QuestionSBA
QuestionChoice
This is a possible differential and distinguishing schizophrenia from mood disorders with psychosis can be difficult, especially since the negative symptoms of schizophrenia can mimic mood disorders closely. Since this patient's psychosis is occurring in the context of a clear, preceding mood disorder, it makes a diagnosis of schizophrenia less likely. Schizophrenia patients will exhibit psychosis in the absence of an identifiable mood disorder. Additional features, such as thought insertion/withdrawal/broadcasting, made impulses, and somatic passivity, make a diagnosis of schizophrenia more likely, which are absent in this case.
53248
b
Schizophrenia
QuestionChoice
Bipolar affective disorder presents with periods of mania and depression. Though this patient reports symptoms of depression, there is no report of episodes of mania, where patients typically experience increased energy, elevated mood, reduced need for sleep, and mood congruent psychotic symptoms including grandiose delusions and hallucinations.
53250
d
Bipolar affective disorder
QuestionChoice
Drug induced psychosis is an important differential, and a comprehensive drug history, and potential drug screen, can be useful in patients presenting with first episodes of psychosis. This question does not refer to the consumption of any drugs, and therefore this option is less likely than psychotic depression.
53251
e
Drug-induced psychosis
QuestionChoice
It is important to rule out organic conditions in patients presenting with mental health disturbance, and space occupying lesions can be associated with psychosis. However, the patient does not have other clinical features of a tumour, such as headaches, weight loss, or neurological disturbance. There is also a life event that has triggered his symptoms in the form of his wife leaving him. As such, an organic cause is unlikely.
53249
c
Cerebral tumour
QuestionChoice
This patient has had a depressive episode lasting more than two weeks, as indicated by the presence of low mood, anhedonia, and loss of appetite. He is also experiencing psychotic symptoms (auditory hallucinations and delusions of reference.) This is termed psychotic depression because he has a major depressive disorder with symptoms of mood congruent psychotic symptoms.
53247
a
Psychotic depression
QuestionComment
is psychotic depression the same as schizoaffective disorder?
28019
QuestionComment
psychotic depression: psychotic symptoms only appear during episodes of severe depression and resolve when mood improves. the psychosis usually aligns with depressive themes.

schizoaffective disorder: involves both psychotic and mood symptoms, with psychosis occurring independently of mood episodes for at least two weeks, making it part of the schizophrenia spectrum.

management -> schizoaffective disorder typically requires antipsychotic medication even outside of mood episodes, while psychotic depression focuses primarily on managing depression and the associated psychosis.
56887
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The Happy Hypopyon
User
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Intubation Hypertension
QuestionComment
Can you diagnose someone with depression, when they only have 3 sx as presented in the clinical vignette above. Dont you need like 5 out of 9 sx (MSIGECAPS) [but must have at least 1 of the core sx- either anhedonia or low mood] present for 2 weeks in order to dx depression?
55510
User
subscriber
NMDAr encephalitis
QuestionComment
what if his wife is just psycho
56608
User
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streptocockus
Concept
Chapter
# Summary

Depression is a common mental health disorder typified by low mood, anhedonia, significant weight change, sleep and activity changes, fatigue, feelings of guilt or worthlessness, or poor concentration. It is defined by the DSM as the presence of 5 out of 8 symptoms for at least 2 weeks. It is more prevalent in females. Key investigations include FBC, TFT, U+E, LFT, Glucose, B12/folate, cortisol, toxicology screen, and CNS imaging to rule out organic causes. Management strategies encompass low to high intensity psychological interventions, pharmacotherapy including anti-depressants, and in severe cases, lithium or ECT.

# Definition

Depression is a mental health disorder characterised by:

- **ICD-11 Criteria:**
  - Depressive Episode: Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.

- **DSM-V Criteria:**
  - Major Depressive Disorder (MDD): Presence of a major depressive episode lasting at least two weeks, with specific criteria regarding mood, cognitive, and physical symptoms.
  - Persistent Depressive Disorder (Dysthymia): A chronic form of depression lasting for at least two years. 

This consists of  the presence of at least five out of a possible eight defining symptoms, during the same two-week period, where at least one of the symptoms is depressed mood or loss of interest or pleasure

**Severity:**

- Mild: Few, if any, symptoms in excess of those required to make the diagnosis (associated symptoms, see below), and the symptoms result in minor functional impairment.
- Moderate: Symptoms or functional impairment between "mild" and "severe."
- Severe: The number of symptoms, intensity, and impairment are all greatly increased.


# Epidemiology

Depression is a highly prevalent mental health disorder. It represents the third most common reason for consulting a general practitioner in the UK. Depression demonstrates a higher prevalence in females.

# Aetiology

The aetiology of depression involves a complex interplay of genetic and environmental factors. History of previous mental health issues, physical illnesses, and social challenges like divorce, poverty, and unemployment can all contribute to its development.

# Clinical Features

Depression is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the presence of 5 out of the following 9 symptoms, occurring nearly every day for at least 2 weeks:

1. **Depressed mood or irritability** for most of the day, indicated by either subjective report (feels sad or empty) or observation by others (appears tearful).
2. **Anhedonia:** Decreased interest or pleasure in most activities, most of the day.
3. Significant **weight change** (5%) or change in appetite.
4. **Sleep alterations:** Insomnia or hypersomnia.
5. **Activity changes:** Psychomotor agitation or retardation.
6. **Fatigue** or loss of energy.
7. **Guilt or feelings of worthlessness:** Excessive or inappropriate guilt or feelings of worthlessness.
8. **Cognitive issues:** Diminished ability to think or concentrate, or increased indecisiveness.
9. **Suicidality:** Thoughts of death or suicide, or formulation of a suicide plan.

### Additional Features (Severe Depression)
- **Psychotic Features:** Delusions (e.g. nihilistic delusions, Cotard's syndrome) and hallucinations.
- **Depressive Stupor:** Profound immobility, mutism, and refusal to eat or drink, sometimes necessitating electroconvulsive therapy (ECT).

# Differential Diagnosis

The main differentials and their key signs and symptoms include:

- **Bipolar Disorder:** Characterised by periods of mania/hypomania (elevated mood, inflated self-esteem, decreased need for sleep, increased talkativeness, distractibility, increased goal-directed activity) alternating with depressive episodes.
- **Anxiety Disorders:** Persistent and excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
- **Psychotic Disorders:** Hallucinations, delusions, disorganised speech, grossly disorganised or catatonic behaviour.
- **Substance/Medication-Induced Mood Disorder:** Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.
- **Adjustment Disorders:** Development of emotional or behavioural symptoms in response to identifiable stressors.


Various organic causes should be considered and ruled out through careful history-taking, physical examination, and relevant investigations. These include:

- Neurological disorders such as Parkinson's disease, dementia, and multiple sclerosis.
- Endocrine disorders, especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing's and Addison's disease).
- Substance use or medication side effects (e.g., steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa).
- Chronic conditions such as diabetes and obstructive sleep apnea.
- Long-standing infections, such as mononucleosis.
- Neoplasms and cancers - low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.


# Investigations

- Standard investigations for depression may include Full Blood Count (FBC), Thyroid Function Test (TFT), Urea and Electrolytes (U&E), Liver Function Test (LFT), Glucose, B12/folate levels, cortisol levels, toxicology screen, and imaging of the Central Nervous System (CNS).
- These help rule out organic causes (listed above) such as endocrine disorders (e.g. thyroid disorders).
- There are several questionnaires that can also be used to help assess depressive symptoms, such as the Hospital Anxiety and Depression (HAD) Scale and Patient Health Questionnaire (PHQ-9).

# Management

Depression is usually managed in primary care. GPs can refer to secondary care (Psychiatry) if there is a high-suicide risk, symptoms of bipolar disorder, symptoms of psychosis, or if there is evidence of severe depression unresponsive to initial treatment.

**Persistent subthreshold depressive symptoms or mild-to-moderate depression:**

- 1st line = Low-intensity psychological interventions (individual self-help, computerised CBT). 
- 2nd line = High-intensity psychological interventions (individual CBT, interpersonal therapy) 
- 3rd line = Consider antidepressants 

**Mild depression unresponsive to treatment and moderate-to-severe depression:**

- 1st line = High-intensity psychological interventions + antidepressants (1st line = SSRI)
- 2nd line (Treatment-resistant depression) – switch antidepressants and then use adjuncts 

**Severe depression and poor oral intake/psychosis/stupor:**

- 1st line = ECT 
- Although the exact mechanism remains elusive, it is thought that the induced seizure, rather than the ECT procedure itself, has therapeutic benefits. Short-term side effects of ECT include headache, muscle aches, nausea, temporary memory loss, and confusion, while long-term side effects can include persistent memory loss. Due to the induced seizure, there is a risk of oral damage, and due to the general anaesthetic, a small risk of death.

**Recurrent depression:** 

- Treated with antidepressant + lithium 


Medical management of depression - additional notes:

- First-line pharmacological treatment typically involves a Selective Serotonin Reuptake Inhibitor (SSRI) such as sertraline. SNRIs such as venlafaxine can also be used first-line, but are less preferable due to the risk of damage from overdose, which is less likely with SSRIs.
- In people aged 18-25 there is an increased risk of impulsivity and suicidal risk upon commencing antidepressant medication and so they should have a follow-up appointment arranged after one week to monitor progress. Initial reviews can otherwise be arranged 2-4 weeks after starting medication in patients >25.
- Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. Tapering should be done gradually over a four-week period when discontinuing antidepressants.



# NICE Guidelines

[NICE Guidance on the Management of Depression](https://www.nice.org.uk/guidance/cg90)
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Depression
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Psychiatry
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Concept
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Depression
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Postpartum depression
10710
A 54-year-old male presents to the GP with concerns about hearing his wife shouting at him in the early hours of the morning. He says his wife has been sending him angry messages through the radio for the past 2 days. He has been experiencing low mood for the past 5 weeks since his wife left him and he no longer finds interest in anything. He says he has stopped eating 3 meals a day during this time. During the consultation, his voice is quiet and monotonous, and he appears distressed.

Which of the following is the most likely diagnosis?
a