Major Depression (Unipolar Depression)

Last updated 20.09.12

 

Definition

-  Mood disorder characterised by periods of depression

 

Features

-  Lifetime prevalence 16% women, 8% men

-  Mean age of onset late 20s

-  Extremely varialbe course, some single episodes

-  50-80% recurrence

-  Screening with K10

 

Associated S/S

-  SAGE CAPS mnemonic for questioning

-  Sleep

-  Anhedonia

-  Guilt

-  Energy

-  Concentration

-  Appetite

-  Psychomotor

-  Suicide

-  Emotion

-  Misery, despair, hopelessness, burdensome, anhedonia (anticipatory, consummatory), non-reactive, guilt

-  Biological

-  Anorexia, weight loss > 5% body weight over 4 months, weight gain (self consolatory eating),

-  Sexual disturbance: decreased libido, impotence, anorgasmia

-  Insomnia, diurnal mood variation (worse in morning), physical slowing (talking, moving, thinking), poor concentration

-  Somatic: dry mouth, pain, pale skin, constipation, menstrual irregularities

-  Suicide

-  Pre-occupation, ideation, thoughts of dying 60%+ pts

-  10-15% pts hospitalized for depression commit suicide

-  Wrist slashing, self mutilation

-  Increased risk of accidents (depressive self-neglect)

-  Psychotic features (psychosis)

-  Usually more severe forms of depression

-  Typically mood congruent

-  Delusions: wothlessness, guilt, persecution, death, nihilism

-  Hallucinations: auditory

-  Mental State Examination

-  May be mild & only apparent to family

-  Downcast, drawn, sullen appearance

-  Stooped posture, furrowed brow

-  Reduced self care, weight loss

-  Psychomotor retardation

-  Slowed activity, lock of spontaneous movement or speech

-  Psychomotor agitation

-  Hand-wringing, restlessness, pacing

-  More frequent spontaneous crying

-  Severe

-  Little modulation of affect, blunting or even flattening

-  Negative & pessimistic speech

-  Suicide risk

-  May have no insight

-  Co-morbidities

-  Anxiety, drug or EtOH abuse, psychosis, smoking

 

DSM IV Dx Criteria

-  1+ of

Depressed mood for most of the day, nearly every day

-  Anhedonia in all or almost all daily activites, nearly every day

-  And 4+ of 

-  Weight loss or gain

-  Insominia or hypersomnia

-  Psychomotor retardation or agitation

-  Fatigue

-  Feelings of worthlessness or excessive guilt

-  Poor concentration

-  Recurrent thoughts of death, suicidal ideation or attempt, or suicide plan

-  Do not meet criteria fora mixed episode

- Symptoms cause clinically significant distress or impairment

- Not due to direct phsysiological effects of substance or medical condition

- Not better accounted for by bereavement (>2 months, marked functional impairment)

 

Subtypes

-  Melancholic

-  Prominent psychomotor disturbance

-  Family Hx v common

-  Diurnal variation (worse in morining)

-  Psychotic

-  Mood congruent: more common, guilt, nihilism, deserving of punishment

-  Mood incongruent: ie: food poisoned, persecution

-  Persistant mood

-  DDx Schizoaffective Disorder

-   Schizophrenia + mood disorder

-   Hallucinations or delusions > 2 weeks without mood disturbance

-  Non-Melancholic

-  Most common forms

-  Social impairment

-  Anxious Depression: common

-  Irritable or Hostile Depression: short fuse, acts out

 

DDx

-  Bipolar

-  Emergence of mania/hypomania

-  Mixed Affective Disorder

-  Simultaneous features of depression & mania

-  Grief

-  < 2 weeks duration

 

Ix

-  TFTs: hypothyroidism

-  FBE

-  CT-Brain/MRI: organic cause

 

Mx

-  Assess role of psychosocial factors

-  1st Episdoe

-  6 months if brief

-  Up to 2 yrs if long

-  Reduce Rx over months, rapid reduction leads to relapse

-  Assess risk

-  Suicide: may require family/friend Hx

-  Neglect, reputation, financial

-  By Subtype

-  Non-Melancholic: TCAs = SSRIs = CBT

-  Melancholic: TCAs x2 SSRIs

-  Psychotic

-  Lifelong treatment

-  Antipsychotic + Antidepressant (TCA) or ECT

-  Mild

-  GP out-pt basis

-  Counseling, psychotherapy (CBT)

-  Moderate to Severe

-  Admission to psych unit as required

-  CBT

-  Anti-depressants

-  Broad actions (ie: Venlafaxine [SSRI]) for melancholic depression

-  Combination w antipsychotic for psychotic depression

-  Common cause of suicide attempt

-  ECT