Clinical features of depression

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Transcript Clinical features of depression

Clinical features of depression Dr. Jorge Zimbron ST4 in General Adult Psychiatry

Overview

• • • Definitions of ‘depression’ Exam questions CASC practice

Definitions of depression

• • ICD-10 DSM IV TR • Both make divisions in view to testing their usefulness.

• Mood: a relatively long lasting emotional state.

Clinically tricky areas

• • • • • • • Substance abuse Organic pathology Negative symptoms vs depression Dementia Personality disorders Bereavement Interphase with other disorders (anxiety, somatoform disorders, etc).

ICD-10

• • Defines depressive episode Defines somatic episode • • • More critical and humble More concrete on mild, moderate, severe – “unwise to include social performance amongst essential criteria of severity” (but a guide) Looser definitions on ‘unspecified’ or ‘other’.

ICD-10

• •

F32 Depressive episode

– F32.0Mild depressive episode • .00 Without somatic syndrome • .01 With somatic syndrome – F32.1 Moderate depressive episode • .10 Without somatic syndrome • .11 With somatic syndrome – F32.2 Severe depressive episode without psychotic symptoms – F32.3 Severe depressive episode with psychotic symptoms – F32.8 Other depressive episodes – F32.9 Depressive episode, unspecified

F33 Recurrent depressive disorder

– F33.0 Recurrent depressive disorder, current episode mild • .00 Without somatic syndrome • .01 With somatic syndrome – F33.1 Recurrent depressive disorder, current episode moderate • .10 Without somatic syndrome • .11 With somatic syndrome – F33.2Recurrent depressive disorder, current episode severe without psychotic symptoms • • • – – – – F33.3Recurrent depressive disorder, current episode severe with psychotic symptoms F33.4Recurrent depressive disorder, currently in remission F33.8Other recurrent depressive disorders F33.9Recurrent depressive disorder, unspecified

F34 Persistent mood [affective] disorders

– F34.0 Cyclothymia – F34.1 Dysthymia – F34.8 Other persistent mood [affective] disorders – F34.9 Persistent mood [affective] disorder, unspecified

F38 Other mood [affective] disorders

– F38.0 Other single mood [affective] disorders • .00 Mixed affective episode – F38.1 Other recurrent mood [affective] disorders • .10 Recurrent brief depressive disorder – F38.8 Other specified mood [affective] disorders

F39 Unspecified mood [affective] disorder

Mild Depressive episode

• • • • At least 2 weeks...but shorter periods if severe or rapid in onset.

At least two of: – – – Depressed mood Loss of interest and enjoyment Increased fatigability Plus two – – – – – – – of: reduced concentration and attention; reduced self-esteem and self-confidence; ideas of guilt and unworthiness bleak and pessimistic views of the future; ideas or acts of self-harm or suicide; disturbed sleep diminished appetite.

Usually, some difficulty in functioning • Mnemonic: DIE GAS FASS

Moderate Depressive episode

• • • • At least 2 weeks...but shorter periods if severe or rapid in onset.

At least two – of: Depressed mood – Loss of interest and enjoyment – Increased fatigability Plus at least three – of: reduced concentration and attention; – reduced self-esteem and self-confidence; – ideas of guilt and unworthiness – bleak and pessimistic views of the future; – ideas or acts of self-harm or suicide; – disturbed sleep – diminished appetite.

Usually, considerable difficulty functioning

Severe Depressive episode

• • • • • At least 2 weeks...but shorter periods if severe or rapid in onset.

All three – of: Depressed mood – Loss of interest and enjoyment – Increased fatigability Plus at least four – of: reduced concentration and attention; – reduced self-esteem and self-confidence; – ideas of guilt and unworthiness – bleak and pessimistic views of the future; – ideas or acts of self-harm or suicide; – disturbed sleep – diminished appetite.

Very unlikely to be able to function Psychotic symptoms: hallucinations, delusions, depressive stupor.

– Mood congruent or incongruent.

Recurrent depressive episode

• • • More than one episode lasting 2 weeks or more...separated by several months.

– Otherwise recurrent affective disorder F38.1 (Recurrent brief depressive disorder) • ~1/month • <2weeks in duration (typically 2-3 days) • Fulfil symptomatic criteria for mild, moderate, or severe Absence of mania.

Hypomania acceptable if following treatment with antidepressant.

Persistent mood [affective] disorder F34

• • • • Rarely if ever sufficiently severe to reach hypomania or mild depression.

At least one year.

Eg. Dysthymia Excludes bereavement (lasting <2y )

Somatic Syndrome ICD-10

• • • “scientific status...questionable...can also be ignored” At least four : – – – – – – – – Loss of interest or pleasure in activities Lack of emotional reactivity EMW (2h) Diurnal variation (worse in the mornings) Psychomotor retardation/agitation Loss of appetite Weight loss (5% in one month) Loss of libido Mneumonic: DEAR WALI

ICD-10

• •

F32 Depressive episode

F33 Recurrent depressive disorder

F34 Persistent mood [affective] disorders

– F34.0 Cyclothymia – F34.1 Dysthymia – F34.8 Other persistent mood [affective] disorders – F34.9 Persistent mood [affective] disorder, unspecified

F38 Other mood [affective] disorders

F39 Unspecified mood [affective] disorder

• • • Mood Episodes Mood Disorders Specifiers

DSM IV TR

Major Depressive Episode

• • One – of: Depressed mood (A1) – Loss of interest or pleasure in nearly all activities (A2) • C&A – may be irritable rather than sad.

PLUS(at least four ): – Changes in appetite or weight(+/- 5%) (A3), sleep (A4), and psychomotor activity (A5).

– – Decreased energy (A6) Worthlessness or guilt (A7)... but not guilt about being ill...unless

delusional.

– Difficulty thinking, concentrating, or making decisions (A8) – Recurrent thoughts of death or suicidal ideation, plans or attempts (A9).

• Most of the day, nearly every day, for 2 consecutive weeks.

Major Depressive Episode

• • • • Symptoms must be new or a clear worsening from premorbid status.

Must accompany clinically significant distress or impairment in social, occupational, or other important areas of functioning.

No mania, no drugs, no organic pathology, no bereavement (2m) causing it.

Not ‘sadness’.

• Course: develops over days to weeks. Prodrome may be longer. Usually >4m if untreated. If >2 years, then ‘ chronic ’.

Major Depressive Disorder (MDD)

• • • • 1 or more depressive episodes.

– End of episode = 2 consecutive months of not meeting criteria.

No mixed/manic/hypomanic episodes.

Not organic/substance induced.

Not schizophrenia, schizoaffective, etc.

Specifiers

• • • Mild, moderate, severe (with or w/o psychotic sx).

– Mild = 5-6 Sx + mild disability or substantial effort.

– – – Severe = nearly all Sx and severe disability.

Moderate = somewhere in between.

Psychotic Sx= Mood congruent or incongruent (poorer prognosis).

Chronic

– At least 2 years Catatonic - at least 2 of: – Catalepsy or stupor – Excessive motor activity – Negativism or mutism – Posturing, stereotyped movements, mannerisms, grimacing – Echolalia or echopraxia

Specifiers

•

Melancholic

One of: – Loss of pleasure in all, or almost all, activities – Lack of reactivity to pleasurable stimuli Plus at least 3 of: – Distinct quality of depressed mood – Worse in the morning – – EMW (2h before).

Psychomotor retardation or agitation – Anorexia or weight loss – Excessive or inappropriate guilt

Specifiers

•

Atypical

– Mood reactivity Plus two or more of: – Weight gain or increase in appetite – Hypersomnia – – Leaden paralysis Long-standing interpersonal rejection sensitivity • • Postpartum (within 4 weeks)

With seasonal pattern

Specifiers

• •

In remission (partial/full) With/without full inter-episode recovery

DSM-IV TR

• • • • • • • • • • • • • • • • • • 296.20

Major Depressive Disorder, Single Episode, Unspecified.

296.21

Major Depressive Disorder, Single Episode, Mild.

296.22

Major Depressive Disorder, Single Episode, Moderate.

296.23

Major Depressive Disorder, Single Episode, Severe Without Psychotic Features 296.24

Major Depressive Disorder, Single Episode, Severe With Psychotic Features.

296.25

Major Depressive Disorder, Single Episode, In Partial Remission.

296.26

Major Depressive Disorder, Single Episode, In Full Remission.

296.30

Major Depressive Disorder, Recurrent, Unspecified.

296.31

Major Depressive Disorder, Recurrent, Mild.

296.32

Major Depressive Disorder, Recurrent, Moderate.

296.33

Major Depressive Disorder, Recurrent, Severe Without Psychotic Features.

296.34

Major Depressive Disorder, Recurrent, Severe With Psychotic Features.

296.35

Major Depressive Disorder, Recurrent, In Partial Remission.

296.36

Major Depressive Disorder, Recurrent, In Full Remission 300.04

Dysthymic Disorder 309.0 Adjustment Disorder with Depressed Mood 311Depressive Disorder NOS (premenstrual dysphoric disorder, minor depressive disorder (single and recurrent), post-psychotic disorder of schizophrenia, depressive episode superimposed on delusional disorder, schizophrenia, psychotic disorder NOS), confusion with regards to aetiology.

V62.82 Bereavement

Dysthymic disorder

• • At least 2 years of depressed mood Additional depressive symptoms that DO NOT meet criteria for a major depressive episode.

Main differences

• ICD 10 – Episode • 4 symptoms for episode (2+2) • • 10 symptoms in total • • • • Bleak future Reduced self-esteem and confidence – – – – – – Somatic syndrome • 4 symptoms • • libido Bereavement 2y No chronic depression Dysthymia = 1y • DSM IV – Episode • 5 symptoms for episode (1+4) • • 9 symptoms in total Weight changes • • • • Psychomotor activity Excludes certain guilt – – – – – – Melancholic • 1 + 3 symptoms • Distinct quality of mood • Bereavement 2m Chronic Depression Dysthymia = 2y Atypical depression More specifiers

• ICD 11 (2015)

The future...

DSM V (2013) • • • • • • • • • •

D 00 Disruptive Mood Dysregulation Disorder

D 01 Major Depressive Disorder, Single Episode D 02 Major Depressive Disorder, Recurrent

D 03 Chronic Depressive Disorder (Dysthymia) D 04 Premenstrual Dysphoric Disorder

D 05 Mixed Anxiety/Depression D 06 Substance-Induced Depressive Disorder D 07 Depressive Disorder Associated with a Known General Medical Condition D 08 Other Specified Depressive Disorder D 09 Unspecified Depressive Disorder

Premenstrual Dysphoric Disorder

• • • • • • • • • • • • • (5) (6) (7) (8) (9) A. In most menstrual cycles during the past year, five (or more) of the following symptoms occurred during the final week before the onset of menses, started to improve within a few days after the onset of menses, and were minimal or absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4): (1) marked affective liability (e.g., mood swings; feeling suddenly sad or teaful or increased sensitivity to rejection) (2) marked irritability or anger or increased interpersonal conflicts (3) (4) markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts marked anxiety, tension, feelings of being "keyed up" or "on edge" decreased interest in usual activities (e.g., work, school, friends, hobbies) subjective sense of difficulty in concentration lethargy, easy fatigability, or marked lack of energy marked change in appetite, overeating, or specific food cravings hypersomnia or insomnia (10) a subjective sense of being overwhelmed or out of control (11) other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of

“bloating,” weight gain

B. The symptoms are associated with clinically significant distress or interferences with work, school, usual social activities or relationships with others (e.g. avoidance of social activities, decreased productivity and efficiency at work, school or home).

Scales

• • • •

Beck Depression Inventory (BDI)

– 21-question multiple-choice self-report inventory

Hamilton Rating scale for depression (HRSD or HAM-D)

– multiple choice questionnaire clinicians use to rate the severity of a patient's major depression.

– 17 questions (although longer versions available)

Montgomery-Åsberg Depression Rating Scale (MADRS)

– 10 items.

– – Used by clinicians More sensitive to antidepressant effects than HSRD

Geriatric Depression Scale (GDS)

– 30 item (yes/no) – Self report – Simpler. Allows more cognitively impaired individuals to complete it.

Psychology

Beck’s Cognitions

• Triad of negative thoughts about – Self – Ongoing experiences – Future

Cognitive distortions

• • • • • Arbitrary inference Selective abstraction Overgeneralization Magnification and minimization Dichotomous thinking

Subspecialties

Differences in Old Age

• • • • Mood disturbance less often as symptom More somatic ? More agitated ? More delusional • Difficulties when symptoms overlap with physical ill health

Depression and cognition

• If cognition normal in depression then no increased risk of dementia • If cognition impaired in depression then risk of dementia increased x4 (even if cognition normalizes with treatment)

• Is there a sub-type of depression in old age that is different from younger adults ?

• Is “vascular depression” a useful concept ?

Depression in Children & Adolescents

- More often presents with irritability – DSM IV

Depression in LD

• Also irritability…

Questions

True or false

• • • • In adults depression occurs more in females compared to males The Geriatric Depression Scale is an observer rated scale that concentrates on biological symptoms of depression Presence of psychosis may interfere with assessment of mood disorder The minimum duration of illness for a diagnosis of major depression according to DSM-IV is 2 weeks

MCQ

• • • • • • • • • • • • • • • • Depression in Children and Adolescents: Please choose the correct answers. There may be more than one correct answer or no correct answer for each question Prevalence of depression in young people – Approximately 1 in 10 Adolescents will get depression in their life-time – – At age 8 more common in girls than in boys Prevalence in young people is increasing – Uncommon in pre-pubertal children The first line of treatment for depression in young people? a) Family therapy b) Cognitive behaviour therapy c) Inter personal therapy d) Fluoxetine e) Sertraline f) Combination of b and d g) Psycho education and watchful waiting f) Any of the above

CASC

• • Elicit a collateral history of depression Suggest management • • DIE GAS FASS DEAR WALI

CASC

• You are seeing Mrs Grey, 38-year-old woman because she wants a second opinion on her management. She has a diagnosis of recurrent depression and has been well for a year on an antidepressant and lithium. She would like to discontinue them. You don’t have access to her previous notes.

• Please assess the need to continue her medication.

CASC

• A 35 year old lady with "depression" is attending psychotherapy and wants to terminate therapy. Give a management plan to the patient and discuss that plan with her.

CASC

• You are asked to take a history from a 15-year old girl with a history of depression. There are some trauma-related symptoms, related to bullying, which are unlikely to meet diagnostic criteria for PTSD.

CASC

• You must interview a woman with post-natal depression and a 7-month old baby. She is now 10 weeks pregnant again.

You are asked to take a history of depression and not required to assess risk.

CASC

• Take a history from a man with a history of depression who is complaining of sexual dysfunction.

Questions

• • • • • • • • • • • • • • • • • • • • • • • • • • The common co morbidities in depression in include?

a) separation anxiety b) conduct disorder c) substance misuse disorder d) learning difficulties e) ADHD f)OCD Which of the following about depression in young people is true?

a) It is normal to be depressed in adolescence b) Children less than 6 years don’t get depressed c) Suicide is a high risk in adolescents d) Detection rates of depression in young people are very high e)Mild forms of depression in young people does not cause impairment A 8 year old child with depression present with the following symptoms (choose one or more) Separation anxiety specific phobias Irritability nightmares inability to gain weight auditory hallucinations delusions of nilhism poor self esteem failure to thrive behavioural problems enuresis obsessive behaviour menstruation problems What about a 16 year old girl....? Choose one or more.

Questions

• • • • • • • • • • • • • • • • • • • • • • • • Children with depression are at a)increased risk of conduct disorders in later life b)increased risk of depression in later life c) increased risk of bi-polar in later life d) increased risk of substance misuse Depression in Children and Adolescents: Please choose the correct answers. There may be more than one correct answer or no correct answer for each question Prevalence of depression in young people – Approximately 1 in 10 Adolescents will get depression in their life-time – At age 8 more common in girls than in boys – Prevalence in young people is increasing – Uncommon in pre-pubertal children The first line of treatment for depression in young people? a) Family therapy b) Cognitive behaviour therapy c) Inter personal therapy d) Fluoxetine e) Sertraline f) Combination of b and d g) Psycho education and watchful waiting f) Any of the above

Questions

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • The common co morbidities in depression in include?

a) separation anxiety b) conduct disorder c) substance misuse disorder d) learning difficulties e) ADHD f)OCD Which of the following about depression in young people is true?

Irritability nightmares inability to gain weight auditory hallucinations delusions of nilhism poor self esteem failure to thrive behavioural problems enuresis obsessive behaviour menstruation problems Children with depression are at a)increased risk of conduct disorders in later life b)increased risk of depression in later life c) increased risk of bi-polar in later life d) increased risk of substance misuse

Clinical features of depression

Transcript Clinical features of depression