How are depressive disorders classified?
Specific symptoms: -major depression -persistent depressive disorder (dysthymia) -other specified / unspecified Dd/o Aetiology: -premenstrual dysphoric d/o -depressive d/o due to medical condition -substance/medication induced depressive d/o
Incidence depressive symptoms reported in primary care? Prevalence major depression?
Depressive symptoms: 30%
Major depression: 10%
Depression v demoralisation and grief?
-tied to thoughts / reminders inciting event
-resolve when circumstances / events imporve
-interspersed with periods of positive emotion and humour
-not accompanied by pervasive feelings of worthlessness and self loathing
-lasts days (cf wk - mo)
-suicidal thoughts and loss of function less likely
BUT CAN PRECIPITATE major depression
Aetiology depression?
- Unknown
- Genetic (~50%) and environmental contributions
- ?changes to NA/DA/5HT neurotransmission
- ?neuroendocrine dysregulation (HPA, HPT axes; growth hormone)
- Psychosocial fx (stress etc)
Theories as to why women at greater risk of depression?
- Greater exposure/response to stresses (+ response to adversity ==> ruminative v active)
- Higher MAO levels
- Higher incidence thyroid dx
- Endocrine changes with menstruation / menopause
- power / parity / marriage role
What is SAD?
- Sx in seasonal pattern
- usually Autumn / Winter
- usually climates with long / severe Winters
Which conditions are commonly accompanied by depression?
- Thyroid / adrenal d/o
- Benign and malignant brain tumours
- Stroke
- AIDS
- Parkinsons
- MS
Which drugs may precipitate depressive d/o?
- Corticosteroids
- Some B-blockers
- Interferon
- Reserpine
- Abuse of recreational drugs (EtOH, amphetamines)
Symptoms of depression?
- Cognitive, psychomotor and other dysfunction:
- -poor concentration
- -fatigue
- -loss of sexual desire
- -anhedonia
- -sleep disturbance
- -suicidal ideation
- -anxiety / panic attacks
Medical sequelae of depression?
- Reduce protective immune responses
- Increased risk CV d/o, MI and stroke
Why does depression have CV consequences?
?in depression cytokines and pro clotting factors are elevated, HR variability decreased (all potential RFx for CV d/o)
Appearance pt with major depression?
- Miserable with tearful eyes
- Furrowed brow
- Down turned corners of mouth
- Slumped posture
- Poor eye contact
- Lack of facial expression
- Little body movement
- Speech changes (soft voice, lack of prosody, monosyllabic)
- May neglect personal hygiene
Symptoms for Dx major depression?
≥ 5 present nearly every day in same 2-wk period, one must be depressed mood or anhedonia (loss of interest or pleasure):
- Depressed mood most of the day
- Markedly diminished interest or pleasure in all or almost all activities for most of the day (anhedonia)
- Significant (> 5%) weight gain or loss or decreased or increased appetite
- Insomnia (often terminal insomnia + EMW) or hypersomnia
- Psychomotor agitation or retardation observed by others (not self-reported)
- Fatigue or loss of energy
- Decreased libido
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think or concentrate or indecisiveness; set shifting
- Recurrent thoughts of death or suicide, a suicide attempt, or a specific plan for committing suicide
What is persistent depressive disorder (PDD)?
-Depressive symptoms that persist for >2y w/o remission
Symptoms and signs of PDD
- Habitually gloomy, pessimistic
- Humorless
- Passive
- Lethargic
- Introverted
- Hypercritical of self and others
- Complaining
Dx symptoms of PDD?
Must have a depressed mood for most of the day for more days than not for ≥ 2 yr plus ≥ 2 of the following:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
What is anxious distress?
Patients feel tense and unusually restless; have difficulty concentrating as worry/fear something awful may happen or they will lose control of themselves
What is melancholia?
- Lost pleasure in nearly all activities
- Do not respond to pleasurable stimuli
- Despondent and despairing
- Excessive or inappropriate guilt
- Early morning awakenings
- Marked psychomotor retardation or agitation
- Significant anorexia or weight loss
Diagnosis of depression?
-Clinical criteria (DSM)
-FBE, UEC, TSH, B12, folate (r/o medical cause)
Severity determined by degree of pain and disability (physical, social, occupational) and duration.
DDx depression?
- Demoralisation and grief
- Anxiety d/o (mimics)
- Major depression must exclude BpD
- Dementia of depression
- Early dementia -> depression
- Physical/ medical d/o
Which main medical conditions are linked with depression?
- Hypothyroidism
- Parkinson disease
- Cushings
- Ca (pancreatic, SClung)
- MS
- HIV
Rx depression?
- Support
- Psychotherapy (CBT, IPT, couple therapy)
- Drugs
- Exercise
- Lifestyle (sleep, diet, reduce EtOH)
- Confiding in others
- ECT
Initial drug of choice?
SSRI
When is ECT required?
- melancholic
- psychotic
- puerperal
- bipolar depression or mania
- prominent suicidality
- poor oral intake
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MSE14
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Schizophrenia43
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Bipolar Disorder45
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Depressive Disorders47
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Delusional disorder11
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Eating Disorders36
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Obsessive Compulsive Disorders22
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Anxiety and Trauma Disorders21
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Personality Disorders24
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Substance Misuse21
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Presentations10
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Somatoform Disorders17
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Psychosis (first ep, substance induced)6
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MH Act, Psych Emerg, ECT24
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Perinatal Mental Health26
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DSM Criteria15
