Psychological medicine

Mood Disorders

Depressive Disorders

Diagnosis of Major Depressive Disorder/Episode (MDE)

  • Handy pneumonic:
    • S: Sleep
    • A: Appetite and weight
    • D: Dysphoria and anhedonia
    • F: Fatigue
    • A: Agitation/retardation
    • C: Concentration
    • E: Esteem
    • S: Suicide
  • DSM IV criteria:
  • 5 or more of the following present during the same 2-week period and represent a change from previous functioning. At least one symptom must be depressed mood or loss of interest/pleasure [NB exclude symptoms clearly related to a general medication condition, delusions or hallucinations]. Note duration and persistence of each symptom, and compare to normal:
    • Depressed mood, most of the day, nearly every day (either self report or observed by others) 
  • Markedly diminished interest or pleasure in all, or all most all, activities (exclude grief reaction) 
  • Significant weight loss/gain or ¯/­ in appetite (exclude cancer, Tb, hypothyroid)
  • Insomnia/hypersomnia nearly every day (exclude sleep apnoea) 
  • Psychomotor agitation or retardation (excessive repetitious and pointless motor activity that is associated with feelings of tension. Needs to be observable, not just felt). Eg have you been fidgety/restless or felt „stuck in the mud‟ or in slow motion? 
  • Fatigue or loss of energy nearly every day 
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day. Eg how do you feel about yourself, have you blamed yourself for things, do you feel guilty?
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day
  • Recurrent thoughts of death, suicidal ideation without a plan, an attempt or a plan
  • Symptoms do not meet criteria for a mixed episode 
  • Symptoms cause significant distress or impairment in social and occupational functioning. Eg what difficulties have all these symptoms caused?
  • Exclude depression if symptoms:
    • Are due to physical illness, medication or street drugs 
    • Occur within 2 months of significant bereavement (except if marked impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation). Key difference between grief and depression is whether they themselves feel worthless or not
  • Also review risk factors: 
    • Prior history of major depressive episode or suicide attempt. Previous episode ® 50% lifetime risk of recurrence 
    • Family history of mood disorder or suicide attempts. If no family history then lifetime risk 10 – 20%. If heavy genetic loading this may double the risk (very polygenic) 
  • Chronic or severe physical illness (may ® demoralisation and hopelessness)
  • Concurrent substance abuse 
  • Recent stressful life events and lack of social support (stress should not be used to „explain away‟ symptoms, stress may precipitate a major depressive episode) 
  • Childhood trauma, abuse, parental conflict or deficient parental care
  • Recent childbirth or other family changes (eg divorce, children leaving home)
  • Responsibilities for caring for others (eg elderly relatives)
  • Differentials:
    • Substance abuse 
    • Other psychiatric disorders, eg anxiety, eating and adjustment disorders, personality disorders, somatization
    • Dementia in older people (a key differential is memory)
    • General medical conditions and medication.  Drugs affecting mood:
      • Steroids: on 20 mg 1.3% get depression, on 80mg 20% get depression 
      • Lipid soluble b blocker
      • New drug affecting P450 metabolism and ­ plasma conc. of existing drug
    • Grief reaction. Depressive symptoms common during periods of grief. Usually begins within 2 – 3 weeks of bereavement and usually resolves without treatment – although supportive counselling/practical help may be indicated
  • In children and adolescents, feelings of guilt, emptiness, self-dislike and failure are common – but are underreported by parents, who may instead report a decline in behaviour or academic performance
  • Can use questionnaires: e.g. GHQ (General Health Questionnaire) or CES-D – useful either for screening or in borderline situations – gives something to discuss with patient
  • Little point in trying to separate exogenous from endogenous depression (often a chicken & egg situation). It‟s usually multifactorial – regardless of cause may well need a multi-factorial approach to management

Subgroups

Epidemiology and Aetiology

  • Lifetime risk of depression in women is 20%
  • Female: Male is 2:1, but in younger cohorts an ­ in male depression is bringing the ratio down to 1.6:1. This is not an artefact of help-seeking behaviour
  • Rate is increasing
  • Variety of theories:
  1. Biological (eg neurotransmitter dysfunction)
  2. Freud: unresolved early childhood events resurrected by similar events in later life
  3. Bent (?): Cognitive triad: people feel helpless ® hopeless ® worthless.  Selective abstraction
  4. Extrapolate from one event to everything. Treatment: Uncover underlying schema. Then challenge faulty thinking (is it always that bad?), challenge automatic thoughts

Assessment

  • Cultural issues:
    • Different cultures have different views on the cause and treatment of depression.
    • Appreciating the cultural perception of the individual ® better therapeutic relationship and ­ effectiveness of intervention.
    • Consider referral to culturally appropriate service.
    • Cultural issues may affect the way the interview is conducted. Eg if Maori, establish initial rapport before asking name and personal information, don‟t make eye contact when discussing sensitive information, a family member speaking on a patient‟s behalf is not being dominating, etc
  • Assessment of severity: Use the number of DSM IV criteria met or severity rating scales. Allows classification into mild, moderate and severe. Can be used to monitor progression of treatment and relapse
  • Assess duration: (> 6 months, > 24 months)
  • Refer to specialist services when:
    • There is serious risk of suicide (or harm to others, especially younger children)
  • The child is under the age of 13 years
  • There are psychotic symptoms or bipolar disorder (depressed phase)
  • The diagnosis is unclear and needs further evaluation
  • Melancholic features are so severe that they are unable to look after themselves and have inadequate community support
  • There are complex problems (eg poor relationship, another psychiatric disorder)
  • Considering enhancing antidepressants with mood stabilisers (eg lithium)
  • Failure to respond to recommended treatment within 12 weeks

Treatment of Major Depressive Disorder

  • Fundamental to treatment is:
    • Establishing positive therapeutic relationship
    • Developing shared understanding of problems
  • Safety: suicide risks common (lifetime risk 25 – 50%). Higher in delusional Major Depressive Episode. Consider safety of others, especially if psychotic beliefs or Postpartum Depression
  • Lifestyle changes that have been shown to be effective: stress management, ¯alcohol and drugs, good sleep patterns, a balanced diet, and physical exercise
  • Role of family, friends and self help groups important in maintaining a supportive environment
  • Education (over time):
    • Depression is an illness not a weakness.
    • Treatment is effective and recovery is normal. 
    • Recurrence is possible so compliance is important. However, sometimes there is only partial remission between episodes. Recognition of warning signs and seeking early treatment will reduce severity
  • Psychological treatment:
    • Indicated if:
      • Person with mild to moderate chooses this as first line
      • If partial response to drugs at week 6 or 12 and residual symptoms are largely psychological 
      • There are continuing issues/cognitive beliefs that ­ the risk of relapse
      • Not as sole treatment in severe, psychotic or melancholic depression
    • Promoting change: behaviour, thoughts, emotion
    • Different therapies:
      • Cognitive behavioural therapy (See Topic: Cognitive Behavioural Therapy (CBT)
      • Problem solving therapy (See Topic: Problem Solving Therapy)
      • Interpersonal therapy
      • Hypnotherapy
      • Psychoanalysis
      • Transactional analysis
      • Martial or family therapy
  • Drug treatment: See Topic : Antidepressant and Mood Stabilising Medication
  • Electroconvulsive Therapy (ECT):
    • Relieves symptoms is 80% of all severe depressions (not just those resistant to medication)
    • Indications:
      • Psychotic depression
      • Depressive stupor (severe psychomotor depression)
      • Severely suicidal
      • Previous good response to ECT 
    • Risks: little risk of brain injury – risks are those of a general anaesthetic. Most troubling side effect is memory loss. Anteriograde loss is usually short lived. Some retrograde loss may be permanent 
    • Response is proportional to length and quality of seizure. Usual course is about 6 cycles. If no response after 12 cycles then stop
    • Also need to establish on an antidepressant that they haven‟t failed on
  • Monitoring treatment in primary care:
    • Check for treatment response, side effects, and alteration in stressors or supports
    • If severe, monitor twice weekly by consultation and phone, if mild then weekly
    • Assess response in week 6