depression KJW Oct 2017 Depression – a definition - PowerPoint Presentation

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depression

KJW

Oct 2017

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Depression – a definition

Diagnosing depressionParticular groups

Differential diagnosisRisk assessment and managementTreatment

Contents

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It is almost the definition of

being

human: We are the animals who mourn.

Hilary Mantel Reith Lectures

2017

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Melancholia

is mentally characterised by a profoundly painful depression, a loss of interest in the outside world, the loss of the ability to love, the inhibition of any kind of performance and a reduction

inthe sense of self, expressed in self-recrimination and self-directed insults, intensifying into the delusory expectation of punishment.

Bear in mind that mourning displays the same traits, apart from one: the disorder of self-esteem is absent.

Freud

Mourning and Melancholia 1917

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Shadows on the ego

Significant others

MourningObject loss, love, hate, desire, conflict…

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… lower mood in response to loss or adversity is an almost universal response.

Depression or sadness?

Milder forms could be

biologically

adaptive responses to loss or social

defeat

…

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Precipitating events

Loss

Humiliation / shame

Entrapment

Danger

6 months

4

weeks+

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Anhedonia

Psychomotor retardationGuiltWorthlessness

and despair

Discriminating diagnostic features

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Depression as socially

situated

Relationship status and qualitySocioeconomic status Object loss

Early relational bonds

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Personality styles

: Response

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Neural Circuit of Depression

Subcallosal Cingulate Cortex (area 25)Right Anterior InsulaAnterior cingulate gyrusAmygdala (increased activity)Hippocampus (fewer and smaller synapses)

Hypothalamus

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Loss of function is a key aspect

for DSM /ICD definition.

Humankind cannot bear very much

reality

TS Eliot

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Diagnosis - DSM 5

Five or more – including 1 and/or 2

Depressed moodAnhedonia

Appetite/weight changeSleep disturbancePsychomotor agitation / retardationFatigue / loss of energy

Worthlessness / guiltDiminished concentration / indecisivenessThoughts of death / suicide

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Diagnosis - DSM 5

Two

weeks minimum

Significant distress / loss of function

Not attributable to physiological effects of a substance or medical condition

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Sub-specifiers – with…

1. anxious distress

2. mixed features

3. atypical features

4. melancholic features

5. psychotic features

Mood congruent

Guilt, disease, death, poverty, nihilism, catastrophe, deserved punishment, persecution.

6.

peripartum

onset

7. seasonal pattern

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Grief

Affect: Emptiness/loss

Comes in waves / pangs

Preoccupied with loss /

memories of loss

Self-esteem preserved

Passive wish to join the person lost

Socioculturally sanctioned process with

reconciliation

Depression

Affect: Sadness / anhedonia

More constant

Self-critical and pessimistic thoughts

Worthlessness and self-loathing

Wanting to die due to feeling worthless, undeserving, or unable to cope with pain

Things unchanging, unresolved, getting worse

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Particular groups

Children

Later life

Medical settings

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Differential diagnosis

Other mood disorders

Anxiety disordersDemoralisationGrief

Personality disorders associated with existential despairOrganic statesNormal sadness

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Suicide risk factors

Clinical depression

50-80%

Substance use 25-50%

Post-discharge & post-attempt vulnerabilityRecency of GP visit

Male: female 4:1

Hospital

admission

15%

Bipolar

disorder

10-15%

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Increased risk

More severe depression

InsomniaAgitation/impulsivityPanic

Weight lossWorthlessnessGuiltHopeless/despairing

Lonely/bereft/isolatedPsychotic features

Increasing

motivation before other symptom improvements

Calm resolve/ relief / circumspection

Suicidal Ideation

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Exploring suicidal ideation

Ask about general themes

Explore specifics[passive to active]

Guilt, depression, despair, existential pain, loneliness and hopelessness, worthlessness, being a

burden.

Psychotic component

Affairs in order

Identification/procurement of means

Precautions about being stopped/found

Suicide note

Lethality of

means

Always seek collateral information

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Rx: In the eye of the beholder

…C

linicians must be attentive to the patient’s subjective experience of the disorder and the management they are receiving. The patient’s perception of the quality of the therapeutic encounter is a strong predictor of adherence, leading some authorities to argue for collaborative treatment plans involving shared decision making.

RANZCP CPG Treatment of Mood Disorders 2015

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Treatment algorithm (RANZCP)

Lifestyle measuresPsychosocial Measures general

Psychosocial Measures specificPharmacotherapyCombination/augmentation approaches

Electroconvulsive Therapy (ECT)

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Lifestyle Measures

Mood lowering agents

Sleep hygieneSmokingAlcohol / substances

DietExercise

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Psychosocial Measures General

Information/education

Low intensity interventions Support groupsBefriending

EmploymentHousing

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Psychological Therapies Specific

CBT (and Behavioural Activation)

Interpersonal Therapy (IPT) Acceptance and Commitment Therapy

Mindfulness-based Cognitive TherapyRelationship therapy

Integrative

and

psychodynamic

therapies

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Psychological mindedness

The inclination towards

and capacity for reflection, self- examination, introspection; a nascent

language for feeling states and self.

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Pharmacotherapy

Type

Examples

Cautions

 

SSRIs

Sertraline

Escitalopram

Fluoxetine in children

Watch for hyponatraemia, osteoporosis in elderly, small risk of prolonged bleeding.

Headache, dry mouth, sweating, agitation, bruxism, sexual dysfunction, weight gain, emotional distancing.

SNRIs

Venlafaxine

 

Duloxetine

Associated with cardiac toxicity in OD

Increased rate of seizures

NaSSA

Mirtazapine

Mianserin

 

Serotonin modulator

Vortioxetine

May enhance cognition in depressive states

Melatonergic

agonist

Agomelatine

 

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Pharmacotherapy contd.

Type

Examples

Indications

Cautions

 

TCAs

Amitriptyline

Imipramine

Clomipramine

Nortriptyline

Melancholic depression

More toxic in overdose

Significant cardiovascular & anticholinergic effects

Lower seizure threshold

MAOI

Phenelzine

Tranylcypromine

Melancholic Depression

 

Tyramine reaction

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Antidepressants

Trial: Minimum of 3 weeks at adequate

doseResponse may be prompt, delayed, partial, complete, or absentConsider both tolerability and

efficacyRisksmall risk of increase in suicidal thoughts in patients younger than 25 early in treatmentassociation with agitation in some

possible associated early risk - increased motivation in absence of other improvements

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Response

Response

Partial

Complete

Ineffective

 

Approach

Consider augmentation

SGA’s

Lithium

Thyroxine

Combination

Continue 1-year post-

euthymia

Withdraw

Try another agent

Review diagnosis

Consider factors

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Psychotic depression

Combined antipsychotic and antidepressant (or ECT) significantly more effective than either alone.

85% vs 25-50%

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ECT

Melancholic depressionPsychotic depression

CatatoniaHigh suicide risk,

high distressPoor oral intakePoor response to medication

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Resources

OnlineMoodGYM

http://moodgym.anu.edu.au/welcomeBlack Dog Institute

www.blackdoginstitute.org.au/

RANZCPRoyal Australian and New Zealand College of Psychiatrists clinical practice guidelines

for

mood

disorders.