisions
  • Thoughts of hopelessness
30
Q

What is the prognosis with dysthymia?

A

Usually less severe than depression but more chronic

Low spontaneous remission rate, on average lasting ~5 years

Only 10% achieve remission within a year of treatment

25% suffer chronic symptoms

31
Q

What are the clinical features of SAD (seasonal affective disorder)? What is the pathophysiology?

A
  • Low mood occurs with change of season i.e. depression in winter with remission in spring
  • There is an increase in appetite including ‘carbohydrate craving’

Pathophysiology: Likely related to melatonin synthesis, sunlight hits the pineal gland with decreases melatonin synthesis (increasing 5HT synthesis)

32
Q

What is the mangement of SAD?

A
  • Simple measures like light therapy (specialised SAD lights)
  • Medication - antidepressants, propranolol
33
Q

What are the general treatment phases of depression?

A
  • Acute phase
  • Continuation phase
  • Maintenance phase

Remission, recovery (remission for significant time) and relapse can occur throughout

34
Q

Which of the following is a core symptom of depression according to the ICD criteria?

  • A. Sleep disturbance
  • B. Diminished appetite
  • C. Reduced self confidence
  • D. Ideas or acts of self harm or suicide
  • E. Reduced energy or fatigue
A

E

35
Q

Which of the following is correct?

  • A. Moderate Depression = 2 core symptoms + 3 other symptoms
  • B. Mild Depression = 3 core symptoms + 1 other symptoms
  • C. Moderate Depression = 3 core symptoms + 2 other symptoms
  • D. Severe Depression = 2 core symptoms + 4 other symptoms
  • E. Mild Depression = 2 core symptoms + 3 other symptoms
A

A

36
Q

A 35 year old woman presents to her GP asking for a sick note. She has been struggling at work as a teaching assistant for the last 2 months ; she struggles to concentrate for long periods and has no energy to run around after the children. She feels guilty as a result and thinks she is no good as a teacher or a human. She comes home from work and cannot face going to her jazzercise class or for dinner with friends. She tells the GP that she had similar symptoms a year ago, and also for the two years preceding this, always during the Christmas term at school.

  • Seasonal Affective Disorder
  • Depression secondary to hypothyroidism
  • Dysthymia
  • Bipolar Affective Disorder Type I
  • Atypical Depression
A

SAD

37
Q

What kind of questions are importnat to ask in depression?

A
38
Q

How do you ask about suicidal thoughts in depression?

A

Do not be afraid to ask as it does not make them more suicidal

Remember to link it in with the question

Must ask in depth questions including why/how/why not yet

39
Q

What else should you ask about self harm/suicide attempt?

A

Get as much detail as possible

  • Was it planned/spur of moment
  • What happened during the incident?
  • What kind of preparation did you go through?
  • What exactly did you take do? Was there anyone around? Any alcohol? What did you do afterwards?

Then ask the most important questions: (1) what they thought would happen and (2) how they feel now

40
Q

What difficult question may need to be asked in depression?

A
41
Q

What biological symptoms are seen in depression?

A
  • reduced sleep
  • appetite
  • energy
  • concentration
  • libido
42
Q

What negative cognitions are seen in depression?

A
  • hopelessness
  • worthlessness
  • guilt

Year 5 - Psychiatry (53 decks)

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