Depressive Disorder

26/12/2013 by admin | Psychiatry

Clinical features

Three core symptoms of depression:

  1. Low mood
  2. Anhydonia (loss of pleasure)
  3. Anergia (low energy)



A history of 2/3 core symptoms for min 2 weeks + 2 of the following seven symptoms:

  • Decreased concentration
  • Reduced self-esteem
  • Guilt
  • Pessimism about the future
  • Self-harm ideation
  • Disturbed sleep
  • Reduced appetite


Severity of depression

Mild four symptoms in total

Moderate five or six symptoms in total

Severe seven symptoms in total including all three of the core symptoms


Beck’s cognitive triad

Describes types of negative thought that occur in depression. These are:

  1. A negative view of oneself
  2. A negative view of the world
  3. A negative view of the future



Lifetime risk is 10-25% in females and 5-12% in males


Risk factors

  • Personality disorders and FHx of bipolar disorder
  • Co-existing medical conditions hypothyroidism, SLE, Cushings syndrome, MS,
  • Certain medications B-blockers, steroids, anticonvulsants, benzodiazepines, antipsychotics, opiates, and NSAIDS.
  • Traumatic life events in the past 6 months
  • Life events: – divorce, maternal death before age 11 etc.



A. Mild to moderate depression

  • Encourage exercise
  • Cognitive behavioural therapy
  • Brief psychological interventions including CBT and counseling

*Antidepressant medications are not recommended for initial treatment


B. Moderate to severe depression

  • Antidepressant medication + CBT at high intensity
  • Electroconvulsive therapy gains fast, short term improvement after other treatments failed.

Drug Tx

SSRI is first line just as effective as tricyclic anti depressants but with less S.E and toxicity.

SSRI’s : Fluoxetine, paroxetine or citalopram

There is normally a 2-week delay before an improvement is noted and treatment must be continued for 6 months after remission.

Side effects hyponataemia, G.I disturbance, insomnia, sexual dysfunction, and agitation.

SSRI withdrawal syndrome stopping abruptly causes transient dizziness, lethargy, nausea and headache.


Varies with the severity:

  • Mild: average length of episode is 6-8 months. Spontaneous recovery likely.
  • Major: 80% of people who have received psychiatric care will have at least one more episode in their lifetime, with a median of 4 episodes.



1. Agro-phobia


A “fear of open spaces” –especially those in which getaway is difficult, which leads to avoidance of the situation.

There are three basic elements:

  1. Phobia
  2. Avoidance of situations that might provoke the anxiety
  3. Severe anxiety


Some patients manage to continue daily lives (with difficulty) whilst others can become incapacitated.



Very common in primary care setting, affects females more than males, age onset 25-35, affects up to 1/3 of patients with panic disorders.



Requires the following:

  1. Avoidance of situations that provoke the anxiety (prominent feature) e.g. .open spaces
  2. Symptoms (psychological and physical) arise mainly from anxiety and the anxiety is not secondary to other underlying psychiatric problems e.g. depression.
  3. Anxiety manifests primarily in two or more of the following:
    1. crowds, public places, travelling alone or away from home.




  • Cognitive behavioural therapy:
    • exposure to the provoking stimulus until the anxiety passes. Done through imagination or in vivo.
  • Education: understand the problem
  • Lifestyle changes: avoid alcohol and illicit drugs



SSRIs- 1st line treatment: Fluoxitine or Paroxetine

Tri-cyclic anti depressants: reduce panic severity and frequency of episodes

Benzodiazepines: give short term relief but not long term since they are addictive.



Relapses are common: 1 in 3 patients have underlying depression and 1 in 5 will attempt suicide.


2. Social phobia


Social phobia is a fear of behaving in an embarrassing way whilst you talk or meet with other people, especially strangers.

It can greatly affect patient’s life but treatment works well in many cases.


Very common: up to 1 in 10 adults have social phobia to some degree. Develops in teenage years and becomes lifelong unless treated.


  • Cognitive therapy
  • Systemic desensitization- ‘flood’ patient with phobic stimulus until anxiety subsides.
  • Medical-
    • Antidepressants- SSRIs- treats depression and reduces the social phobia even if you don’t have depression. Takes 2-4 weeks to take effect.
    • Benzodiazepines- taken before exposure to phobia
    • Beta-blockers- treat the somatic/physical symptoms- e.g. shaking and palpitations. Advantage is they are not addictive.
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