Depressive Disorder

Mood disorders

Clinicals - History

Fact Explanation
Syndromic diagnosis and can be graded in severity to mild, moderate and severe This has a collection of signs and symptoms (described below) and if they last for more than 2 weeks with significant effect on daily functioning, diagnosis is made. Depressive disorders were the second leading cause of YLDs (years lived with disability) in 2010 with females are commonly affected having 1:4 lifetime risk and men having 1:10 lifetime risk. More common in late twenties. The biochemical basis of depression is thought to be due to depletion of monoamines (Noradrenaline and Serotonin) in brain. There are various psychological theories which have been implicated to explain the aetiology as well. Depression is diagnosed using ICD-10 criteria and categorized as mild, moderate and severe. There are 3 core features (A symptoms) listed as first 3 in the symptoms and the next 7 are B symptoms. If there were 2 A symptoms and 2 B symptoms, it's mild depression. 2 A and 3 B symptoms it's moderate and 3A and 3B symptoms it's diagnosed as severe. Severe depression can be associated with Psychotic symptoms too which is explained in the examination part. Syndromic diagnosis and can be graded in severity to mild, moderate and severe
This has a collection of signs and symptoms (described below) and if they last for more than 2 weeks with significant effect on daily functioning, diagnosis is made. Depressive disorders were the second leading cause of YLDs (years lived with disability) in 2010 with females are commonly affected having 1:4 lifetime risk and men having 1:10 lifetime risk. More common in late twenties. The biochemical basis of depression is thought to be due to depletion of monoamines (Noradrenaline and Serotonin) in brain. There are various psychological theories which have been implicated to explain the aetiology as well. Depression is diagnosed using ICD-10 criteria and categorized as mild, moderate and severe. There are 3 core features (A symptoms) listed as first 3 in the symptoms and the next 7 are B symptoms. If there were 2 A symptoms and 2 B symptoms, it's mild depression. 2 A and 3 B symptoms it's moderate and 3A and 3B symptoms it's diagnosed as severe. Severe depression can be associated with Psychotic symptoms too which is explained in the examination part.
Low mood/ Depressed mood Low mood is seen. There could be diurnal variation in the mood, typically worsening in the morning but in mild depression, mood is low in the evening. This is listed as a core feature or A symptom. Low mood/ Depressed mood
Low mood is seen. There could be diurnal variation in the mood, typically worsening in the morning but in mild depression, mood is low in the evening. This is listed as a core feature or A symptom.
Loss of interest/ Anhedonia There's loss of interest and pleasure in things that used to be interesting and pleasurable. This is listed as a core feature or A symptom. Loss of interest/ Anhedonia
There's loss of interest and pleasure in things that used to be interesting and pleasurable. This is listed as a core feature or A symptom.
Reduced energy/ Decreased activity Patients complain that they are tired always and are unable to function normally. This is listed as a core feature or A symptom. Reduced energy/ Decreased activity
Patients complain that they are tired always and are unable to function normally. This is listed as a core feature or A symptom.
Difficulty in concentration They have a trouble in concentrating. This is a B symptom. Difficulty in concentration
They have a trouble in concentrating. This is a B symptom.
Ideas of guilt and worthlessness They feel guilty or worthless due to even small reasons and this is a B symptom. Ideas of guilt and worthlessness
They feel guilty or worthless due to even small reasons and this is a B symptom.
Reduced self esteem and confidence They have low self esteem and always look down upon themselves. This is a B symptom. Reduced self esteem and confidence
They have low self esteem and always look down upon themselves. This is a B symptom.
Pessimistic thoughts They have lots of negative thoughts. This is a B symptom. Pessimistic thoughts
They have lots of negative thoughts. This is a B symptom.
Ideas of self harm/ Suicide Thoughts about death/ suicide/ or self harm are seen. This is a B symptom. Ideas of self harm/ Suicide
Thoughts about death/ suicide/ or self harm are seen. This is a B symptom.
Decreased appetite Loss of appetite and/or weight loss is commonly seen but rarely,increase in appetite and/or undesired weight gain is complained in atypical depression. This is a B symptom. Decreased appetite
Loss of appetite and/or weight loss is commonly seen but rarely,increase in appetite and/or undesired weight gain is complained in atypical depression. This is a B symptom.
Disturbed sleep Insomnia (Waking up early/ disturbed sleep/ difficulty in initiating sleep) is seen and can be very disturbing. This is a B symptom. Disturbed sleep
Insomnia (Waking up early/ disturbed sleep/ difficulty in initiating sleep) is seen and can be very disturbing. This is a B symptom.
Loss of libido These are considered biological symptoms of depression. Loss of libido
These are considered biological symptoms of depression.
Constipation These are considered biological symptoms of depression. Constipation
These are considered biological symptoms of depression.

Clinicals - Examination

Fact Explanation
Neglected appearance There's neglected dress and grooming seen as well as psycho motor retardation is seen. Neglected appearance
There's neglected dress and grooming seen as well as psycho motor retardation is seen.
Facial features Appearance of horizontal furrows in the forehead and gaze is directed downwards. Reduced rate of blinking and gestures seen. Facial features
Appearance of horizontal furrows in the forehead and gaze is directed downwards. Reduced rate of blinking and gestures seen.
Poverty of speech There's reduced rate, variance in speech as well as hesitancy Poverty of speech
There's reduced rate, variance in speech as well as hesitancy
Miserable mood The mood is low. Mood can also be anxious, irritable or agitated Miserable mood
The mood is low. Mood can also be anxious, irritable or agitated
Morbid thoughts There's pessimistic thoughts regarding the past, present and the future. There's cognitive triad of hopelessness, helplessness and worthlessness. Homicidal/ Suicidal thoughts are seen as well Morbid thoughts
There's pessimistic thoughts regarding the past, present and the future. There's cognitive triad of hopelessness, helplessness and worthlessness. Homicidal/ Suicidal thoughts are seen as well
Delusions Delusions of worthlessness/ guilt, impoverishment, nihilism, hypochondrial, and persecutory delusions. Persecutory delusions are mood congruent. Delusions
Delusions of worthlessness/ guilt, impoverishment, nihilism, hypochondrial, and persecutory delusions. Persecutory delusions are mood congruent.
Hallucinations Second person auditory hallucinations of derogatory content are common. As well as visual hallucinations with scenes of death and destruction are seen. Hallucinations
Second person auditory hallucinations of derogatory content are common. As well as visual hallucinations with scenes of death and destruction are seen.
Impaired attention/ concentration "Depressive pseudo-dementia" is seen and this is due to impaired attention and concentration rather than due to true memory impairment. Impaired attention/ concentration
"Depressive pseudo-dementia" is seen and this is due to impaired attention and concentration rather than due to true memory impairment.

Investigations - Diagnosis

Fact Explanation
Serum TSH level Hypothyroidism can cause depression and the motor retardation in hypothyroidism could be difficult to differentiate from depression, therefore serum TSH level is done to exclude hypothyroidism. Serum TSH level
Hypothyroidism can cause depression and the motor retardation in hypothyroidism could be difficult to differentiate from depression, therefore serum TSH level is done to exclude hypothyroidism.
Fasting blood sugar Diabetes Mellitus can cause depression therefore, this should be excluded. Fasting blood sugar
Diabetes Mellitus can cause depression therefore, this should be excluded.
(CT) scanning or magnetic resonance imaging (MRI) of the brain This maybe considered if organic brain disorder is considered as a differential diagnosis (CT) scanning or magnetic resonance imaging (MRI) of the brain
This maybe considered if organic brain disorder is considered as a differential diagnosis

Investigations - Management

Fact Explanation
Serum electrolytes During serotonin reuptake inhibitors treatment, serum electrolyte level is done as it can cause hyponatremia in elderly. Serum electrolytes
During serotonin reuptake inhibitors treatment, serum electrolyte level is done as it can cause hyponatremia in elderly.
Electrocardiogram Arhythmias, and ischemic heart diseases are contraindications for tricyclic antidepressants. Therefore in elderly patients an ECG is done to assess the fitness to start these drugs. Also prior to electroconvulsive therapy (ECT), ECG is performed. Electrocardiogram
Arhythmias, and ischemic heart diseases are contraindications for tricyclic antidepressants. Therefore in elderly patients an ECG is done to assess the fitness to start these drugs. Also prior to electroconvulsive therapy (ECT), ECG is performed.
Chest X-ray This is also done prior to general anesthesia for ECT Chest X-ray
This is also done prior to general anesthesia for ECT
Full blood count This is also done prior to general anesthesia for ECT to exclude any anemia Full blood count
This is also done prior to general anesthesia for ECT to exclude any anemia
Serum electrolytes This is also done prior to general anesthesia for ECT to exclude any renal impairment. Also prior starting serotonin reuptake inhibitors, serum electrolyte level is done as it can cause hyponatremia in elderly. Serum electrolytes
This is also done prior to general anesthesia for ECT to exclude any renal impairment. Also prior starting serotonin reuptake inhibitors, serum electrolyte level is done as it can cause hyponatremia in elderly.
Fasting Blood sugar This is also done prior to general anesthesia to exclude any diabetes mellitus, in ECT Fasting Blood sugar
This is also done prior to general anesthesia to exclude any diabetes mellitus, in ECT
Patient Health Questionnaire-9 (PHQ-9) This is self administered questionnaire having 9 components. Patient Health Questionnaire-9 (PHQ-9)
This is self administered questionnaire having 9 components.
Beck Depression Inventory (BDI) This is a self administered tool with 21 components. Beck Depression Inventory (BDI)
This is a self administered tool with 21 components.
BDI for primary care This is a self administered questionnaire with 7 questions. This is adapted from BDI BDI for primary care
This is a self administered questionnaire with 7 questions. This is adapted from BDI
Zung Self-Rating Depression Scale This is a self administered questionnaire with 20 questions. Zung Self-Rating Depression Scale
This is a self administered questionnaire with 20 questions.
Center for Epidemiologic Studies-Depression Scale (CES-D) This is a self administered questionnaire with 20 questions. Center for Epidemiologic Studies-Depression Scale (CES-D)
This is a self administered questionnaire with 20 questions.
Hamilton Depression Rating Scale (HDRS) This is performed by a health care professional who is trained for this. Hamilton Depression Rating Scale (HDRS)
This is performed by a health care professional who is trained for this.
The Geriatric epression Scale (GDS) This is for screening for depression in elderly. The Geriatric epression Scale (GDS)
This is for screening for depression in elderly.

Management - Supportive

Fact Explanation
Risk assessment In a patient with depression, risk assessment plays an important role. Assessment of suicidal risk is important as well as homicidal risk. There's a risk of self neglect as well by reduction in food intake and social isolation. Risk assessment
In a patient with depression, risk assessment plays an important role. Assessment of suicidal risk is important as well as homicidal risk. There's a risk of self neglect as well by reduction in food intake and social isolation.
Deciding treatment setting Depending on the severity of illness, social support, patient preference, treatment setting should be decided. In severe depression, psychotic depression, risk of self harm inward treatment is advised. Deciding treatment setting
Depending on the severity of illness, social support, patient preference, treatment setting should be decided. In severe depression, psychotic depression, risk of self harm inward treatment is advised.
Patient and family education Patient and the family should be educated about the aetiology, symptoms, treatment options, the effect of drug treatment may take some time and the need of continuation for sometime after the illness, and prognosis of the illness. Patient and family education
Patient and the family should be educated about the aetiology, symptoms, treatment options, the effect of drug treatment may take some time and the need of continuation for sometime after the illness, and prognosis of the illness.
Identifying social support and ensuring optimal quality of life Social support for each patient should be assessed and it's important to ensure their quality of life is optimal. Identifying social support and ensuring optimal quality of life
Social support for each patient should be assessed and it's important to ensure their quality of life is optimal.
Diet Dietary restrictions are needed if they are put on monoamine oxidase inhibitors (MAOIs). Foods high in tyramine, cause a hypertensive crisis with MAOIs, therefore should be avoided. Cheese is one of these food items Diet
Dietary restrictions are needed if they are put on monoamine oxidase inhibitors (MAOIs). Foods high in tyramine, cause a hypertensive crisis with MAOIs, therefore should be avoided. Cheese is one of these food items
Activity Activity may be helpful to reduce stress and also enhances the recovery Activity
Activity may be helpful to reduce stress and also enhances the recovery

Management - Specific

Fact Explanation
Pharmacological therapy with Selective serotonin reuptake inhibitors (SSRIs), This is considered as the first line drug. Easy dosage and low toxicity in overdose are their advantages. Pharmacological therapy with Selective serotonin reuptake inhibitors (SSRIs),
This is considered as the first line drug. Easy dosage and low toxicity in overdose are their advantages.
Pharmacological therapy with Serotonin/norepinephrine reuptake inhibitors (SNRIs) SNRIs, which include venlafaxine, duloxetine, play an important role as second-line agents in patients who fail to respond to SSRIs. Pharmacological therapy with Serotonin/norepinephrine reuptake inhibitors (SNRIs)
SNRIs, which include venlafaxine, duloxetine, play an important role as second-line agents in patients who fail to respond to SSRIs.
Pharmacological therapy with atypical antidepressants Atypical antidepressants include mirtazapine, trazodone are effective in monotherapy in major depressive disorder and can be used in combination therapy as well. Pharmacological therapy with atypical antidepressants
Atypical antidepressants include mirtazapine, trazodone are effective in monotherapy in major depressive disorder and can be used in combination therapy as well.
Pharmacological therapy with Tricyclic antidepressants (TCAs) They are not used commonly now because of their side-effect profile and their high toxicity in overdose Pharmacological therapy with Tricyclic antidepressants (TCAs)
They are not used commonly now because of their side-effect profile and their high toxicity in overdose
Pharmacological therapy with Monoamine oxidase inhibitors (MAOIs) Hypertensive crisis with some food items has reduced the use of MAOIs in depression. Pharmacological therapy with Monoamine oxidase inhibitors (MAOIs)
Hypertensive crisis with some food items has reduced the use of MAOIs in depression.
Electroconvulsive therapy Onset of action is rapid than from drug treatment. Indications for the use of ECT include drug resistant depression, patient preference, high risk of suicide, psychotic depression and severe postpartum depression. Electroconvulsive therapy
Onset of action is rapid than from drug treatment. Indications for the use of ECT include drug resistant depression, patient preference, high risk of suicide, psychotic depression and severe postpartum depression.
Supportive psychotherapy This includes praise, reassurance and encouragement to become physically active and engage in activities. Supportive psychotherapy
This includes praise, reassurance and encouragement to become physically active and engage in activities.
Cognitive behavior therapy (CBT) CBT is a first-line treatment for depression and it's particularly helpful to prevent relapses. It includes behavioral therapy with activity rescheduling, and cognitive component is managed with maintaining a diary to manage their thoughts. They are helped to identify morbid thoughts,to challenge negative thoughts and develop rational alternative thoughts. Cognitive behavior therapy (CBT)
CBT is a first-line treatment for depression and it's particularly helpful to prevent relapses. It includes behavioral therapy with activity rescheduling, and cognitive component is managed with maintaining a diary to manage their thoughts. They are helped to identify morbid thoughts,to challenge negative thoughts and develop rational alternative thoughts.
Interpersonal psychotherapy This is also helpful as a method of treatment for depression Interpersonal psychotherapy
This is also helpful as a method of treatment for depression
Transcranial magnetic stimulation (TMS) This has shown to be effective in major depression. Transcranial magnetic stimulation (TMS)
This has shown to be effective in major depression.
Vagus nerve stimulation (VNS) This has shown to be effective in treatment resistant depression as well Vagus nerve stimulation (VNS)
This has shown to be effective in treatment resistant depression as well
Deep brain stimulation (DBS) This seems to be a safe and effective for treatment-resistant depression. Deep brain stimulation (DBS)
This seems to be a safe and effective for treatment-resistant depression.
Augmentation therapy Augmentation with Lithium, Triiodothyronine with any antidepressant may help. Augmentation therapy
Augmentation with Lithium, Triiodothyronine with any antidepressant may help.
Bright light therapy This is mainly done for seasonal affective disorder Bright light therapy
This is mainly done for seasonal affective disorder
Treatment of postpartum depression Electroconvulsive therapy gives a rapid response and safe in pregnancy. Additionally psychotherapy can be given. From anti depressants, Paroxetine, sertraline, and nortriptyline are considered safe Treatment of postpartum depression
Electroconvulsive therapy gives a rapid response and safe in pregnancy. Additionally psychotherapy can be given. From anti depressants, Paroxetine, sertraline, and nortriptyline are considered safe

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