Semester 2 Depression 2 Aims and Objectives To develop an understanding of the psychopathology and diagnosis in Depression To develop an understanding of possible complications of antidepressant medications ID: 908388
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Slide1
General Adult
Depression 2
(Semester 2)
Slide2Depression - 2Aims and ObjectivesTo develop an understanding of the psychopathology and diagnosis in Depression.
To develop an understanding of possible complications of antidepressant medications
Slide3Depression - 2Expert Led Session
Depression Pathophysiology and Diagnosis
Slide4ContentsClinical features of depressionAssessing psychopathologyRating scales for depressionClassification in ICD10 and DSM IV
Differential diagnosesReferences & Further Reading
Slide5Clinical features - moodMood of misery – persistent Mood does not get better in circumstances where ordinary feelings of sadness would be alleviated. Often experienced as different from ordinary sadness.
Diurnal variation – usually worse in the morning, improving a little as the day wears on.
Slide6Clinical features- depressive cognitionsNegative cognitionsWorthlessnessPessimism Guilt
HopelessnessHelplessnessCan progress to thoughts of suicide
Slide7Clinical features – goal-directed behaviourAnhedonia - lack of interest and enjoyment [Roots: Latin- An=not; hedon = pleasure]
Social withdrawal Lethargy, reduced energy, everything is an effort. Poor motivation
Slide8Clinical features – psychomotor changesPsychomotor retardationslow speech, actions, thoughts, delayed responsesNegativism
Blunting of affectPsychomotor agitation – Restlessness, can’t relax, can’t sit for longEcholalia , echopraxiaIrritability
Slide9Clinical features- biological symptomsSleep disturbance – early morning waking with depressive thinking is usually characteristic; also delay in falling asleep and waking during the night. Diurnal variation of mood
Loss of appetite + weightConstipationLoss of libidoAmenorrhoeaSomatic complaints – often about pre-existing symptoms.
Slide10Clinical features - otherDepersonalisationFeel empty, blunt, rigidSevere – Entfremdungs depression (depersonalised depression)Obsessional symptoms
Panic attacksDissociative symptoms (fugue, loss of function of a limb)Memory problems – impairments in the retrieval and recognition of recently learned material particularly prominent [If severe, it may resemble dementia: depressive pseudodementia]
Slide11Psychotic depression ‘Mood congruent’ delusions – delusions have the same theme as the non-delusional thinking, on depressive themes – worthlessness, guilt, ill-health, poverty (rare).Persecutory delusions
usually the patient believes that the supposed persecution is brought upon by himself/herself; he/she is ultimately to blameindicates worse prognosis. Cotard’s syndrome – nihilistic delusion (more common in older adults)
Slide12Clinical variants of depressionAgitated depression – with agitation as a prominent featureRetarded depression – with prominent psychomotor retardationDepressive stupor / catatonia – motionless and mute patient
Atypical depression – variably depressed mood with mood reactivity to positive events; overeating and oversleeping; extreme fatigue and heaviness in the limbs; pronounced anxiety
Slide13Pointers for assessmentSeverity Duration Social networkViews of self, world and futureSuicidal thoughts
Past historyFactors affecting symptomsBiological features
Slide14Course - Kupfer’s curve
Slide15ICD-10 criteria [F32, F33]
Key Symptoms(MUST have at least 2)Persistent low mood
Loss of interest or pleasureFatigue or low energyIf any of the above then ask about:Disturbed sleepPoor conc. Or indecisivenessLow self confidencePoor or increased appetiteSuicidal thoughts or actsAgitation or slowing of movementGuilt or self blameSeverity 4 symptoms = mild5-6 symptoms = moderate7+ symptoms= severe (+/- psychotic symptoms)
Slide16Classification of depressive disorders
ICD-10DSM IVDepressive
episodeMajor Depressive episode Mild, moderate, severe, severe with psychotic symptomsSameOther depressive episodes Atypical depression - Recurrent depressive disorderMajor depressive disorder- recurrent Currently mild, moderate, severe, Severe with / with out psychotic symptoms, In remission-
Persistent mood disorders
Dysthymic disorder
Cyclothymia
Dysthymia
Other mood disorders
Depressive disorders,
NOS
Recurrent brief depression
Recurrent brief
depression
[ Shorter Oxford Textbook of Psychiatry, Ed 5
th
]
Slide17Major Rating Scales
ScaleSalient features
Hamilton Scale for Depression (HAM-D)Clinician-rated; 17 item, derived from clinical interview, refers to previous 1-2 weeks, for rating severityMontgomery-Asberg Depression Rating Scale (MADRS) Observer-rated, 10 item, sensitive to response to treatment, for measuring change in depressed patient. Beck Depression Inventory (BDI)Self-reported, 21 item, lacks discriminatory power among those with very severe depressionZung Depression Scale Self-rating, 20 item; >=50 indicates depression, global index of intensity of patient’s depressive symptoms
[ Seminars in general adult psychiatry, Synopsis of Psychiatry ]
Slide18Differential diagnosesNormal sadnessAdjustment disorderAnxiety disordersSchizophrenia –
esp simple schizophreniaSchizoaffective disorderOrganic brain syndromes
Slide19References & Further ReadingGelder M, Harrison P, Cowen P (2006) Shorter Oxford Textbook of Psychiatry (Ed 5th) Oxford University Press. Stein G, Wilkinson G (Ed)(2007) Seminars in General Adult Psychiatry (Ed 2nd) Gaskell.
Sadock BJ, Sadock VA (2007) Kaplan & Sadock’s Synopsis of Psychiatry (Ed 10th) Lippincott, Williams & Wilkins.WORLD HEALTH ORGANIZATION. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva, World Health Organization.
Slide20Depression - 2MCQ 11. Glucocorticoid receptor hypothesis is associated with which of the following (choose one answer):
Depression Generalised anxiety disorder Dementia Mania Schizophrenia
Slide21Depression - 2MCQ 1The correct answer is: A - Depression
Explanation: Hyperactivity of the hypothalamus–pituitary–adrenal (HPA) axis and increased levels of glucocorticoid hormones in patients with depression have mostly been linked to impaired feedback regulation of the HPA axis, possibly caused by altered function of the receptor for glucocorticoid hormones, the glucocorticoid receptor (GR). Antidepressants, in turn, ameliorate many of the neurobiological disturbances in depression, including HPA axis hyperactivity, and thereby alleviate depressive symptoms.
Slide22Depression - 2MCQ 22. What is the approximate male : female ratio of completed suicide in England, Scotland and Wales?
7:13:1 5:1 1:1 2:1
Slide23Depression - 2MCQ 2The correct answer is: B - 3:1
Slide24Depression - 2MCQ 33. Which of the following statements about unipolar depression is TRUE?
Unipolar depression is three times more likely in females than in males. Relatives of patients with unipolar depression do not have increased rates of bipolar disorder or schizoaffective disorder. In twin studies, concordance rate for unipolar disorder but not bipolar disorder is higher in monozygotic than dizygotic twins. The familial segregation of mood disorders fits a simple
Mendelian pattern. There is no evidence to suggest that depressive disorder in later life is associated with parental separation, especially divorce.
Slide25Depression - 2MCQ 3
The Correct Answer is A. Unipolar depression is three times more likely in females than in males
Slide26Depression - 2MCQ 44. Which of the following abnormalities in monoamine neurotransmission is NOT found in depression?
Decreased plasma tryptophan Increased brain 5-HT reuptake sitesIncreased D2 receptor bindingClinical relapse after tryptophan depletion
Decreased brain 5-HT1A receptor binding
Slide27Depression - 2MCQ 4AThe correct answer is: B.
Brain 5 HT reuptake sites are decreased in depression
Slide28Depression - 2MCQ 55. Which of the following antidepressants is associated with increased risk of cardiovascular defects in foetus, when used in the 1st trimester?
Duloxetine Sertraline Mirtazapine Venlafaxine Paroxetine
Slide29Depression - 2MCQ 55. The correct answer is: E - Paroxetine
Explanation: The use of paroxetine during the first trimester of pregnancy was associated with major cardiac and congenital malformations in the foetus.
Slide30Depression - 2Any Questions?Thank you.