Depression - F33 Flashcards
What is some epidemiology for depression?
4-10% of people in England will experience depression in their lifetime
Mixed anxiety and depression is the most common mental disorder in Britain – 11.4% of people meet the criteria for diagnosis
Depression is the most common mental health problem worldwide
Major depression is thought to be the second leading cause of disability worldwide (behind lower back pain, 2013) and a major contributor to the burden of suicide and ischemic heart disease - 50% increased mortality
What is some epidemiology for suicide and self harm?
(England, 2016)
Suicide attempts – 16.6/100,000
Self harm – 7.3/100
Suicide is far more common in men
i) 78% m vs 22% f (2013 study)
What is the aetiology of depression?
Genetic susceptibility + lifestyle factors
Environment
i) Social situation i.e. single mums
ii) Drug or alcohol dependence
iii) Abuse – potential sexual origins, often in childhood
iv) Unemployment
v) Urban populations
Other
i) Previous psychiatric diagnosis
ii) Chronic disease
iii) Post-natal – 10% of all mothers
What is the pathophysiology of depression?
Very complicated, not completely understood
Monoamine theory -
depression is a result of the under activity of monoamine neurotransmitters ie 5HT and NAd and increased numbers of their receptors
i) Theory is supported by the efficacy of drugs used to treat depression that act on these neurotransmitters that are are also responsible for the decrease of their receptors over a number of weeks
Anatomy - 5HT neurons in the Raphe area of the midbrain with projections to the limbic system and cerebral cortex; locus cereleus and lateral tegumental areas of the midbrain; hypothalamic areas etc
Also CRH/ATCH level imbalances; neuronal loss in certain areas
How does depression present?
Low mood – little fluctuation in the day to day, though may be worse in mornings/evenings, unresponsive to circumstance; may experience emotional numbness
Anhedonia – a reduction in enjoyment in activities previously enjoyed
Reduced energy (above 3 are core)
Reduced concentration (leading to memory problems)
Ideas of guilt/worthlessness
DSM/SI/SA
Psychomotor retardation (slowing of thoughts and movements including speech and affect)
Marked tiredness, even after minimum effort
Sleep disturbance – may wake in mornings (>2) hours before usual time
Appetite disturbance – decrease, unintentional weight loss (or gain)
Agitation
Loss of libido
What is a mnemonic to remember the symptoms of depression?
FACESLIPS
i) Feelings of guilt/anger/worthlessness
ii) Appetite/diet/weight change
iii) Concentration impaired
iv) Energy (to perform daily activities) low
v) Sleep disturbances
vi) Libido decrease, + loneliness
vii) Interests and hobbies – doesn’t do
viii) Psychomotor agitation (emotional distress and restlessness i.e. pacing, wringing hands, uncontrollable tongue movement, damaging own skin, chewing nails/fingers/lips
ix) Self harm/suicidal ideation or plan
How do you classify depressive episodes?
Episodes last at least 2 weeks with symptoms experienced for at least part of the day every day for that time
Mild depressive episode – core + 2-3 symptoms usually present, patient distressed but able to continue with most activities
Moderate depressive episode – core + 4 or more symptoms, patient likely to have great difficulty in continuing with ordinary activities
Severe depressive episodes w/o psychotic symptoms – several of these symptoms present, patient markedly distressed, loss of self-esteem and guilt/worthlessness are common, as are suicidal thoughts and acts
How do you diagnose recurrent depression disorder?
Repeated episodes of depression without any history of mood elevation and increased energy (mania)
i) There may be episodes of hypomania immediately following episodes of depression and potentially precipitated by antidepressant treatment
Classification into the severity of the current episode – mild/moderate/severe/+- psychosis
How do you treat mild depression?
Watchful waiting
Self help i.e. exercise, mindfulness
Computerised CBT
How do you treat moderate-severe depression?
Pharmacology
i) SSRI’s are the first line – fluoxetine, citalopram
ii) If 1st unsuccessful, try another in the same class before changing classes
iii) Other drugs are tricyclics, MAOIs, NASSAs, St John’s Wort
Psychological interventions
Social support
How do you treat treatment-resistant or psychotic depression and those at high risk?
Poly-pharmacology
i) Add antipsychotics if necessary
Intensive and complex psychological interventions
ECT
What else is important in the treatment of depression?
Make sure patient knows is aware of crisis services should they be required
Be aware for potential increased agitation, anxiety and suicidal ideation early in treatment or at times of stress - actively seek out these symptoms during reviews and review treatment if these symptoms persist/develop
What is the prognosis for depression?
Very good, most will make a full recovery (though episodes may continue throughout life)
Greatest mortality risk is from suicide when treatment taking time to work
Treatment should be continued for a minimum of 6-12 months after symptoms stop or patients highly likely to relapse
Factors for increased likelihood of positive outcome
i) Large loss event precipitating the depression
ii) Normal pre-morbid personality
What is some epidemiology of post natal depression?
Affects 10% of women after childbirth
Suicide is the leading cause of maternal death postpartum
Important as affects woman’s health as well as children and newborn
What is a grief reaction?
Normal response to a significant loss e.g. of spouse, or being diagnosed with a serious illness (e.g. grieving the loss of your health)
