What is the key epidemiology of depression (i.e. lifetime prevalence, difference b/w men and women)?
~15 -20% population experience over a lifetime
Women have higher prevalence than men (2:1)
Men have higher rates of suicide than women (4:1)
What is the genetic influence in developing depression?
Strong genetic predisposition - strong FHx
Multiple genes thought to be implicated - i.e. genes involved with serotonin transporting
What are some key interpersonal predisposing factors to depression?
Early childhood - abuse, insecure attachment/lack of affection, poor parenting, maternal depression, parental loss
Adult experiences - lack of confiding relationship, dysfunctional or abusive relationship, lower SES, unemployment, social isolation
What are some factors that may precipitate depression?
Environmental factors and stressful life events (esp. loss)
Loss - bereavement, loss of role or autonomy
Ongoing issues with danger, entrapment or humiliation
Social isolation
Outline the principles of 2 behavioural/cognitive theories to the development of depression
- Seligman’s theory - learned helplessness model of depression - repeated exposures to stressful events - learn that you cannot change it and ‘give up’
- Beck’s triad (basis of CBT) - Your view/experiences of self, world and future inform your thoughts - can lead to negative thoughts - depress mood - further cycle of negative thoughts (worthlessness, guilt, helpless, hopeless)
Outline the principles behind the neurochemical theory of depression
- Deficiency of neurotransmitters (serotonin, NA, DA) lead to depression and biological symptoms of depression
- Decreased levels of their precursors and metabolites found in serum and CSF of depressed people
How is depression diagnosed? What are the core/cardinal symptoms?
Clinical diagnosis
Most have at least 2 of the following present for at least 2 weeks
- Anhedonia (more characteristic)
- Low/depressed mood
What are some biological symptoms in depression?
- Sleep disturbance - initial insomnia, early waking, hypersomnia
- Anorexia, wt loss
- weight gain *
- Aches/pains, headaches
- Menstrual disturbance
- psychomotor retardation
- decreased libido
What are some psychological/cognitive features of depression?
- Memory loss, slowed thinking, difficulty attention/focusing
- Anxiety
- Suicidal ideation
- Thoughts of helplessness, hopelessness, guilt, shame
- Nihilism, pesimissm
What are psychotic features of depression?
Delusions
- Usually extension of themes of depression
- Nihilistic, persecutary, shame/guilt, catastrophic, hypochondrial
Hallucinations
- Auditory - derogatory voices
- Rarely visual
Only occur in severe depression
What are DDx for depression?
- Physical causes - dementia, hypoactive delirium, parkinson’s disease, head injury, cancer, hypothyroidism, diabetes
- Normal sadness
- Bereavement
- Demoralisation
- Schizoaffective disorder/schizophrenia, Bipolar disorder
- Substance use
- Post-natal depression
- Adjustment disorder
What are key features to ask on history when someone presents with low mood?
- HOPC - duration, severity (distress, function), associated biological & psychological symptoms
- Question for associated factors - risk factors, precipitating and perpetuating
- Risk assessment - self-harm and suicidal ideation
- Question to exclude physical causes, bipolar (previous manic episodes) and other psychotic disorders
- Question to identify co-morbid psychiatric disorders - anxiety, personality disorder, substance use
- Psychiatric history + FHx
- Medical and medication hx
- Collateral history - dementia, delirium
What examinations would you perform on someone presenting with low mood?
- Vitals + general health assessment (BMI)
- Endocrine - thyroid, cushing’s
- Neurological - neurodegenerative disorders, stroke
- Inspect for signs of self harm
- Signs of malignancy
What investigations would you perform on someone presenting with low mood?
- Bloods - FBE, LFT, U&E, TFTs, Diabetes screen, Fe studies, B12, folate, Vit D
If indicated - test for cushing’s, addison’s and HIV
- Urine drug test if indicated
- CT/MRI if cerebral pathology suspected
What is the prognosis of depression?
> 50% will have at least one subsequent depressive episode
Each episode generally last ~8-9 months but can be reduced to ~2-3 months with effective treatment
Can resolve spontaneously if untreated/inadequately but last months - years and can become chronic
What are negative symptoms of schizophrenia?
Aboulia (lack of motivation/initiation)
Avolition (apathy)
Alogia (poverty of speech/thought, blocking)
Anhedonia (lack of interest/pleasure in things)
Affective flattening (blunting)
When is clozapine indicated in Rx of schizophrenia
Treatment resistant - failure of at least 2 other antipsychotics (at least one being atypical) that were used at therapeutic doses & adequate time for effect
Treatment of severe tardive dyskinesia on other antipsychotics
ASADFACES: Depression
Appetite change Sleep change Anhedonia Dysphoria Fatigue Agitation/retardation Concentration (decreased) Esteem (low)/guilt Suicidal thoughts
DIGFAST: Mania
Distractibility Indiscretion Grandiosity Flight of ideas Activity increase Sleep deficit Talkativeness
TRAUMA: PTSD
Traumatic event Re-experience Avoidance Unable to function Month or more of symptoms Arousal increased
FINISH: anti-depressant discontinuation syndrome
Flu-like symptoms Insomnia Nausea Imbalance Sensory disturbances Hyper-arousal (anxiety, agitation)
FEVER: NMS
Fever Encephalopathy Vital sign instability Elevated WBC/CK Rigidity
HARMED: serotonin syndrome
Hyperthermia Autonomic instability Rigidity Myoclonus Encephalopathy Diaphoresis
IMPULSIVE: borderline personality disorder
Impulsive Moodiness Paranoia or dissociation under stress Unstable self-image Labile intense relationships Suicidal gestures Inappropriate anger Vulnerable to abandonment Emptiness (feelings of)
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CAH- Development46
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CAH- Immunisations17
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Buzzwords18
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CAH- Common presentations149
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WH- Obstretrics83
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WH- Gynaecology33
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WH- Neonatology17
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GP- Common presentations78
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CAH- Emergencies13
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MH- Common presentations25
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PHARM- Antimicrobials27
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AC - Rehabilitation27
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AC - Continence16
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AC - Parkinson's Disease11
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AC - Dementia & Delirium38
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GP - Women's health30
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MH- Pharmacology28
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AC - Legal Issues/Capacity8
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AC - Polypharmacy4
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AC - Orthogeriatrics & Falls19
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AC - Palliative Care43
