CLINlCAL DEPRESSION

 

A.      Should be distinguished from:

transient/fleeting feelings of irritation. dissatisfaction, disappointment boredom or sadness

 

B.       Is used to describe consistent feelings of dvsphoria (sadness or hopelessness) for a significant duration which seem disproportionate to the patient's circumstances

 

 

DIAGNOSTIC CRITERIA

 

Consistently lowered mood little reactivity

2 or more weeks duration

Subjectively depressed

Objectively corroborated

Biological symptoms

Atypical symptoms

 

 

 

MISSED DIAGNOSES

 

1.       Masked depression (Biological symptoms present although the patient may complain of a different or unrelated complaint)

 

2.       Undiagnosed underlying physical illness­

-       endocrine disease

-       drug/alcohol abuse

-       dementia

 

3.       Understandable reasons for feeling sad:­

-       unemployment, redundancy, debts

-       family illness & bereavement

-       severe or debilitating illness, e.g. CA

-       cardiac/lung disease, arthritis

4.       Personality disorders:

              - affective

              - cyclothymic

              - borderline

 

ASSESSMENT

 

1.       Biological symptoms - observer report

 

2.       Negative cognitions - ? delusional

 

3.       + and - rewarding experiences

 

(avoidance of work/socialising  feed into negative cognitions, perpetrate illness)

 

4.       Personality - understanding traits exaggerated by illness, underlying P.D. may vulnerability or chaotic lifestyle stressors  -'I depression

 

5.       Social situation - work, money, family, marital problems

 

6.       Precipitating and perpetuating factors

 

BIOLOGICAL/VEGETATIVE SYMPTOMS

 

Low mood, anhedonia with:

 

insomnia, EMW, anorexia,

- weight

-DV of mood

-retardation

-concentration

- libido fatigue and lethargy

 

plus  social withdrawal

self blame/guilt/worthlessness -? delusional

futility

suicidal thoughts

 

Atypical symptoms

 

Appetite, weight gain, hypersomnia

 

Symptoms should be subjectively reported and objectively corroborated (by observation or informants report)

          concerning the self                                worthlessness

                                                                    self blame

                                                                    guilt

          concerning the future                           helplessness

                                                                   hopelessness

 

concerning the outside world

 

Are there internally directed cognitions, are they overvalued/delusional?

 

POSITIVELY AND NEGATIVELY REWARDING EXPERIENCES

 

Positive

Negative

Family

 

 

children

affirmed valued good sexual relationship

 

loyal successful

criticism nagging infidelity

 

 

rebellious difficulties

occupational

 

recreational religious

achieving goals valued

 

 

enjoyment affirmation

failing criticised

 

 

 

guilt

Social

in company stimulated valued

lonely bored undervalued

 

 

avoidance of positive          negative             perpetuate

               experiences        cognition            depression

 

Effect of patient's negativity on the spouse

 

·        Is the spouse depressed?

·        Is the spouse about to leave?

·        Is the spouse informed about the illness?

·        Is the spouse offered appropriate support?

 

 

Object of the spouse's negativity on the patient

 

·        For how many years has the present marital interaction been like this?

·        Is the supportive intervention indicated?

·        Is marital therapy indicated?

 

ASSESSMENT OF PREMORBID PERSONALITY

 

Is there a personality disorder?

 

occupational Hx, adequacy of intimate relationships psychosexual Hx, forensic Hx

(is there a depressive personality/cyclothymic personality

episodes of elevated/depressed mood for most of the time subsyndromal in severity, accompanied by behavioural change?)

 

Are there -  dependent anxious hysterical

obsessional personality traits?

 

Is there evidence of a borderline personality disorder?

-such patients suffer dysthymia/chronic boredom with cutting/ O/D/ binge eating/binge drinking to relieve dysphonia. But also have increased vulnerability to depression (?underlying genetic/biological factors

                   ? chaotic life style      1' stress      depression).

 

 

 

 

MANAGEMENT

1.       Physical treatment (drugs, ECT)

2.       Cognitive therapy

3.       Behaviour therapy

4.       Brief psychotherapy

5.       Marital/family therapy

6.       Analytic psychotherapy

7.       Counseling

 

in isolation or combination

 

 

INDICATIONS FOR INPATIENT CARE

 

Suicide risk

Self neglect

Assessment of resistant depression

 

 

ASSESSMENT OF SUICIDE  RISK

1.       Life not worth living

2.       Wish to die

3.       Suicidal thoughts

-        some, fleeting easily resisted

reasons not to act on them

4.       Suicidal thoughts              many

                                                distressing/relief/comfort

                                                hard to resist

 

RELATIVE RISK FACTORS

 

1.       Social isolation

2.       Perceived rejection by others

3.       Life situation very bleak

4.       Medical illness

 

Plus age, male sex, past attempts, alcohol etc

1.       Clinical diagnosis of depression

2.       Biological symptoms (anhedonia anergia, anorexia, EMW, etc) Atypical symptoms (hypersomnia hyperphagia)

3.       Some loss of social or occupational functioning

Plus other symptoms:         A. Anxiety             psychic

                                                                    somatic

                                        B. Obsessional

INDICATIONS FOR ECT

 

Suicide risk not eating/drinking

psychotic depression resistant depression

post partum depression depression in elderly

 

 

 

 

 

INDICATIONS FOR COGNITIVE THERAPY

Negative cognitions evident

Some hope

Biological features

Social problems

Personality difficulties

Psychologically minded

Motivated

-        not too severe

-        not too severe

 

INDICATIONS FOR BEHAVIOURAL TREATMENT

 

Few positively rewarding experiences -possibility of increasing these Negative experiences - possible interventions to reduce these

 

 

INDICATIONS FOR BRIEF PSYCHOTHERAPY

 

Single issue related to depression understandable in terms of history and unconscious motivation

 

INDICATIONS FOR FAMILY/MARITAL THERAPY OR ANALYTICALLY BASED PSYCHOTHERAPY

 

As in any other situation

Psychotic depression a relative contraindication

 

 

AIMS OF COGNITIVE TREATMENT

 

to modify thinking

to identify automatic negative thoughts to appreciate their effect upon mood to replace negative with positive thoughts

 

 

AIMS OF BEHAVIOURAL TREATMENTS

 

modification of behaviour

to increase number of positively rewarding experiences and decrease the negative (voluntary work etc)

 

AIMS OF BRIEF FOCUSED PSYCHOTHERAPY (12 weeks)

 

resolution of a crisis

through an understanding of the historical and unconscious origins of that crisis no "personality change" implied except for normal process of personality

growth

 

CHOICE OF DRUG TREATMENT

1.      Type of illness (B.P. concurrent LCICBZ psychotic - neuroleptics)

2.      Past Hx of good response to previous Tx

3.      Family Hx of treatment response

         Patient's symptom profile -          anxiety

initial insomnia anorexia/weight loss weight gain

5.      Patient's situation - working/driving

6.      P.H. of DSH/current suicide risk

7.      Patients age and physical state or concurrent medication

 

 

 

 

 

DRUG TYPES

 

1.      Tricyclics (eg. Amitriptyline, Prothiaden) pros: unequivocal efficacy

sedative, anxiolytic, increased appetite

 

cons: anticholinergic S.E. - sedation, constipation, urinary hesitancy, blurred vision, dry mouth, tremor, postural hypotension, weight gain, 4 fit threshold (N.B. epilepsy and secret drinkers),? poor compliance. Cardiotoxicity - dangerous in O.D.

 

2.      MAOIs (eg. pheneizine, tranylcypramine)

pros: anxiolytic, good in "atypical" and "neurotic" pictures

 

cons: dietary restrictions, activation (prescribe a.m. and noon) hypertensive crises

dangerous in O.D. reluctance to stop treatment

 

3.      Tetracyclics - (eg. Mianserin) cons: less anticholinergic, less cardiotoxic pros: bone marrow suppression

 

4.                          New generation - 5HT reuptake inhibitors RIMAs

 

eg. Moclobemide (1 5O-6OO mg/day)

Inhibits monoamine oxidase A

Effect reversible

Post treatment washout unnecessary

Minimal interactions with other drugs (but avoid pethidine, codeine, SSRIs1 TCAs)

Few dietary restrictions

Low in anticholinergic side effects

Low risk in O.D. (>75 x daily dosage)

Effective in depression with anxiety

Less effective in atypical depression than the old fashioned MAOls

 

5HT REUPTAKE INHIBITORS

 

Fluoxetine, Fluvoxamine, paroxetine, Sertraline

 

pros:  low incidence of anticholinergic S.E. (~ dry mouth, constipation, urinary retention, postural hypotension)

less weight gain (may lose weight) non sedative

no cardiovascular effects well tolerated (elderly) -? better compliance safer in O.D.

 

GOOD FOR:-overweight, atypical symptoms (hyperphagia), working, DSH, elderly

 

Not to be combined with TCAs or MAOIs Not as useful in BPD/resistant depression

 

 

 

DRUG TREATMENT

 

Should be maintained for 6/12 after recovery from an episode - then reduced before discontinuation

(maintenance vs. prophylaxis)

 

SEASONAL AFFECTIVE DISORDER

 

DSM lII-R

 

Simplified Diagnostic Criteria

1.       Major depression

2.       Onset same 60 day window

3.       offset same 60 day window

 

Treatment:-

1.       2500 lux artificial daylight

2.       Onto the retina

3.       3-6 hours/day

4.       Particularly early morning

 

TREATMENT RESPONSE

(2(3 of all cases) (2(3 of all cases)

 

1.      Patients who respond do so in 4-5 days of treatment

2.      Treatment continued by patients

3.      Some subsequently relapse.