Psychiatry
Seán Keenan
2022
,Depression
Description
Depression is a common mental disorder that causes people to experience depressed mood, loss of interest or
pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. In
2014, 19.7% of people in the UK aged 16 and over showed symptoms of anxiety or depression - a 1.5% increase from
2013. This percentage was higher among females (22.5%) than males (16.8%)
Physiological Changes in Depression
Neurotransmitters Brain Matter
- Path: Decreased levels of neurotransmitters - Path: Changes mediated by stress and trauma
- NB: ↓ Serotonin; ↓ Norepinephrine; ↓ Dopamine - Neurons: ↓Neuronal density; ↓ Neurogenesis
- Drugs: Target to increase levels of neurotransmitters - Volume: Regional changes (esp. hippocampus)
Screening and Grading Depression
Screening Assessment
- Questions: Ask one of following felt over past month - HAD Scale: Hospital Anxiety + Depression Scale
- Q1: Have you often been bothered by feeling down, - PHQ-9: Patient Health Questionnaire
depressed or hopeless? - DSM-IV: Used by NICE for grading depression
- Q2: Have you often been bothered by having little
interest or pleasure in doing things?
,Subthreshold Depression
Management
- General: Sleep hygiene - Drug: Avoid using antidepressants routinely
- Monitor: Actively monitor if Pt. declines intervention - Counselling: Low-intensity CBT (see below)
Low-Intensity Psychosocial Interventions
CBT Notes
Delivery : 6-8 sessions over 9-12 wks
Individual guided self-help based on
Education : Include written materials
CBT principles
Review: Supported by trained professional over 9-12 wks + follow-up
Delivery : Review of progress ober 9-12 wks
Computerised CBT Education : Explain CBT model; Encourage tasks between sessions
Review: Supported by trained professional over 9-12 wks + follow-up
Delivery : 3 sessions per wk over 10-14 wks
Structured group physical activity
-
programme
-
Delivery: 10-12 meetings over 12-16 wks; 8-10 participants
Group-Based CBT Education: Based on model such as 'coping with depression'
Review: Takes place over 12-16 wks + follow up
SubThreshold Depression
Category Fewer than five symptoms
Few, if any, symptoms in excess of the 5 required to make
Mild Depression
the diagnosis, and symptoms result in only minor functional
Symptoms or functional impairment are between 'mild' and
Moderate Depression
'severe'
Most symptoms, and the symptoms markedly interfere with
Severe Depression
functioning. Can occur with or without psychotic symptoms
Major Depressive Disorder
Presentation Indications for Management
- Core Symptoms - Subthreshold: Persistent subthreshold
o Mood: Low Mood depression
o Anhedonia: Loss of pleasure - Resistant: Mild or moderate depression
o Energy: Low energy levels - Severity: Moderate-severe depression
- Accessory Symptoms Medical Management
o Somatic: Separate from brain symptoms - 1L: SSRI (e.g. Citalopram; Sertraline; Fluoxetine)
o Concentration: Loss of concentration/attention - Duration: Continue 6 months post-remission
o Esteem: Lack of self-esteem/confidence - Children: Fluoxetine is 1L in those <18 YO
o Ideation: Guilt; Self-harm; Suicide Other Management
o Loss: Libido; Sleep-wake cycle; Appetite; Weight - ECT: Electroconvulsive therapy (see below)
- Counselling: CBT sessions (see below)
- Severity Grading
- Group CBT: Depression linked to LT physical
o Mild: 2 Core sx + 2 Minor sx
illness
o Mod: 2 Core sx + 3 Minor sx
o Severe: 3 Core + ≥4 Minor sx
Electroconvulsive Therapy
Indications Long-Term SE
- Severe: Severe refractory depression - Memory: Some report loss of memory
- NB: Catatonia Contraindications
Short-Term SE - ↑ ICP: Complete CI
- Memory: Short-term memory impairment - Cardiac: Severe CAD; HF; Valvular heart disease
- Cardiac: Catecholamine surge Arrythmia Preparations
- Meds: ↓ Antidepressant but do not stop
, - Other: Headache; N&V; Cardiac arrhythmia
Cognitive Behavioural Therapy in Depression
CBT Notes
Delivery: 16-20 sessions over 3-4 months
Individual CBT Follow-Up : Consider 3-4 follow-ups over next 3-6 months
NB: Consider 2 sessions/wk for first 2-3 wks in mod-severe depression
Delivery: 16-20 sessions over 3-4 months
Interpersonal Therapy (IPT) NB: Consider 2 sessions/wk for first 2-3 wks in severe depression
-
Delivery: 16-20 sessions over 3-4 months
Behavioural Activation Follow-Up : Consider 3-4 follow-ups over next 3-6 months
NB: Consider 2 sessions/wk for first 3-4 wks in mod-severe depression
Delivery: Typiucally 15-20 sessions over 5-6 months
Behavioural Couples Therapy -
-
Switching Anti-Depressants
Management
- Guide: Based on Maudsley Hospital Guidelines
- SSRI SSRI: First SSRI withdrawn before alt. started
- Fluoxetine SSRI: Leave gap of 4-7d between meds
- SSRI Tricyclic: Cross-taper (↓ SSRI while ↑ TCA)
- NB: Withdraw fluoxetine before starting TCA
- SSRI Venlafaxine: Cross taper cautiously + slowly
- NB: Withdraw fluoxetine before starting venlafaxine
Depression vs Dementia
Factors Favouring Depression
- Memory: Global vs recent memory loss - Worry: Pt. is worried about poor memory
- Onset: Short Hx with a rapid onset - NB: Feels test anxiety + disappointment
- Sx: Biological signs (weight loss; insomnia) - Test: Mini-mental test score is variable
Seasonal Affective Disorder (SAD)
Description Management
- Seasonal: Depression usually in winter months - CBT: Psychological therapies
Presentation - Meds: SSRI may be required
- Depression: Sx in keeping with depression disorder - NB: Sleeping medication is CI as may worsen SAD
Grief Reaction
Description Presentation
- Stages: Most popular models is five stages of grief - Denial: Numbness; Pseudohallucinations
- NB: Not all patients will go through all stages - Anger: Against family or medical professionals
- Atypical: Delayed or Prolonged grief - Bargaining: E.g. “If I could trade my life” etc.
- Delayed: Can occur >2 wks after event - Depression: Despair; Recognition of mortality
- Prolonged: Difficult to define; >12 months - Acceptance: Embraces reality and stabilises
Pseudodementia
Description Presentation
- Path: Depression may cause reduced cognition - Memory: Anterograde intact; Acute onset
- NB: Many deny depressive symptoms - Awareness: Distressed + aware of ↓ cognition
Seán Keenan
2022
,Depression
Description
Depression is a common mental disorder that causes people to experience depressed mood, loss of interest or
pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration. In
2014, 19.7% of people in the UK aged 16 and over showed symptoms of anxiety or depression - a 1.5% increase from
2013. This percentage was higher among females (22.5%) than males (16.8%)
Physiological Changes in Depression
Neurotransmitters Brain Matter
- Path: Decreased levels of neurotransmitters - Path: Changes mediated by stress and trauma
- NB: ↓ Serotonin; ↓ Norepinephrine; ↓ Dopamine - Neurons: ↓Neuronal density; ↓ Neurogenesis
- Drugs: Target to increase levels of neurotransmitters - Volume: Regional changes (esp. hippocampus)
Screening and Grading Depression
Screening Assessment
- Questions: Ask one of following felt over past month - HAD Scale: Hospital Anxiety + Depression Scale
- Q1: Have you often been bothered by feeling down, - PHQ-9: Patient Health Questionnaire
depressed or hopeless? - DSM-IV: Used by NICE for grading depression
- Q2: Have you often been bothered by having little
interest or pleasure in doing things?
,Subthreshold Depression
Management
- General: Sleep hygiene - Drug: Avoid using antidepressants routinely
- Monitor: Actively monitor if Pt. declines intervention - Counselling: Low-intensity CBT (see below)
Low-Intensity Psychosocial Interventions
CBT Notes
Delivery : 6-8 sessions over 9-12 wks
Individual guided self-help based on
Education : Include written materials
CBT principles
Review: Supported by trained professional over 9-12 wks + follow-up
Delivery : Review of progress ober 9-12 wks
Computerised CBT Education : Explain CBT model; Encourage tasks between sessions
Review: Supported by trained professional over 9-12 wks + follow-up
Delivery : 3 sessions per wk over 10-14 wks
Structured group physical activity
-
programme
-
Delivery: 10-12 meetings over 12-16 wks; 8-10 participants
Group-Based CBT Education: Based on model such as 'coping with depression'
Review: Takes place over 12-16 wks + follow up
SubThreshold Depression
Category Fewer than five symptoms
Few, if any, symptoms in excess of the 5 required to make
Mild Depression
the diagnosis, and symptoms result in only minor functional
Symptoms or functional impairment are between 'mild' and
Moderate Depression
'severe'
Most symptoms, and the symptoms markedly interfere with
Severe Depression
functioning. Can occur with or without psychotic symptoms
Major Depressive Disorder
Presentation Indications for Management
- Core Symptoms - Subthreshold: Persistent subthreshold
o Mood: Low Mood depression
o Anhedonia: Loss of pleasure - Resistant: Mild or moderate depression
o Energy: Low energy levels - Severity: Moderate-severe depression
- Accessory Symptoms Medical Management
o Somatic: Separate from brain symptoms - 1L: SSRI (e.g. Citalopram; Sertraline; Fluoxetine)
o Concentration: Loss of concentration/attention - Duration: Continue 6 months post-remission
o Esteem: Lack of self-esteem/confidence - Children: Fluoxetine is 1L in those <18 YO
o Ideation: Guilt; Self-harm; Suicide Other Management
o Loss: Libido; Sleep-wake cycle; Appetite; Weight - ECT: Electroconvulsive therapy (see below)
- Counselling: CBT sessions (see below)
- Severity Grading
- Group CBT: Depression linked to LT physical
o Mild: 2 Core sx + 2 Minor sx
illness
o Mod: 2 Core sx + 3 Minor sx
o Severe: 3 Core + ≥4 Minor sx
Electroconvulsive Therapy
Indications Long-Term SE
- Severe: Severe refractory depression - Memory: Some report loss of memory
- NB: Catatonia Contraindications
Short-Term SE - ↑ ICP: Complete CI
- Memory: Short-term memory impairment - Cardiac: Severe CAD; HF; Valvular heart disease
- Cardiac: Catecholamine surge Arrythmia Preparations
- Meds: ↓ Antidepressant but do not stop
, - Other: Headache; N&V; Cardiac arrhythmia
Cognitive Behavioural Therapy in Depression
CBT Notes
Delivery: 16-20 sessions over 3-4 months
Individual CBT Follow-Up : Consider 3-4 follow-ups over next 3-6 months
NB: Consider 2 sessions/wk for first 2-3 wks in mod-severe depression
Delivery: 16-20 sessions over 3-4 months
Interpersonal Therapy (IPT) NB: Consider 2 sessions/wk for first 2-3 wks in severe depression
-
Delivery: 16-20 sessions over 3-4 months
Behavioural Activation Follow-Up : Consider 3-4 follow-ups over next 3-6 months
NB: Consider 2 sessions/wk for first 3-4 wks in mod-severe depression
Delivery: Typiucally 15-20 sessions over 5-6 months
Behavioural Couples Therapy -
-
Switching Anti-Depressants
Management
- Guide: Based on Maudsley Hospital Guidelines
- SSRI SSRI: First SSRI withdrawn before alt. started
- Fluoxetine SSRI: Leave gap of 4-7d between meds
- SSRI Tricyclic: Cross-taper (↓ SSRI while ↑ TCA)
- NB: Withdraw fluoxetine before starting TCA
- SSRI Venlafaxine: Cross taper cautiously + slowly
- NB: Withdraw fluoxetine before starting venlafaxine
Depression vs Dementia
Factors Favouring Depression
- Memory: Global vs recent memory loss - Worry: Pt. is worried about poor memory
- Onset: Short Hx with a rapid onset - NB: Feels test anxiety + disappointment
- Sx: Biological signs (weight loss; insomnia) - Test: Mini-mental test score is variable
Seasonal Affective Disorder (SAD)
Description Management
- Seasonal: Depression usually in winter months - CBT: Psychological therapies
Presentation - Meds: SSRI may be required
- Depression: Sx in keeping with depression disorder - NB: Sleeping medication is CI as may worsen SAD
Grief Reaction
Description Presentation
- Stages: Most popular models is five stages of grief - Denial: Numbness; Pseudohallucinations
- NB: Not all patients will go through all stages - Anger: Against family or medical professionals
- Atypical: Delayed or Prolonged grief - Bargaining: E.g. “If I could trade my life” etc.
- Delayed: Can occur >2 wks after event - Depression: Despair; Recognition of mortality
- Prolonged: Difficult to define; >12 months - Acceptance: Embraces reality and stabilises
Pseudodementia
Description Presentation
- Path: Depression may cause reduced cognition - Memory: Anterograde intact; Acute onset
- NB: Many deny depressive symptoms - Awareness: Distressed + aware of ↓ cognition
