1. Depression: Psychopathology & diagnosis Dr Brijesh Desai, Consultant psychiatrist Northwestern School of Psychiatry MRCPsych course

2. Contents  Clinical features of depression  Assessing psychopathology  Rating scales for depression  Classification in ICD10 and DSM IV  Differential diagnoses  References & Further Reading

3. Clinical features - mood  Mood of misery – persistent  Mood does not get better in circumstances where ordinary feelings of sadness would be alleviated.  Often experienced as different from ordinary sadness.  Diurnal variation – usually worse in the morning, improving a little as the day wears on.

4. Clinical features- depressive cognitions  Negative cognitions  Worthlessness  Pessimism  Guilt  Hopelessness  Can progress to thoughts of suicide

5. Clinical features – goal-directed behavoiur  Anhedonia - lack of interest and enjoyment [Roots: Latin- An=not; hedon = pleasure]  Social withdrawal  Lethargy, reduced energy, everything is an effort.

6. Clinical features – psychomotor changes  Psychomotor retardation- slow speech, actions, thoughts, delays in responding to questions.  Psychomotor agitation – restlessness, can’t relax, can’t sit for long  Anxiety – frequent in moderate depression  Irritability

7. Clinical features- biological symptoms  Sleep disturbance – early morning waking with depressive thinking is usually characteristic; also delay in falling asleep and waking during the night.  Diurnal variation of mood  Loss of appetite  Loss of weight  Constipation  Loss of libido  Amenorrhoea  Complaints about physical symptoms are common (fatigue, aches and pains, constipation). More worries about pre-existing physical problems.

8. Clinical features - other  Depersonalization  Obsessional symptoms  Panic attacks  Dissociative symptoms (fugue, loss of function of a limb)  Memory problems – impairments in the retrieval and recognition of recently learned material particularly prominent [If severe, it may resemble dementia: depressive pseudodementia]

9. Psychotic depression  ‘Mood congruent’ delusions – delusions have the same theme as the non- delusional thinking, on depressive themes – worthlessness, guilt, ill-health, poverty (rare).  Persecutory delusions also occur (usually the patient believes that the supposed persecution is brought upon by himself/herself; he/she is ultimately to blame); indicates worse prognosis.  Cotard’s syndrome – extreme nihilistic delusion (rare)

10. Clinical variants of depression  Agitated depression – with agitation as a prominent feature  Retarded depression – with prominent psychomotor retardation  Depressive stupor- motionless and mute patient  Atypical depression – variably depressed mood with mood reactivity to positive events; overeating and oversleeping; extreme fatigue and heaviness in the limbs; pronounced anxiety.

11. Pointers for assessment  Severity  Duration  Social network  Views of self, world and future  Suicidal thoughts  Past history  Factors affecting symptoms  Biological features

12. Course - Kupfer’s curve

13. ICD-10 criteria [F32, F33] Key Symptoms (MUST have at least 2) A.Persistent low mood B.Loss of interest or pleasure C.Fatigue or low energy If any of the above then ask about:1.Disturbed sleep 2.Poor conc. Or indecisiveness 3.Low self confidence 4.Poor or increased appetite 5.Suicidal thoughts or acts 6.Agitation or slowing of movement 7.Guilt or self blame Severity4 symptoms = mild 5-6 symptoms = moderate 7+ symptoms= severe (+/- psychotic symptoms)

14. Classification of depressive disorders ICD-10DSM IV Depressive episodeMajor Depressive episode Mild, moderate, severe, severe with psychotic symptoms Same Other depressive episodes Atypical depression- Recurrent depressive disorderMajor depressive disorder- recurrent Currently mild, moderate, severe, severe with psychotic symptoms, in remission - Persistent mood disordersDysthymic disorder Cyclothymia Dysthymia Other mood disordersDepressive disorders, NOS Recurrent brief depression [ Shorter Oxford Textbook of Psychiatry, Ed 5 th ]

15. Major Rating Scales ScaleSalient features Hamilton Scale for Depresion (HAM-D)Clinician-rated; 17 item, derived from clinical interview, refers to previous 1-2 weeks, for rating severity. Montgomery-Asberg Depression Rating Scale (MADRS) Observer-rated, 10 item, sensitive to response to treatment, for measuring change in depressed patient. Beck Depression Inventory (BDI)Self-reported, 21 item, lacks discriminatory power among those with very severe depression Zung Depression ScaleSelf-rating, 20 item; >=50 indicates depression, global index of intensity of patient’s depressive symptoms [ Seminars in general adult psychiatry, Synopsis of Psychiatry ]

16. Differential diagnoses  Normal sadness  Anxiety disorders  Schizophrenia  Organic brain syndromes

17. References & Further Reading  Gelder M, Harrison P, Cowen P (2006) Shorter Oxford Textbook of Psychiatry (Ed 5th) Oxford University Press.  Stein G, Wilkinson G (Ed)(2007) Seminars in General Adult Psychiatry (Ed 2nd) Gaskell.  Sadock BJ, Sadock VA (2007) Kaplan & Sadock’s Synopsis of Psychiatry (Ed 10th) Lippincott, Williams & Wilkins.  WORLD HEALTH ORGANIZATION. (1992). The ICD - 10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva, World Health Organization.