Depression

Question 1

Screening for depression questions

Answer 1

1. Quantify mood
   - Mood inc. times of day when worse, variations throughout the day
   - “How has your mood been? From 0 to 10 - where on average in past couple of weeks
   - “When things were generally well, what score

Biological
- Sleep cycle inc. difficulties in getting to sleep, waking up early and finding it difficult to get back to sleep
“Has your sleep changed in anyway”

• Energy
• “Have you been feeling tired or worn out?”
• Concentration e.g. reading, television - “difference in following the story “
• Appetite inc. changes in appetite, diet, weight loss/gain/ clothes looser
• Libido ; overall hows your sex drive been - same level or noticed changes

Core symptoms
Anhedonia
What things normally give you happiness or joy
Are you still enjoying them /changes in ability to enjoy

Guilt
- more disappointed in self than usual
- have u noticed u’ve been blaming urself more than usual , in what way?

Hopeless/ worthlessness
- Has it reached the point you don’t want to live anymore
- cont suicide risk

Amotivation
- “Do you feel like you have lost interest or
motivation in doing things?”
- Been feeling overly tired

Question 2

questions additional to screening need to ask for depression

Answer 2

Impact of low mood on life/Function
- “What difficulties in your life has you mood caused?”
- “Does it bother you a lot that you feel this way?”
- “Has it caused problems in your job/school?
Marriage? Relationship with friends/family? Social life?”

• Ruling out other diagnoses
• Mania - “have you ever experiencing periods of feeling particularly high/energetic/euphoric?”
• Psychosis - signpost carefully - “heard voices speaking when no one is around?” etc.
• Substance abuse

Assess risk

Question 3

What are the differentials of depression

Answer 3

• Depressive episode of BPAD
• Schizoaffective disorder
• Dysthymic disorder - persistent depressive disorder: Chronic (≥2yrs)
• 2x neurovegetative symptoms + feeling down/ poor self-esteem/hopeless etc.
• Caused by medication/medical condition -benzodiazepines, zopiclone, opioids, antipsychotics, beta-blockers, corticosteroids,
  anticonvulsants, NSAIDs, anti-Parkinson agents
  (esp. levodopa), H2 receptor antagonists (e.g.ranitidine)
• Atypical depression - improved mood when exposed to pleasurable or enjoyable events i.e. mood reactivity
• Seasonal affective disorder - depressive disorder with seasonal pattern

Dementia - can present similarly to depression in an elderly patient - ‘pseudo-depression of dementia’

Adjustment disorder
- After stressful life event, Symptoms more severe than expected
- Within 3 months of stressful life event

Bereavement
- Symptoms for >2 months characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, psychomotor retardation
- ≥6 months is an abnormal grief reaction

Question 4

What is the diagnostic criteria for major depressive disorder DSM 5

Answer 4

A. ≥2 weeks of depressed mood or anhedonia + ≥2 week hx of + ≥ 5 of
nearly every day, different from previous fx
- Significant weight loss or gain
- Insomnia or hypersomnia
- Psychomotor agitation/retardation
- Fatigue/loss of energy
- Feelings of worthlessness or excessive/ inappropriate guilt
- Diminished concentration, indecisiveness
- Recurrent thoughts of death/suicidality

B. Clinically significant distress or impairment in social/occupational/ interpersonal function

C. Not attributable to substances or another medical condition e.g.
endocrine disorder,
antihypertensives, alcohol/cocaine/PCP/
steroids, schizoid disorder.
= must not have hx of mania /hypomania

Question 5

What is the expected MSE for major depressive disorder

Answer 5

Appearance & Behaviour - disheveled, poorly kept, poor eye contact, psychomotor agitation/ retardation
- Speech & Language - slow, limited in prosody, low volume
- Mood & Affect - dysthymic mood, restricted, affect, congruent
- Thought Form & Content - suicidality, anxiety symptoms, negative cognitions,rumination,
delusions (guilt/poverty/nihilistic)
- Perception - may have auditory hallucinations
- Cognition
- Insight & Judgement - insight often good
- Risk - suicide/self-harm risk, self cares (poor oral intake, hygiene, adverse effects of medications)

Question 6

What is the main framework of IX and management for major depressive disorder

Answer 6

1) decide where
- admit MHA if risk to safety/informal
- 1’ care - fam and friends
- Community treatment - crisis intervention, respite

2) confirm dx
- Collateral hx + old notes, view onset, pattern, severity, self care and previous risk

Ix for organic cause
- review of
- FBC, Iron, U&E, lipids,TFT
- urine tox, MSU, bcg
- baseline ecg ,
- brain imaging - Ct, MRI
- cognitive screening

3.Treatment - Bio , Psycho, Social

Question 7

What is involved in treatment of major depressive disorder

Answer 7

Bio
Antidepressants
1st line: SSRI- ECT if severe
2nd line = SNRI -eg. lafaxine, mirtazapine
3rd line = TCA
Can augment with Lithium if severe

Trial for 4-8 weeks before changing med

Psychological:
o Psychoeducation
o CBT (works best together with meds)
o Interpersonal T, Problem solving therapy
- family, group therapy
- Relaxation techniques - mindfulness
- Lifestyle - sleep hygiene, regular exercise/
healthy diet, reduce alcohol/drug use

o Social (housing, finances, work)
- Mobilise social supports inc. family, help build social networks
- Home/living environment - help organise benefits, housing
- Encourage interests/hobbies
- Optimise protective factors
- Cultural support groups

Question 8

What are the cautions of starting SSRI

Answer 8

• Serotonin syndrome - hyperthermia, agitation, shivering, hyperreflexia, tremor, sweating, dilated pupils, diarrhoea, progressing to seizures, LOC
• Suicidal thoughts/anxiety may develop in a small number of patients taking SSRIs during the first 2-4 weeks of treatment
• Manic switch

Question 9

Explain to a patient, in layman’s terms their diagnosis, situation, treatments for mdd

Answer 9

• You came here today because you were worried about your .. fatigue/poor sleep/ low mood/ feelings about self.
• From the we’ve talked about today, it seems that these symptoms you are struggling with most likely fit a diagnosis of depression.
• Depression is a very common illness, affecting up to 1 in 5 people in their lifetime. This is caused by a variety of factors.
  We believe it is due to problems with brain cells involved in emotion regulation communicating with each other. It is often caused by a combination of factors - eg. our genes, stress and life problems, grief, substance use, chronic illness.
• Depression is a treatable illness with most people recovering from a period of depression within 3-6 months, although it may take longer depending on the severity.
• The main treatments include talking therapies in combination with medications as well as strengthening the support available to you in this time.
• Talking therapies like CBT help you to break the cycle between negative thoughts and actions which can make our mood worse .
• Medications help by balancing certain chemicals in the brain involved in regulating our emotions, it usually takes 1-2 weeks to start working. You may be on them until a few months after you’ve started feeling better.