Depression

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• May be precipitated by anxiety neurosis so look for features

Depressive episode

• depressed mood
• loss of interest and enjoyment (anhedonia)
• reduced energy leading to increased fatiguability and diminished activity

History

• Presentation
  • first symptoms
• Emotional
  • Sad
  • Helpless
  • Anxious
  • Agitated

Cognitive Features

• Self-hate
• Blame
• Indecisiveness
• Worthlessness
• Hopelessness
• Poor Thinking
• Suicide
• Present
  • unhappy side of events
  • think they are failing in everything
  • think others perceive them as failing, discount evidence to contrary
• Future
  • expect the worst
  • foresee failure in every aspect of life
  • can progress to thoughts of suicide
• Past
  • prominent ideas of guilt and self-blame
  • focus of past failures

Biological features

Characteristically there is global slowing, psychomotor retardation

• Loss of appetite, weight
• Decreased sleep
  • early morning waking
  • diurnal mood variation, worse in mornings
• Decreased libido, decreased energy
• psychomotor retardation
  • slow speech
  • poverty of speech
  • mutism
  • reduced movements / depressive stupor
• psychomotor agitation/ restlessness
  • especially when depression and anxiety coexist
• reduced concentration
• indecisiveness
• subjective memory disturbance
• amenorrhoea
• constipation
• New symptoms
  • headache
  • backache
  • dizziness

Precipitants

• Losses

PMH

• Depression
• Mania
• Psychosis
• Serious medical illness

FHx

• Bipolar
• Current illnesses

Personal

• childhood losses
• insecurity
• abuse

History

• marriage
• Occupation
• Social

Pre-Morbid

• Low self esteem
• Level of function
• coping skills
• locus of control

DHx

• Treatment
• Predisposing
  • beta-blockers
  • steroids
  • anti-arrhythmics
• Smoking
• Alcohol
  • may be excessive

ROS

• Exclude Thyroid / other disease

Examination

Mental State Exam

• Behaviour
  • poor eye contact
  • poor posture
  • increased / decreased activity
  • self neglect
• Speech
  • slow
  • little spontaneous
  • coherent
• Mood 
  • low
• Thought
  • worthless
  • hopeless
  • guilt
  • blame
  • suicide
• Perception
  • Psychotic symptoms
    • these may accompany a severe depressive episode
    • mood-congruent
      • e.g. themes of worthlessness or guilt
    • nihilistic delusions
      • patients believe something important has ceased to exist
  • may have hallucinations
• Orientation
  • usually normal
• Memory
  • impaired if poor attention
• Insight
  • may be preserved

Physical Exam

• General medical illness

Investigations

• Exclude organic disease
• FBC
• U&E
• ESR
• Calcium
• TFT
• ECG (if palpitations)

ICD-10 classification

Depressive episode - every day for greater than 2 weeks...

• Depressed mood
• loss of interest and enjoyment (anhedonia)
• reduced energy and decreased activity

• reduced concentration
• reduced self-esteem & confidence
• ideas of guilt and unworthiness
• pessimistic thoughts
• ideas of self harm
• disturbed sleep
• diminished appetite

Severity

• Mild
  • 2 of A + 2 of B
• Moderate
  • 2 of A and 3 of B
• Severe
  • 3 of A and 4 of B

Variants

• Depressive stupor
• Masked depression
  • depressed mood not particularly prominent but other features of depression present
  • sleep disturbance
  • diurnal mood variation
  • depressive cognitions
  • loss of pleasure
• Atypical depression
• Seasonal Affective Disorder

Treatments for Depression

Management issues

• In-patient or out patient
• Risk of suicide / Need for "Section"
• Risk to dependants
• Work?
• Activity
  • Suitable activity
  • Occupy patient and provide social stimulation
  • Not be too demanding because failure may make depression worse

Antidepressants

• Tricyclic Antidepressants
• SSRIs
• MAOIs

Other physical Treatments

• Lithium
• Anticonvulsants
• Tri-iodothyronine
• Olanzapine
• ECT

Psychological treatments

• Specific psychotherapies can be used in mild to moderate depression esp. if patient doesn’t want to take drugs
• Can be as effective as drug therapy
• Can be slower than drugs
• In severe depression too much self examination at early stage can make condition worse

• Supportive Psychotherapy
  • Identification and resolution of current life difficulties
• Cognitive Therapy
• Interpersonal Psychotherapy
  • Systemic and standardised approach to personal
• Marital Therapy
  • May be useful adjunct to treatment where marital discord seems to have contributed to causing or maintaining depressive disorder
• Sleep deprivation
  • Keeping patient up all night can help alleviate symptoms of depression but effect very short lived
  • Research and possibly to speed onset of action of medication
• Bright Light Treatment
  • For treatment of seasonal effective disorder
  • 1-2 hours / day exposure to bright (10,000 lux) light
  • Patients with atypical symptoms appear to respond best

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