4.5 - Depression (tutorial)

Question 1

What are the three triads of depression?

Answer 1

• core symptoms
• biological symptoms
• cognitive symptoms

Question 2

What are the three core symptoms of depression?

Answer 2

• low mood
• anergia
• anhedonia

Question 3

What are the three biological symptoms of depression?

Answer 3

• sleep
• libido
• appetite

Question 4

What are the three cognitive symptoms/aspects of depression?

Answer 4

• the world
• oneself
• the future

Question 5

How long must symptoms be present for to diagnose depression?

Answer 5

Symptoms must be present for more days than not over a period of at least two weeks

Question 6

What do we assess in a mental state examination?

Answer 6

• appearance and behaviour
• speech
• mood/affect
• thought (content and form)
• perceptions
• cognition
• insight

Question 7

What do we look out for in appearance and behaviour in depression? (6)

Answer 7

• clothes
• poor self-care e.g. greasy hair, smell
• tearful
• limited eye contact, looking down
• usually no evidence of psychomotor agitation/retardation
• normal movements

Question 8

What do we look out for in speech in depression? (3)

Answer 8

• quietly spoken
• monotonous
• normal/slightly reduced rate

Question 9

What do we look out for in mood (objective) in depression? (3)

Answer 9

• low in mood
• flattened affect (reduced emotional range)
• tearful

Question 10

What do we look out for in mood (subjective) in depression? (6)

Answer 10

• fed up, miserable
• reduced energy and motivation
• anhedonia
• feels guilty and useless
• poor concentration
• biological symptoms - disturbed sleep, early morning waking, reduced appetite, reduced libido

Question 11

What do we look out for in thought form in depression?

Answer 11

Thoughts are logically connected and easy to follow - no evidence of formal thought disorder

Question 12

What do we look out for in thought content in depression?

Answer 12

Evidence of hopelessness (‘what is the point’, ‘everything seems black’)

Question 13

What do we look out for in perceptions in depression? (2)

Answer 13

• objective - not objectively responding to perceptual stimuli
• subjective - no hallucinatory experiences reported

Question 14

What do we look out for in cognition in depression?

Answer 14

• not formally assessed using a validated measure (e.g. ACE-III)
• cognition intact, oriented to time, place and person
• no obvious confusional state
• NB pseudodementia important differential to consider in older adults presenting with cognitive symptoms

Question 15

What do we look out for in insight in depression?

Answer 15

• reasonable in depression
• consider insight in several domains - unwell? physical/psychiatric? treatment? risk to themself/others?

Question 16

What are the key features to look for on mental state examination in depression? (5)

Answer 16

• low mood
• poor self-care (self neglect)
• reduced eye contact
• flattened affect
• speech that is monotonous and lacking in prosody

Question 17

When can depression present with a mood congruent psychosis?

Answer 17

E.g. delusions of nihilism guilt or Cotard’s syndrome

Question 18

What makes up the psychiatric history - depression? (5)

Answer 18

• history of presenting complaint
• past psychiatric history
• family history
• treatment history
• substance misuse

Question 19

What do we ask about history of presenting complaint? (8)

Answer 19

• insidious vs acute onset (i.e. due to life event)
• core/cognitive/biological symptoms
• current episode duration?
• diurnal variation?
• suicidal ideation/plans/intent?
• thoughts/acts of self-harm?
• exacerbating and relieving factors - are they taking meds and is it helping? psychological stressors/support?
• relevant physical health conditions e.g. hypothyroidism, anaemia, Cushing’s, chronic pain

Question 20

What do we ask about past psychiatric history as part of psychiatric history (depression)? (7)

Answer 20

• previous episodes? duration?
• did previous episodes resolve with/without treatment?
• history of any other mental illness? (important to rule out manic episodes)
• previous admissions (informal vs under mental health act)
• collateral history (important if patient guarded/poor historian)
• medical notes if available
• previous self harm/suicide attempts

Question 21

What do we ask about family history as part of psychiatric history (depression)? (3)

Answer 21

• any mental illness/intellectual disability/neurodevelopmental diagnoses?
• who e.g. first degree relative?
• what are family relationships like?

Question 22

What do we ask about treatment history as part of psychiatric history (depression)? (7)

Answer 22

• antidepressants?
• antipsychotics?
• mood stabilisers?
• side effects?
• ECT?
• psychology?
• ask: when? how long? what exact medication? doses? well tolerated? did it help?

Question 23

What do we ask about substance misuse as part of psychiatric history (depression)? (2)

Answer 23

• cannabis/alcohol/cocaine/heroin (opiates)/hallucinogens?
• used as self-medicating?

Question 24

What do we ask about forensic history as part of psychiatric history (depression)? (4)

Answer 24

• offending as a youth (consider oppositional defiance disorder and conduct disorder), Youth Rehabilitation Orders
• arrests/cautions/incarcerations/forensic mental health act admissions/probation involvement
• include offences that were perpetrated but for which they were not caught
• NB comorbid substance misuse is biggest risk factor for offending

Question 25

What do we ask about personal history as part of psychiatric history (depression)? (6)

Answer 25

- birth and early developmental (antenatal/perinatal complications, developmental milestones) - schooling (academic performance, truancy at school, peer relationships/bullying) - higher/further education - employment - psychosexual history - premorbid personality

Question 26

How is the risk assessment for depression classified?

Answer 26

- to self - to others - from others

Question 27

How can one pose a risk to oneself? (5)

Answer 27

- current suicidal ideation/plans/intent - previous attempts (method/how many episodes/how did they feel when they survived) - self harm/cutting - self neglect/poor care of physical illness - risk of misadventure (accidental injury due to impulsive and disinhibited acts e.g. in mania)

Question 28

How does one pose a risk to others (depression)?

Answer 28

- rarer in depression but still ask - thoughts/plans to harm others? - command hallucinations (general risk factor for violence) - relevant forensic history - arson, violent offending etc

Question 29

How are depression patients at risk from others?

Answer 29

- vulnerability to exploitation - risk of retaliation from others (esp in manic states when overfamiliar, irritable, disinhibited)

Question 30

What are some differentials to consider when thinking about depression and mania? (6)

Answer 30

- bipolar disorder vs unipolar depression - bipolar disorder vs borderline personality disorder/EUPD - depression vs psychotic prodrome - psychotic depression vs schizoaffective disorder (depressive type) - mania vs schizoaffective disorder (manic type) - mania vs ADHD

Question 31

Why aren't antidepressants used for bipolar disorder?

Answer 31

- appear to be mostly ineffective in acute bipolar depression and in prophylaxis - can cause acute manic/hypomanic episodes - have been shown to worsen the long-term course of bipolar illness in some subjects, especially those with a rapid-cycling course (>4 mood episodes in 12 months) - in rapid-cycling cases they appear to lead to more mood episodes, including depressive states

Question 32

What is a personality disorder?

Answer 32

- maladaptive patterns of behaviour, cognition and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture - these patterns develop early, are inflexible, and are associated with significant distress or disability

Question 33

How do the signs of personality disorder manifest?

Answer 33

As clusters (A, B, C), with each cluster containing different signs

Question 34

What signs of personality disorder are in cluster A? (3)

Answer 34

- paranoid - pattern of irrational suspicion and mistrust of others - schizoid - lack of interest and detachment from social relationships, apathy, and restricted emotional expression - schizotypal - extreme discomfort interacting socially, and distorted cognition and perceptions

Question 35

What signs of personality disorder are in cluster B? (4)

Answer 35

- antisocial - pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour - borderline - pervasive pattern of abrupt mood swings, instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivity - histrionic - pervasive pattern of attention-seeking behaviour and excessive emotions - narcissistic - pervasive pattern of grandiosity, need for admiration, and a perceived or real lack of empathy ## Footnote Antisocial, borderline and narcissism make this hard to distinguish with bipolar affective disorder (BPAD)

Question 36

What signs of personality disorder are in cluster C? (3)

Answer 36

- avoidant - pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation - dependent - pervasive psychological need to be cared for by other people - obsessive-compulsive personality disorder - rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct from OCD)

Question 37

What are the similarities between bipolar affective disorder (BPAD) and borderline personality disorder (BPD)?

Answer 37

- rapid mood changes - unstable interpersonal relationships - impulsive sexual behaviour - suicidality

Question 38

What are the differences between bipolar affective disorder (BPAD) and borderline personality disorder (BPD)?

Answer 38

- BPAD - episodic, genetic, grandiosity, mood states typically less affected by environment - BPD - mood changes over course of hours/days rather than days/weeks, poor self image, fear of abandonment, feeling of emptiness, history of self-harm, history of trauma/disrupted attachment

Question 39

What are the similarities between bipolar affective disorder (BPAD) and schizoaffective disorder?

Answer 39

Both can present with psychosis and mood symptoms (depression and mania)

Question 40

What are the differences between bipolar affective disorder (BPAD) and schizoaffective disorder?

Answer 40

- BPAD - episodic delusions/hallucinations (rarely chronic) - schizoaffective disorder - episodic delusions/hallucinations (residual symptoms more likely); more prominent disorganisation of thought, paranoid delusional beliefs and auditory hallucinations

Question 41

What are the similarities between bipolar affective disorder (BPAD) and attention deficit hyperactivity disorder (ADHD)?

Answer 41

- hyperactivity - impulsivity - impaired concentration - impairment of executive function - abnormal working and short term memory

Question 42

What are the differences between bipolar affective disorder (BPAD) and attention deficit hyperactivity disorder (ADHD)?

Answer 42

BPAD: - not necessarily present in childhood - episodic - family history (genetic) - recurrent depressive episodes - amphetamines worsen mania

Question 43

What are some organic/iatrogenic causes of depression? (5)

Answer 43

- endocrine - hyper/hypothyroidism, hyper/hypoparathyroidism, hypoglycaemia, Cushing's syndrome, Addison's disease - systemic - viral infections, SLE, HIV, cancers (cytokines can cause depression) - deficiencies - vitamin B12, folic acid - neurological - MS, Alzheimer's, Parkinson's - medications - beta blockers, steroids, anti-Parkinson's, some antibiotics (e.g. ciprofloxacin), statins, oestrogen, opiates, acne medications

Question 44

What are two types of depression caused by organic causes?

Answer 44

- vascular depression (subcortical ischaemic depression) - poststroke depression

Question 45

What is vascular depression (subcortical ischaemic depression)?

Answer 45

- associated with white matter hyperintensities - these can impact on cognitive function making the individual more vulnerable to stressors - important to treat vascular risk factors e.g. diabetes/hypertension and address smoking and alcohol use

Question 46

What is poststroke depression?

Answer 46

- sometimes becomes persistent - retardation in thinking and behaviour is sometimes prominent - it has been reported that lesions in left frontal lobe or basal ganglia are able to cause depression - more frontal the lesion, more severe the symptoms