Depression
Characteristics
Lifetime prevalence
15-17%
major depressive episode
Around 1 in 6 people
Causes
genetic
Heritability estimates ~40%
multiple genes
small effects
environmental
stress
trauma
Pathological findings
Hippocampal atrophy
reversible by antidepressants!
serotonergic cells
small
dysfunctional
5HT receptors
Functional MRI
different to normal
Classification
Mild
2 core symptoms
2 additional symptoms
>2 weeks
functioning ok
Moderate
2 core symptoms
3 additional symptoms
>2 weeks
most of the time
functioning difficult
Severe
2 core symptoms
4 additional symptoms
> 2 weeks
most of the time
50% do not function
+/- biological features
+/- delusions/hallucinations
+/- mania
acute/chronic/recurrent
Undertreated disease
~30% of cases treated
S&S
Core
Mood
Diurnal variation
worse in mornings
Anergia
Anhedonia
Additional
Becks triad
Hopeless
Helpless
Worthless
Psychological
Self-esteem
Confidence
guilt
Physiological
Concentration
disturbed sleep
Early morning waking
>2hrs before normal time
psychomotor agitation
Appetite changes
with corresponding weight changes
decreased libido
impaired memory
Psychomotor retardation
Risk
suicidal ideations
self-harm ideations
2ary auditory hallucinations
Delusions
Nihilistic
Complications
Suicide
Self-harm
Increased risk of dying
Relative risk 1.5 to 2 of normal
Biopsychosocial Management
Investigations
FBC
folate
U&E
LFTs
Thyroid
Cortisol
Treatment
Antidepressants
SSRIs
first line
Venlafaxine
Tricyclics
dangerous in overdose
MAOIs
rarely used
St. John's Wort
interacts with contraception
not recommended
Monitor response
no response 6wks
Increase dose
change drug
Long-term continuation
6 months after resolution
5 years if multiple episodes
Lithium
For BPAD or suicidal depression
Antipsychotics
ECT
suicidal
refractory
Psychological intervention
CBT
first line
synergistic effect with drugs
decrease relapse
unknown duration of effect
expensive
not widely available
Interpersonal psychotherapy
Social intervention
finances, etc...
Experimental
transcranial magnetic stimulation
deep brain stimulation
Differential
Organic
Substance abuse
Post-partum
Anaemia
Hypothyroidism
Addisons Disease
Psychiatric
Dysthymia
long term
not enough Sx to meet criteria
Cyclothymia
BPAD
Examination
Intro & Rapport
Onset?
precipitating factors
perpetuating factors
Symptoms
Ideas, Concerns, Expectations
Coping strategies
Social support?
Alcohol and drugs
Suicidal risk
view of future?
Mx, Rx, Psych Hx
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