Taking a history of DEPRESSION 30/10/2007 Core symptoms of depression are: ---LOW MOOD --- ANERGIA *(needed for diagnosis) --- ANHEDONIA *
Must have 2/3 of these symptoms, one of which should be anhedonia
Physical changes in depressed patients: MRI – Hippocampal atrophy in severely depressed patients (reversed with antidepressants!) fMRI -cognitive areas depressed, 5-HT neurones smaller and decreased function compared to normal individuals. - Upregulation of 5-HT receptors to compensate. Statistics * * * * * *
1/6 people will have a severe depressive episode X2 risk of dying early 30% people with major (severe) depression actually get treated ECT – effective treatment for suicidal/psychotic, untreatable depression Deep Brain Stimulation (similar to PD treatment) Transcranial Magnetic
20ish clinical symptoms of depression 1. Sleep pattern change (typically EMW ->2hrs before normal) 2. Appetite change (typically ↓) Biological 3. Libido change (typically ↓) features 4. Low mood – consider diurnal variation in mood 5. Anergia - fatigue 6. Anhedonia 7. Loss of concentration 8. Memory impairment 9. Psychomotor retardation 10.Low self-esteem 11.Dichotomous thinking 12.Loss of confidence
Core features
Psychological features
13.Beck’s Cognitive Triad – helplessness, worthlessness, hopelessness (world, self, future) 14.Hallucinations – typically auditory (2nd person more common) – hostile, critical 15.Delusions – nihilistic, persecutory, guilt 16.Deliberate Self Harm/neglect 17.Suicidal ideation
Psychotic features Risk assessment
ICD-10 Classification of depression Time frame Symptoms Function
Mild (2, 2) Moderate (2, 3) Severe ± Psychotic symptoms (2, 4)
Also! Older classification into • Endogenous – depressed for no reason (=genetics?) • Reactive – result of social circumstances 9e/g/ divorce, unemployment) General Tips NB. DO NOT SHAKE HANDS WITH – Depressed, manic, or OCD patients Always enquire about sleep in detail e.g. when do you normally wake up? Taking the History 1. Introduction, establish rapport etc 2. Ask open questions (e.g. I understand you’ve come to the GP today because….could you just tell me a little more about that?) 3. Ask about ONSET (when did these problems start? Is there anything that you can think of that might have triggered these feelings?) 4. Enquire about alterations in MOOD, ENERGY and INTEREST (core symptoms) a. Mood – How have you been feeling recently? Ask about diurnal variation. b. Anhedonia - Have you lost interest In doing things that you used to enjoy? c. Anergia- How do you find your energy nowadays? 5. Enquire about Physiological function a. Sleep – Have you had any trouble getting off to sleep in the last few weeks? Have you noticed any change in your sleeping patterns recently? Do you wake up early in the mornings?) b. Appetite/weight (what has your appetite been like recently? Has there been a recent change in your weight?) 6. Elicit any of the patient’s concerns a. Do you have any concerns about how you’ve been feeling recently? b. I can see that this is really difficult for you – how have you been coping with it all?!....NB. Could lead to ALCOHOL and related issues!. 7. Ask about any triggers (e.g. relationships, family, work stressors) a. Is there anything that you can think of that might have triggered these feelings? b. Have you been under pressure at hoem or at work? c. Is there anyone at all that you feel you can talk to about this? 8. Ask about psychological symptoms a. Anxiety – have there been times lately when you’ve fely very anxious or frightened?) b. Bipolar – have there been times (other occasions) when you’ve felt the opposite e.g. elated, really happy? c. Psychomotor retardation – have you noticed a change in your movements and reactions recently? Do you seem to have slowed down in your movements or have too little energy?) d. Concentration - have you had any trouble concentrating on things/work recently?
9. Assess suicidality a. Do you feel that life is still worth living? Have there been any times when you’ve just wished that you could end it all? Have you ever acted on these feelings? What did you think that you actually might do? HAVE YOU ACTUALLY TRIED IT?). 10.Ask about hopelesseness a. How do you see the future? b. Have you given up, or does there still seem to be some reason to keep trying? 11.Elicit Past psych History a. Aks what, when, duration of care, diagnosis, precipitants, treatment, outcome 12.Elicit Past Medical History and any accidental injuries 13.Elicit Family Psych Hx a. To your knowledge is there anyone in your family who has had to see a psychiatrist/with mental illness? 14.Drug History a. Specifically ask about ALCOHOL and substance misuse. b. Allergies! ABOVE ALL! Show empathy and listen to the patient! Always make use of REFLECTION (because it shows empathy and opens up to new discussion) Interviewing technique All depends on your attitude towards the patient and towards depression (try to empathise) STRUCTURE – Have a skeleton framework Minute 1: Just listen to the patient and be empathetic Minute 2: Open Question – main ideas, concerns and expectations Minute 3-4: clarifying questions – try to elicit symptoms to include differentials (e.g. bipolar) Minute 4-5: Scan for psychotic symptoms, risk factors and suicidal ideation Minute 5-6: Family Hx, Drug Hx and regular medication -try to SUMMARISE
