Depression

Friday, 19 April 2013 1:11 PM

Introduction Important to differentiate reactive vs. pathological depression Under what circumstances can you be clinically depressed, but have depression as an illness as such? Reactive depression Alcohol / substance Hypothyroidism Disease = Dis ease = Subjective feelings Epidemiology Life time prevalence (inc. mild/minor depressive symptoms) 20% women (7:10) 10% men (4:10) Diagnostic instability Gender ?Response bias "Men don't cry" Urban > Rural ?Low Socio Economic Class Women (only UK studies) Ethnicity: insufficient data, but take into context Cohort effect: increased incidence in younger population Increased reporting? Aetiology Genetics Neurochemistry: low concentration of serotonin, noradrenalin, dopamine underactivity Neuroendocrinology Hypothalamic-pituitary-adrenocortic system Hypothalamic-pituitary-thyroid system Circadian rhythms (SAD - seasonal affective disorder) Winter depression/blues Social factors (loss, abuse, life threatening events) Brain imaging: reduced hippocampal volume and amygdala cerebral ventricular enlargement Depressive symptoms Depressed mood Loss of interest Loss of reactivity Anhedonia Avolition Hopelessness Worthlessness Guilt Suicidality Fatigue/Exhaustion Irritability Loss of appetite Weight change Insomnia/Hypersomnia Loss of libido Psychomotor retardation Psychotic symptoms Age groups Babies with depression = failure to thrive School age = sleeping disorders When Mum goes into hospital for a new baby
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 When Mum goes into hospital for a new baby Older = complain about physical health, regardless of presence or absence Report symptoms mainly due to losses Subtypes Melancholic ? Atypical Mood worse in the evening, increasing apetite, weight and sleep, leaden paralysis, interpersonal sensitivity Catatonic Severe psychomotor depression Not seen so much any more, most likely correction of actual pathology (e.g. Syphilis) Agitated Higher rates of harm and suicide ?Increased dis-ease "Psychotic depression" ** Just from him, not on power point In severe cases, can lose touch with reality Mild, Moderate, Severe, Primary (biological), Secondary (reactive) Depression and physical illness Drugs (cannabis and alcohol) Neurological disorders CVA, Parkinson's, epilepsy, demyelinating disorders, dementias, HIV, brain tumour Endocrine disorders Hypo/hyperthyroidism, Cushings, ? Depression and comorbidities Anxiety spectrum disorder Alcohol and substance abuse Personality disorders Schizophrenia spectrum Chronic fatigue syndrome, fibromyalgia Predictors of suicide Suicidal thoughts and hopelessness Suicidal plan Preparations for death High level of irritability/impulsivity Rural location Low mood EtOH/Substance misuse FHx of Suicide Middle age Male Single/Divorce Self-harmers Younger, female, don't have major depression, personality problems, lots of difficulties dealing with daily stressors First point of call = ?Mother and family Two periods where drop of suicide rates Two world wars Treatment of biological SSRI's SNRI's NARI (reboxetine) Mirtazapine TCA (cardac and conduction) MAOI's (irreversible tyramine response!)
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MAOI's (irreversible tyramine response!) Asenapine, melatonin Antipsychotics Benzodiazepines Dosings Blister packs, controlled release from pharmacy have reduced suicides Treatment physical ECT DBS - Deep brain stimulation TMS - Transcranial magnetic stimulation Light therapy (SAD) Treatment psychological CBT IPT Psychodynamic therapy Interpersonal social rhythm therapy (for bipolar depression) Family therapy Specific therapies for comorbid anxiety disorders e.g. graded exposure - response prevention So what do we do? Treatment choice dictated by Diagnosis Training Treatment guidelines (RANZCP, APA, RCP) Personal experience/preference Local culture (hospital, clinic, community) And of course PATIENT CHOICE No point offering treatment if the patient doesn't do it!

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