Describe the core symptoms of depression.
- Low mood
a. Pervasively low for 2 weeks (1 week if very severe – in this case will also be very out of touch with reality)
b. May show diurnal variation - Anhedonia
a. Loss of pleasure, even in things previously enjoyed - Low energy
a. Can be very extreme
Describe the cognitive features of depression.
- Distorted thoughts
- Slowed speed of thought
- Reduced concentration and attention (depressive pseudo-dementia)
- Reduced self-esteem and self-confidence
- Ideas of guilt and worthlessness
- Bleak and pessimistic views of the future
- Hopelessness
- Ideas or acts of self harm/suicide
Describe the somatic features of depression.
- Disturbed sleep
- Diminished appetite
- Weight loss
- Loss of libido
- Low energy
- Constipation
- Amenorrhoea
Describe the psychotic features of depression.
- Delusions (“fixed false ideas that are not in keeping with the patient’s usual beliefs”)
a. Mood congruent (i.e. negative)
b. Often involve guilt, poverty, hypochondriasis or persecutory delusions - Hallucinations (“perception in the absence of external stimuli”)
a. Often auditory
Discuss the prevalence of depression.
Point prevalence: 4-7%
Lifetime incidence: 20%
Female:male ratio of 2:1
List the causes of depression.
- Biological causes
a. Genetics
b. Neurochemistry
c. Neuroendocrine - Psychological causes
a. Psychodynamic
b. Behavioural
c. Cognitive distortion - Social causes
a. Predisposing
b. Precipitating
Describe the biological causes of depression.
- Genetics
a. 40-50% concordance in monozygotic twins - Neurochemical theories
a. Dopamine loss
b. Serotonin
c. Noradrenaline - Neuroendocrine theories
a. Hypothalamo-pituitary-adrenal axis
b. Hypothalamo-pituitary-thyroid axis (e.g. hypothyroidism)
Describe the types of cognitive distortion which may cause depression.
- Arbitrary interference
- Selective abstractions
- Magnification
- Minimisation
- Overgeneralisation
- Personalisation
What investigations would you want to do in a patient presenting with depression?
- Good clinical history
- Risk assessment
- MSE
- Blood tests to rule out other causes, e.g.
a. Thyroid
b. Anaemia
c. Medications (e.g. steroids, propranolol)
Describe the biological (pharmacological) treatment of depression.
- SSRIs (selective serotonin reuptake inhibitors)
a. Examples:
- –Sertraline
- –Fluoxetine - TCAs (tricyclic antidepressants)
a. Used less frequently now
b. Example:
- –Amitriptyline - Second line medications:
a. Serotonin-noradrenaline reuptake inhibitors (SNRIs)
- –Example: Venlafaxine
b. Noradrenergic and specific serotonergic antidepressants (NASSAs)
- –Example: Mirtazepine
c. Noradrenergic reuptake inhibitors (NARIs)
- –Example: Reboxetine
List some side effects of SSRIs.
- Nausea/vomiting
- Agitation
- Sexual dysfunction
- Hyponatraemia
- Sweating
Describe the psychological treatment of depression.
- Behavioural therapy
- Cognitive therapy
- Psychotherapy
Describe the social treatment of depression.
- Advice or help with adverse social circumstances, e.g.
a. Housing
b. Finances
c. Employment
d. Relationships
Describe the 2 different theories of adjustment to death/illness.
Kubler Ross:
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Murray Parkes:
- Numbness
- Pining
- Disorganisation and despair
- Reorganisation
What are the features of an abnormal grief reaction?
- Unexpected loss
- Grief despite ambivalent relationships with the person who’s died
- Chronic grief
- Delayed grief
List the steps in the standardised format of an MSE.
- Appearance and behaviour
- Speech
- Mood and affect
- Thought form and content
- Perception
- Cognition
- Insight
Describe what features you would assess in the appearance and behaviour category of an MSE.
Appearance:
- Describe patient’s general appearance
- Biological/chronological age - do they look old for their age?
- Well kempt or not
- Evidence of self-neglect
- Look ill or intoxicated
- Distinguishing features, especially:
a. Self harm scars
b. Tar stains on fingers
Behaviour:
- Level of motor activity (agitation/retardation)
- Eye contact
- Rapport and engagement with interview
- Body language
- Posture
- Unusual/socially inappropriate behaviour
Describe what features you would assess in the speech category of an MSE.
- Rate and quantity of speech
- Rhythm
- Volume
- Tone (e.g. monotone)
- Spontaneity
Describe what features you would assess in the mood and affect category of an MSE.
Mood - “emotional state overall”
- How are they feeling most of the time?
- Subjective - use direct quotes from the patient
- Objective - your impression of the person’s mood during the interview
Affect - “changes in person’s emotions that you observe moment to moment during the interview”
- Reactive - appropriate reaction to the situation or topic being discussed
- Flattened - limited emotional reaction
- Blunted - no observed emotional reactions
- Labile - excessive emotional fluctuations
Describe what features you would assess in the thought form and content category of an MSE.
Thought form:
- Patterns in the patient’s thoughts - are there logical connections?
a. No formal thought disorder - normal pattern
b. Flight of ideas - rapid flow of speech, moving from topic to topic with logical connections
c. Loosening of associations/knight’s move thinking - little/no logical connections
Thought content:
- Delusions - “fixed false beliefs that is not in keeping with the patient’s usual beliefs”
a. Paranoid - perceived threat from others
b. Grandiose - considerable overestimation of ability or possession of special powers
c. Nihilistic - belief that they are dead or do not exist at all
d. Delusions of reference - belief that external events/objects are directly related to them
e. Thought interference - insertion, withdrawal or broadcasting of thoughts - Over-valued idea
- Obsessions - “reccurent, intrusive, distressing ideas/impulses/images that the patient recognises as their own”
Describe what features you would assess in the perception category of an MSE.
- Hallucinations - “perception in the absence of external stimulus”
- Illusion - “false perception of a real stimulus”
Describe what features you would assess in the cognition category of an MSE.
- Alertness
- Orientation
- Attention/concentration
- Memory
- Learning disabilities
Describe what features you would assess in the insight category of an MSE.
- Do they believe their experience is unusual?
- Do they think it is part of an illness?
- Do they think they require treatment?
- Do they think they need to be admitted to hospital?
Describe a full MSE.
- Appearance and behaviour
- Speech
a. Rate
b. Quantity
c. Rhythm
d. Volume
e. Tone
f. Spontaneity - Mood and affect
a. Mood
b. Affect
i. Reactive
ii. Flattened
iii. Blunted
iv. Labile - Thought form and content
a. Thought form:
i. No formal thought disorder
ii. Flight of ideas
iii. Loosening of associations/knight’s move thinking
b. Thought content:
i. Delusions
- –Paranoid
- –Grandiose
- –Nihilistic
- –Delusions of reference
- –Thought interference
ii. Over-valued idea
iii. Obsessions
c. Risk - Perception
a. Hallucination
b. Illusion - Cognition
a. Alertness
b. Orientation
c. Attention/concentration
d. Memory
e. Learning disabilities - Insight
