Depression

Question 1

What is depression?

Answer 1

Refers to both negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities)

Question 2

Def: Euthymic

Answer 2

Normal mood

Question 3

Def: Hyperthymic

Answer 3

Elevated mood

Question 4

Def: Cyclothymic

Answer 4

Variable mood

Question 5

Def: Anhedonia

Answer 5

Loss of enjoyment/pleasure

Question 6

Def: Anergia

Answer 6

Lack of energy

Question 7

Def: Amotivation

Answer 7

Lack of motivation

Question 8

Def: Diurnal variation

Answer 8

Varying over the course of the day

Question 9

Def: Early morning wakening

Answer 9

Waking at least 2 hours before expected waking time

Question 10

Def: Psychomotor retardation

Answer 10

Subjective or objective slowing of thoughts and/or movement

Question 11

Def: Stupor

Answer 11

Absence of relational functions (E.g. Action and speech)

Question 12

What are some risk factors for depression?

Answer 12

• Genetic susceptibility
• Life factors - i.e. social situation e.g. single mums
• Alcohol/drug dependence
• Abuse (sexual or not) - particularly in childhood
• Unemployed
• Previous psychiatricdiagnosis
• Chronic disease
• Lack of a confiding relationship
• Urban population
• Post natal period

Question 13

What are some sub-types of depression?

Answer 13

Psychotic depression
Cotard’s syndrome (Nihilistic delusion)
Somatic syndrome
Atypical depression
Late-onset depression

Question 14

What is meant by psychotic depression?

Answer 14

A form of depression in which there are psychoses, occasionally paranoid, which are typically hypochondriacal and are congruent with mood

Question 15

What is Cotard’s syndrome

Answer 15

A syndrome of severe depression in which the person believes they are dead or they are an empty shell with rotting innards
Most common in the elderly

Question 16

What are some somatic symptoms of depression

Answer 16

• Marked loss of interest or pleasure in activities that are normally pleasurable
• Lack of emotional reactions to events or activities that normally produce an emotional response
• Waking in the morning 2 hours or more before the usual time
• Depression worse in the morning
• Objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people)
• Marked loss of appetite
• Weight loss (5 % or more of body weight in the past month)
• Marked loss of libido

Question 17

What are the features of atypical depression?

Answer 17

• Mood reactivity (that is, mood brightens in response to actual or potential positive events)
• Significant weight gain or increase in appetite
• Hypersomnia
• Leaden paralysis (heavy, leaden feelings in arms or legs)
• Long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

Question 18

What is late-onset depression?

Answer 18

Depression occurring for the first time in later life (>65)

Question 19

What are some risk factors for late-onset depression?

Answer 19

• Genetic susceptibility
• Life events (i.e. loss of spouse)
• Social factors (i.e. Loneliness, financial hardship)
• Poor physical health (especially vascular disease)

Question 20

What are some symptoms of depression?

Answer 20

• Classic triad:
  
  • Anhdonia - loss of enjoyment/pleasure
  • Anergia - lack of energy
  • Amotivation
• Diurnal variation - typically worse earleier in the day
• Early morning wakening - waking at least 2 hours before the expected/normal waking time

Question 21

MSE - Depression - Appearance

Answer 21

May be signs of personal neglect

Question 22

MSE - Depression - behaviour

Answer 22

• Rapport is often difficult to establish
• Reduced eye contact
• Reduced facial expression
• Brow is classically ‘furrowed’
• Limited gesturing - movements may be slowed, or absent
• Psychomotor retardation - subjective or objective slowing of thoughts and/or movements

Question 23

MSE - Depression - Speech

Answer 23

• Reduced rate of speech
• Lower in pitch
• Reduced volume
• Reduced intonation
• Increased speech latencies
• Limited content

Question 24

MSE - Depression - Mood

Answer 24

• ‘Low, ‘down’, ‘miserable’, ‘unhappy’, ‘sad’
• Can be described as ‘flat’
• Often ‘empty’, ‘black’, ‘numb’

Question 25

MSE - Depression - Affect

Answer 25

- Depressed i.e. low - Reduced range (stays low throughout) - Limited reactivity - affect doesn't respond or react to changes in subject, context, or emotion - May report emotional paralysis

Question 26

MSE - Depression - Thought

Answer 26

- Form: typically normal - Flow: thoughts are slow, pondering, can be almost absent - Content: negative, self-accusatory, failure, guilt, low self-esteem, pessimism, delisions, suicidal thinking - Cotard's syndrome (nihilistic delusions)

Question 27

MSE - Depression - Perception

Answer 27

- In most cases there is no perceptual disturbance - Some people report increased self-reference thinking ('people are talking about me' - Hallucinations can occur - almost always auditory, usually second person and derogatory ('you are a bad person and deserve to die')

Question 28

MSE - Depression - Cognition

Answer 28

- Subjectively, cognition is slow with complaints of poor memory - 'Pseudo-dementia' - Typical deficits involve working memory, attention, and planning - Often compounded by anxiety

Question 29

MSE - Depression - Insight

Answer 29

- Insight is typically preserved - People are usually aware of their symptoms - recognition is commonly intact - However, attribution can often be affected by the illness - symptoms may be blamed on sins, physical illness, personal failings, or weakness

Question 30

What is the main diagnostic criteria used for depression in the UK and Europe?

Answer 30

ICD-11

Question 31

What are the 4 main depressive disorders recognised by ICD-11?

Answer 31

- Single episode depressive disorders - Recurrent depressive disorder - Dysthymic disorder - Mixed depressive and anxiety disorder

Question 32

What are the 3 severity classifications for depression?

Answer 32

Mild Moderate Severe

Question 33

What is the ICD-11 criteria for classification of a depressive episode

Answer 33

A period of depressed mood or diminished interest in activities occurring most of the day, nearly every day during a period lasting at least 2 weeks, accompanied by other symptoms such as: - Loss of confidence or self-esteem - Unreasonable feeling of self-reproach or excessive and unreasonable guilt - Recurrent thoughts of death/suicide, or any suicidal behaviour - Complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation - Change in psychomotor activity - with agitation or retardation (either subjective or objective) - Sleep disturbance of any type - Change in appetite (increase or decrease) with corresponding weight change

Question 34

Criteria for mild depression

Answer 34

- Patient is distressed by the symptoms - Has some difficulty continuing to function in one or more domains (E.g. Social, occupational) - No delusions or hallucinations

Question 35

Criteria for moderate depression?

Answer 35

- Several symptoms to a marked degree OR - A large number of symptoms to a lesser degree - There is usually considerable difficult functioning in multiple domains (E.g. Social, occupational)

Question 36

Criteria for severe depression

Answer 36

- Many or most symptoms to a marked degree OR - A few symptoms to an intense degree - Serious difficulty in most domains (E.g. Social, occupational)

Question 37

Management of mild depression

Answer 37

No anti-depressants Watchful waiting and assessment within 2 weeks Possible low-intensity interventions such as CBT

Question 38

Management options for moderate-severe depression

Answer 38

Anti-depressants (1st line) High-intensity psychological treatment (CBT, interpersonal therapy) Psychiatric referral (If required) ECT (Severe)

Question 39

1st line pharmacological management of depression

Answer 39

SSRI

Question 40

2nd line pharmacological management of depression

Answer 40

Switch SSRI

Question 41

3rd line pharmacological management of depression

Answer 41

Add or swap antidepressant (E.g. SNRI, Tricyclic, MAOI)

Question 42

What is ECT?

Answer 42

Electroconvulsive therapy Given under general anaesthetic twice a week Very useful in severe depression

Question 43

Management of mild depression in children

Answer 43

- Watchful waiting for 2 weeks - Group IPT/CBT, non-directive supportive therapy for 2-3 weeks

Question 44

Management of unresponsive or moderate-severe depression in children

Answer 44

1. Individual CBT, IPT, family therapy, psychodynamic psychotherapy 4-6 sessions 2. Fluoxetine 3. Sertraline or citalopram

Question 45

How is response to management in depression monitored?

Answer 45

There are 2 main symptomatology questionnaires used for monitoring response in depression treatment: - IDS-30-SR (30 item patient-rated scale) - QIDS (Quick version)