Depressive Disorders-oxford shoter
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Questions and Answers

Depressed mood is a unique symptom of depressive disorders.

False

Depressive disorders always present with depressed mood as the most prominent symptom.

False

The clinical presentations of depressive states are uniform and consistent.

False

The concept of an 'episode' of clinical depression is universally agreed upon.

<p>False</p> Signup and view all the answers

The ICD-10 classification provides a clear distinction between severe and less severe depressive disorders.

<p>True</p> Signup and view all the answers

Reduced energy is not a central feature of depressive disorders.

<p>False</p> Signup and view all the answers

Neurological disorders can cause depressed mood as a symptom of the disorder.

<p>True</p> Signup and view all the answers

The mood of a patient with severe depressive episode is alleviated in circumstances where ordinary feelings of sadness would be alleviated, such as in pleasant company or after hearing good news.

<p>False</p> Signup and view all the answers

Some patients with severe depressive episode maintain a smiling exterior despite deep feelings of depression.

<p>True</p> Signup and view all the answers

The gestalt of a patient with severe depressive episode is characterized by erect posture and an upright head.

<p>False</p> Signup and view all the answers

Patients with severe depressive episode often experience a diurnal variation of mood, with their mood improving as the day wears on.

<p>True</p> Signup and view all the answers

Depressive cognitions in patients with severe depressive episode are limited to feelings of worthlessness and pessimism.

<p>False</p> Signup and view all the answers

Feelings of guilt in patients with severe depressive episode are always attached to specific past events.

<p>False</p> Signup and view all the answers

Lack of interest and enjoyment is a rare symptom in patients with severe depressive episode.

<p>False</p> Signup and view all the answers

In depression, psychomotor changes include increased energy and speed of thought.

<p>False</p> Signup and view all the answers

Anhedonia is not a key symptom of melancholic depression.

<p>False</p> Signup and view all the answers

Biological symptoms include decreased appetite and weight gain.

<p>False</p> Signup and view all the answers

Depressed patients always experience sleep disturbance in the form of excessive sleeping.

<p>False</p> Signup and view all the answers

Anxiety is a rare symptom in severe depression.

<p>False</p> Signup and view all the answers

Irritability is never a core presenting feature in adolescents with depression.

<p>False</p> Signup and view all the answers

Depressed patients never experience depersonalization or dissociative symptoms.

<p>False</p> Signup and view all the answers

Depressive pseudodementia is a condition that is more common in younger individuals than in the elderly.

<p>False</p> Signup and view all the answers

In psychotic depression, there is no impairment of insight and patients are aware of their mistaken beliefs.

<p>False</p> Signup and view all the answers

Delusions of severe depressive disorders are always mood-incongruent.

<p>False</p> Signup and view all the answers

Patients with a delusion of guilt may believe that they have done something good and will be rewarded.

<p>False</p> Signup and view all the answers

Cotard's syndrome is a mild depressive disorder characterized by a lack of energy.

<p>False</p> Signup and view all the answers

Agitated depression is a condition that is seen more commonly among younger individuals than among middle-aged and elderly patients.

<p>False</p> Signup and view all the answers

Retarded depression is a condition that is characterized by excessive motor activity.

<p>False</p> Signup and view all the answers

Inattention to basic hygiene and nutrition is a common feature of mild depressive disorders.

<p>False</p> Signup and view all the answers

Depressive disorders are always characterized by a complete loss of function in social and occupational spheres.

<p>False</p> Signup and view all the answers

Depressive stupor is a common occurrence in patients with severe depressive disorder.

<p>False</p> Signup and view all the answers

Patients in depressive stupor often exhibit aggressive behavior.

<p>False</p> Signup and view all the answers

Patients in depressive stupor always recall events that took place during the period of stupor.

<p>False</p> Signup and view all the answers

Atypical depression is a severe form of depressive disorder.

<p>False</p> Signup and view all the answers

Kraepelin's description of depressive stupor mentioned that patients often defend themselves from pinprick.

<p>False</p> Signup and view all the answers

Patients in depressive stupor often feed themselves without assistance.

<p>False</p> Signup and view all the answers

Patients with atypical depression have a later onset of illness and a more acute course.

<p>False</p> Signup and view all the answers

Depressive stupor is characterized by a high level of physical activity.

<p>False</p> Signup and view all the answers

Mixed depression is characterized by a complete lack of anxiety and agitation.

<p>False</p> Signup and view all the answers

Mild depressive disorders are characterized by delusions and hallucinations.

<p>False</p> Signup and view all the answers

Patients with mild depressive disorders often experience early-morning waking.

<p>False</p> Signup and view all the answers

The diagnosis of atypical depression predicts a poor response to modern antidepressant drug treatment.

<p>False</p> Signup and view all the answers

Mixed depression is only seen in patients with bipolar disorder.

<p>False</p> Signup and view all the answers

The ICD-10 classification provides a clear distinction between mild and severe depressive disorders.

<p>True</p> Signup and view all the answers

In ICD-10, patients with minor anxiety– depressive disorder are diagnosed under the category of mood disorders.

<p>False</p> Signup and view all the answers

The DSM-5 includes a category of 'Mixed Anxiety and Depressive Disorder'.

<p>False</p> Signup and view all the answers

Patients with minor anxiety– depressive disorders rarely present to primary care doctors with somatic symptoms.

<p>False</p> Signup and view all the answers

In DSM-5, Persistent Depressive Disorder (Dysthymia) requires symptoms to have persisted for at least 1 year.

<p>False</p> Signup and view all the answers

Dysthymia is characterized by depressive symptoms that are severe enough to meet criteria for a depressive episode.

<p>False</p> Signup and view all the answers

The diagnosis of minor anxiety– depressive disorder is clearly defined in both ICD-10 and DSM-5.

<p>False</p> Signup and view all the answers

Patients with minor anxiety– depressive disorders typically present with a uniform set of symptoms.

<p>False</p> Signup and view all the answers

In most cultures, sadness, joylessness, anxiety, and lack of energy are uncommon symptoms of depression.

<p>False</p> Signup and view all the answers

Somatization of depression is more frequent and prominent in western cultures.

<p>False</p> Signup and view all the answers

Particular cultures have no unique ways of dealing with painful emotions produced by loss.

<p>False</p> Signup and view all the answers

The diagnosis of depression should not take cultural variations into account.

<p>False</p> Signup and view all the answers

The term ‘minor’ accurately captures the serious consequences of affective disorders for an individual.

<p>False</p> Signup and view all the answers

Depression is overdiagnosed in primary care, particularly in most countries.

<p>False</p> Signup and view all the answers

Somatic presentations of depression are rare in non-western cultures.

<p>False</p> Signup and view all the answers

Cultural stigmatization of mental illness has no impact on the presentation of depression.

<p>False</p> Signup and view all the answers

The use of somatic metaphors for emotional suffering is uncommon in non-western cultures.

<p>False</p> Signup and view all the answers

The classification of depressive disorders based on presumed aetiology is widely accepted.

<p>False</p> Signup and view all the answers

The symptomatic picture of melancholic depression is uniform and consistent across patients.

<p>False</p> Signup and view all the answers

The concept of reactive depression is no longer used in modern classification systems.

<p>True</p> Signup and view all the answers

The distinction between severe and less severe depressive disorders is clearly defined in ICD-10.

<p>False</p> Signup and view all the answers

Lewis (1934) suggested that every illness is solely the result of environmental factors.

<p>False</p> Signup and view all the answers

Aetiological factors are not considered in classifying depressive disorders.

<p>False</p> Signup and view all the answers

Classification by symptomatic picture is a widely accepted method of classifying depressive disorders.

<p>False</p> Signup and view all the answers

DSM-5 and ICD-10 have a unified approach to classifying depressive disorders.

<p>False</p> Signup and view all the answers

According to the classification by symptom profile, melancholic depression is a type of non-major depressive episode.

<p>False</p> Signup and view all the answers

The presence of psychotic features in depression is always accompanied by melancholic symptoms.

<p>True</p> Signup and view all the answers

Kraepelin's classification included a division into three groups: unipolar depression, bipolar disorder, and schizoaffective disorder.

<p>False</p> Signup and view all the answers

Atypical depression is a type of melancholic depression.

<p>False</p> Signup and view all the answers

Most patients with depressive disorders have melancholic symptoms of some kind.

<p>True</p> Signup and view all the answers

Neurobiological abnormalities are more commonly found in patients with non-melancholic depression.

<p>False</p> Signup and view all the answers

The diagnosis of melancholic depression is not a distinct subtype of depression, but rather a point on a continuum of severity of depression.

<p>True</p> Signup and view all the answers

Tricyclic antidepressants are less effective in treating melancholic depression than selective serotonin reuptake inhibitors (SSRIs).

<p>False</p> Signup and view all the answers

DSM-5 and ICD-10 are entirely satisfactory classification systems.

<p>False</p> Signup and view all the answers

Comorbidity with anxiety disorders is a rare occurrence in depressive disorders.

<p>False</p> Signup and view all the answers

In DSM-5, the term 'unipolar mania' is still used to describe a specific type of mania.

<p>False</p> Signup and view all the answers

The 12-month prevalence of major depression in the community is around 10–20%

<p>False</p> Signup and view all the answers

The full diagnostic criteria for major depression are always met in adjustment disorders.

<p>False</p> Signup and view all the answers

Rates of major depression are about three times as high in women as in men, across different cultures.

<p>False</p> Signup and view all the answers

Seasonal affective disorder is characterized by symptoms such as insomnia and decreased appetite.

<p>False</p> Signup and view all the answers

Dementia and depressive disorders can be easily distinguished based on cognitive impairment.

<p>False</p> Signup and view all the answers

Recurrent brief depression is a type of depression that is only seen in women and is linked to the menstrual cycle.

<p>False</p> Signup and view all the answers

The epidemiology of depressive disorders is well-established and easily determinable.

<p>False</p> Signup and view all the answers

The lifetime rates of major depression in different studies vary considerably, in the range 1–10%.

<p>False</p> Signup and view all the answers

The mean age of onset of major depression is about 35 years.

<p>False</p> Signup and view all the answers

In DSM-5, mood disorders secondary to a medical condition are classified as a separate category.

<p>False</p> Signup and view all the answers

The distinction between depressive disorders and schizophrenia is always clear-cut.

<p>False</p> Signup and view all the answers

Major depression has a low comorbidity with other disorders, particularly anxiety disorders and substance misuse.

<p>False</p> Signup and view all the answers

The ICD-10 classification provides a clear distinction between depressive disorders and anxiety disorders.

<p>False</p> Signup and view all the answers

ICD-10 and DSM-5 both classify depressive episodes based on the presence of psychotic features.

<p>True</p> Signup and view all the answers

The lifetime risk for dysthymia is around 10%.

<p>False</p> Signup and view all the answers

For most clinical purposes, it is better to classify disorders rather than describe them systematically.

<p>False</p> Signup and view all the answers

Atypical depression is a separate category in ICD-10, but is classified as a specifier in DSM-5.

<p>True</p> Signup and view all the answers

The ICD-10 classification provides a clear distinction between severe and less severe depressive disorders, but does not specify the exact criteria for the distinction.

<p>True</p> Signup and view all the answers

The 1-week prevalence of mixed anxiety and depression in the community is around 5%.

<p>False</p> Signup and view all the answers

Recurrent brief depression is classified under the same heading in both ICD-10 and DSM-5.

<p>False</p> Signup and view all the answers

Rates of dysthymia are higher in men and in the unemployed.

<p>False</p> Signup and view all the answers

The risk of depression in a first-degree relative of a proband is increased about twofold.

<p>False</p> Signup and view all the answers

Investigators have employed only one main conceptual approach to elucidate the mechanisms of depression.

<p>False</p> Signup and view all the answers

The aetiology section in the current chapter is not structured to illustrate various ways of approaching research into the causation of psychiatric disorder.

<p>False</p> Signup and view all the answers

Family and twin studies have not found any correlation between depression and genetic factors.

<p>False</p> Signup and view all the answers

The psychological and biological approaches to depression research represent the same level of enquiry.

<p>False</p> Signup and view all the answers

The current chapter does not provide any information about the role of current life difficulties and stresses in provoking depression.

<p>False</p> Signup and view all the answers

The text does not mention anything about the predisposing factors of depression in adulthood.

<p>False</p> Signup and view all the answers

There is complete knowledge about the mechanisms involved in the translation of predisposing and provoking factors into clinical symptomatology.

<p>False</p> Signup and view all the answers

The heritability of major depression is estimated to be higher than that of bipolar disorder or schizophrenia.

<p>False</p> Signup and view all the answers

Twin studies have suggested that susceptibility to major depression and generalized anxiety disorder involves different genes and environmental risk factors.

<p>False</p> Signup and view all the answers

The genetic liability to depression results from the combined action of a single gene of major effect.

<p>False</p> Signup and view all the answers

The gene coding for the serotonin transporter has a single allelic variant that influences the expression of transporter sites.

<p>False</p> Signup and view all the answers

GWAS studies in depression have reported several convincingly replicated loci.

<p>False</p> Signup and view all the answers

A recent whole genome sequencing study identified multiple genetic markers associated with depression.

<p>False</p> Signup and view all the answers

The mode of inheritance of depression fits a simple Mendelian pattern.

<p>False</p> Signup and view all the answers

The heritability estimates for depression are consistently higher in men than in women.

<p>False</p> Signup and view all the answers

The first approach to overcome the third problem of association is to separate events that are undoubtedly independent of illness from events that may have been secondary to the illness.

<p>True</p> Signup and view all the answers

There is a sixfold excess of adverse life events in the months before the onset of depressive disorder, but only in established melancholic-type disorders.

<p>False</p> Signup and view all the answers

Life events are important antecedents of all forms of depression, but are relatively more important in established melancholic-type disorders.

<p>False</p> Signup and view all the answers

Neuroticism, as measured by the Eysenck Personality Questionnaire, is associated with decreased risk of depression after adverse life events.

<p>False</p> Signup and view all the answers

Loss of a parent by death in childhood increases the risk of depressive disorder in adulthood.

<p>False</p> Signup and view all the answers

Remission from depression is often associated with 'threat' life events.

<p>False</p> Signup and view all the answers

Gross disruption of parent-child relationships, such as physical and sexual abuse, is a risk factor for anxiety disorders only.

<p>False</p> Signup and view all the answers

The importance of life events in the onset of a depressive episode increases as the number of episodes increases.

<p>False</p> Signup and view all the answers

Mothers with postnatal depression often manifest a rearing style that is characterized by overprotection and excessive care.

<p>False</p> Signup and view all the answers

Vulnerability factors, such as poor social support, are not associated with an increased risk of depression.

<p>False</p> Signup and view all the answers

The mechanism of the association between poor social support and depression is clear and well-established.

<p>False</p> Signup and view all the answers

Stressful events are not a precipitating factor for depressive disorders.

<p>False</p> Signup and view all the answers

Cognitive style characterized by sociotropy is associated with decreased risk of depression after adverse life events.

<p>False</p> Signup and view all the answers

The events immediately preceding a depressive disorder are always the direct cause of the disorder.

<p>False</p> Signup and view all the answers

Personality features have no influence on the way people respond to adverse circumstances and, thus, do not affect the likelihood of depressive disorders.

<p>False</p> Signup and view all the answers

The genetic risk of depression is not influenced by inheritance of particular character traits and cognitive styles.

<p>False</p> Signup and view all the answers

The effects of physical illness can only lead to mood disorders in predisposed individuals.

<p>False</p> Signup and view all the answers

Endocrine disorders are a type of brain disease that can cause mood disorders.

<p>False</p> Signup and view all the answers

Major depression occurs in all patients with Cushing’s disease.

<p>False</p> Signup and view all the answers

Organic mood disorders can never provide clues to aetiology.

<p>False</p> Signup and view all the answers

The puerperium is a medical illness that can cause mood disorders.

<p>False</p> Signup and view all the answers

Cushing’s disease is the only medical condition that can cause mood disorders.

<p>False</p> Signup and view all the answers

Depressive disorders in patients with Cushing’s disease always remit after cortisol levels are restored to normal.

<p>True</p> Signup and view all the answers

The distinction between organic and non-organic mood disorders is always clear-cut.

<p>False</p> Signup and view all the answers

Cognitive theories propose that depressive cognitions are a result of a primary disturbance of mood.

<p>False</p> Signup and view all the answers

Patients with severe depressive episode often experience a diurnal variation of mood, with their mood worsening as the day wears on.

<p>False</p> Signup and view all the answers

Cognitive distortions include arbitrary inference, selective abstraction, and rationalization.

<p>False</p> Signup and view all the answers

Beck's theory proposes that depressive cognitions are limited to feelings of worthlessness and pessimism.

<p>False</p> Signup and view all the answers

Cognitive theories suggest that depressive disorders are a result of illogical ways of thinking, but do not specify what these ways are.

<p>False</p> Signup and view all the answers

Most psychiatrists regard depressive cognitions as a primary cause of depressive disorders.

<p>False</p> Signup and view all the answers

Dysfunctional beliefs or schemas, such as 'No-one really likes me', are established in adulthood and affect the way a person responds to stress and adversity.

<p>False</p> Signup and view all the answers

Abnormalities in information processing, such as negative biases in facial expression recognition, can only be demonstrated in depressed patients.

<p>False</p> Signup and view all the answers

The monoamine hypothesis suggests that depressive disorder is due to an abnormality in the release of a single neurotransmitter, serotonin, in the brain.

<p>False</p> Signup and view all the answers

Structural and functional imaging techniques have not been used to elicit changes in the neural circuitry that underpins the expression of clinical affective symptomatology.

<p>False</p> Signup and view all the answers

Depressive disorders are not associated with distinct and persistent neuropathological changes in relevant brain regions.

<p>False</p> Signup and view all the answers

The prognosis of mood disorders improves as the number of episodes increases.

<p>False</p> Signup and view all the answers

Plasma tryptophan levels are increased in untreated depressed patients, particularly in those with melancholic depression.

<p>False</p> Signup and view all the answers

There is consistent evidence that depressed patients who have died, usually by suicide, have lowered brain concentrations of 5-HT or 5-HIAA.

<p>False</p> Signup and view all the answers

Cerebrospinal fluid (CSF) studies have found a consistent reduction in CSF concentrations of 5-hydroxyindoleacetic acid (5-HIAA) in drug-free patients with major depression.

<p>False</p> Signup and view all the answers

Neurochemical brain imaging studies have found a widespread increase in 5-HT1A receptor binding throughout the cortical and subcortical regions in depressed individuals.

<p>False</p> Signup and view all the answers

The synthesis of 5-HT in the brain is independent of the availability of its precursor amino acid, l-tryptophan.

<p>False</p> Signup and view all the answers

Decreases in plasma tryptophan levels are likely to be an important causal factor in the impairments of brain 5-HT function in depressed patients.

<p>False</p> Signup and view all the answers

Tryptophan depletion in healthy subjects with a family history of mood disorder produces significant clinical depressive symptomatology.

<p>False</p> Signup and view all the answers

Noradrenaline receptors in the brain can be divided into only two subclasses.

<p>False</p> Signup and view all the answers

Low brain 5-HT function is sufficient to cause depression.

<p>False</p> Signup and view all the answers

Increasing brain noradrenaline function decreases plasma concentrations of adrenocorticotropic hormone (ACTH), cortisol, and growth hormone.

<p>False</p> Signup and view all the answers

The synthesis of brain 5-HT is dependent on the availability of its amino acid precursor, tyrosine.

<p>False</p> Signup and view all the answers

Unmedicated euthymic patients with a personal history of mood disorder do not undergo a rapid but temporary depressive relapse when exposed to tryptophan depletion.

<p>False</p> Signup and view all the answers

GABA concentrations are higher in patients with panic disorder.

<p>False</p> Signup and view all the answers

There is evidence for increased levels of glutamate in the anterior brain regions in depressed patients.

<p>False</p> Signup and view all the answers

The NMDA-receptor antagonist ketamine has no effect on patients with treatment-refractory depression.

<p>False</p> Signup and view all the answers

About 20% of patients with Cushing's syndrome suffer from major depression.

<p>False</p> Signup and view all the answers

Endocrine abnormalities are not found in depressive disorder.

<p>False</p> Signup and view all the answers

The hypothalamic-pituitary-adrenal axis is not affected in depressive disorders.

<p>False</p> Signup and view all the answers

Plasma cortisol secretion is decreased in about 50% of patients with depressive disorder.

<p>False</p> Signup and view all the answers

The adrenal gland is decreased in size in patients with depressive disorder.

<p>False</p> Signup and view all the answers

Cortisol response to corticotropin (ACTH) challenge is decreased in patients with depressive disorder.

<p>False</p> Signup and view all the answers

Glutamate levels are not being studied in mood disorders.

<p>False</p> Signup and view all the answers

Desipramine and clonidine stimulate the release of growth hormone in patients with melancholic depression.

<p>False</p> Signup and view all the answers

α-Methyl-para-tyrosine (AMPT) causes significant depressive symptoms in healthy subjects.

<p>False</p> Signup and view all the answers

Dopamine function is well studied and clearly understood in depression.

<p>False</p> Signup and view all the answers

Low levels of homovanillic acid (HVA) are found only in patients with psychomotor retardation.

<p>False</p> Signup and view all the answers

Abnormalities in monoamine function are only found in unmedicated depressed patients.

<p>False</p> Signup and view all the answers

Lowering 5-HT and dopamine function is sufficient to cause clinical depression in anyone, regardless of prior illness.

<p>False</p> Signup and view all the answers

Decreased levels of free thyroxine are commonly found in depressed patients.

<p>False</p> Signup and view all the answers

Administration of CRH to animals produces changes in neuroendocrine regulation, sleep, and appetite that are opposite to those found in depressed patients.

<p>False</p> Signup and view all the answers

Childhood trauma does not affect HPA axis regulation.

<p>False</p> Signup and view all the answers

CRH has a neurotransmitter role in cortical regions of the brain.

<p>False</p> Signup and view all the answers

About 50% of depressed patients have a blunted TSH response to intravenous TRH.

<p>False</p> Signup and view all the answers

Cytokines can induce expression of the tryptophan-metabolizing enzyme indoleamine 2, 3-dioxygenase, which increases tryptophan levels.

<p>False</p> Signup and view all the answers

HPA axis changes in depressed patients are always state abnormalities that remit when the patient recovers.

<p>False</p> Signup and view all the answers

About 80% of depressed inpatients do not show the normal suppression of cortisol secretion induced by administering 1 mg of the synthetic corticosteroid dexamethasone.

<p>False</p> Signup and view all the answers

In experimental animal studies, early adverse experiences do not produce longstanding changes in HPA axis regulation.

<p>False</p> Signup and view all the answers

Dexamethasone non-suppression is more common in depressed patients with anxiety.

<p>False</p> Signup and view all the answers

Abnormalities in the dexamethasone suppression test are confined to mood disorders.

<p>False</p> Signup and view all the answers

The glucocorticoid receptor hypothesis of depression suggests that dysfunction of the HPA axis and the resulting depressive syndrome are linked to genetic or acquired defects of serotonin receptors.

<p>False</p> Signup and view all the answers

Animal experimental studies have found that antidepressant medication decreases expression of glucocorticoid receptors.

<p>False</p> Signup and view all the answers

The dexamethasone suppression test is a diagnostic marker of melancholic depression.

<p>False</p> Signup and view all the answers

The dexamethasone suppression test is a specific test for mood disorders.

<p>False</p> Signup and view all the answers

The dexamethasone suppression test is a highly sensitive test for diagnosing depression.

<p>False</p> Signup and view all the answers

Abnormalities in functional brain imaging in depression support a single structure model of mood disorders.

<p>False</p> Signup and view all the answers

The default mode network becomes active during task-based activity.

<p>False</p> Signup and view all the answers

Deficits in executive function are not prominent in patients with depression.

<p>False</p> Signup and view all the answers

Cognitive impairments in patients with depression persist even after the mood disorder remits.

<p>True</p> Signup and view all the answers

The neural circuitry that underpins emotional processing in depression is characterized by decreased limbic processing of aversive material.

<p>False</p> Signup and view all the answers

Adverse early experiences such as parental conflict or abuse do not play a part in shaping features of personality that determine vulnerability to depression.

<p>False</p> Signup and view all the answers

The predisposition to develop depressive disorders has no genetic contribution.

<p>False</p> Signup and view all the answers

Neuropsychological changes in mood disorders are limited to attention and learning.

<p>False</p> Signup and view all the answers

Recordings of the sleep EEG have shown a decrease in deep sleep in patients with major depression.

<p>True</p> Signup and view all the answers

Selective REM sleep deprivation can produce a temporary worsening of mood in depressed patients.

<p>False</p> Signup and view all the answers

Enlarged lateral ventricles are typically seen in younger subjects with early-onset depression.

<p>False</p> Signup and view all the answers

The neurotrophic hypothesis of depression suggests that stress can lead to an increase in neurons and upregulation of adult neurogenesis, particularly in the hippocampus.

<p>False</p> Signup and view all the answers

In major depression, decreased deep white matter hyperintensities are associated with late onset of depressive disorder.

<p>False</p> Signup and view all the answers

Cerebral blood flow and metabolism are negatively correlated.

<p>False</p> Signup and view all the answers

Decreased REM sleep latency is not a characteristic of sleep changes in depression.

<p>False</p> Signup and view all the answers

Many effective antidepressant drugs increase REM sleep time and the latency to its onset.

<p>False</p> Signup and view all the answers

The neural basis of emotional processing is not closely related to the pathophysiology of depressive disorders.

<p>False</p> Signup and view all the answers

Monoamine neurotransmission is not capable of altering emotional processing at both a behavioural and neural level.

<p>False</p> Signup and view all the answers

Adverse childhood experiences do not play a significant role in the risk of subsequent depression.

<p>False</p> Signup and view all the answers

Genetic factors do not interact with environmental and interpersonal factors in a complex manner to contribute to the development of depressive disorders.

<p>False</p> Signup and view all the answers

Recent stressful life events and difficulties are not significant risk factors for the development of depressive disorders.

<p>False</p> Signup and view all the answers

Neurobiological and psychological mechanisms of depressive disorders are mutually exclusive.

<p>False</p> Signup and view all the answers

The impact of genetic factors on the risk of depression is not partially mediated through an increased risk of early adverse experiences.

<p>False</p> Signup and view all the answers

Major depression is not a disorder with important genetic, environmental, and interpersonal determinants.

<p>False</p> Signup and view all the answers

About 75% of patients with recurrent depression achieve a period of 5 years of clinical stability with good social and occupational performance.

<p>False</p> Signup and view all the answers

About 5% of patients who present with a depressive disorder will eventually have a manic illness.

<p>False</p> Signup and view all the answers

Dysthymia is a chronic disorder that lasts for less than a year.

<p>False</p> Signup and view all the answers

The development of mania is a common occurrence in patients with dysthymia.

<p>False</p> Signup and view all the answers

The average length of a depressive episode is about 1 year.

<p>False</p> Signup and view all the answers

Patients with minor depressive disorders have a higher recurrence rate than those with major depression.

<p>False</p> Signup and view all the answers

Around 50% of patients with major depression will experience further episodes.

<p>False</p> Signup and view all the answers

Mortality is decreased in patients with depression due to lower rates of suicide.

<p>False</p> Signup and view all the answers

Patients with recurrent major depression experience on average about 2 further episodes over a 25-year follow-up.

<p>False</p> Signup and view all the answers

Treatment of depression has no impact on mortality rates.

<p>False</p> Signup and view all the answers

About 20% of depressed patients do not achieve complete symptom remission between episodes.

<p>False</p> Signup and view all the answers

The risk of suicide is higher in bipolar disorder than in unipolar disorder.

<p>False</p> Signup and view all the answers

The age of onset of major depression typically occurs after the age of 21.

<p>False</p> Signup and view all the answers

The interval between episodes of major depression becomes progressively longer.

<p>False</p> Signup and view all the answers

Duloxetine fatalities have been reported after consumption of as little as 500 mg.

<p>False</p> Signup and view all the answers

MAOIs are recommended as first-line antidepressant drugs.

<p>False</p> Signup and view all the answers

Moclobemide is more effective than conventional MAOIs for patients with resistant depression.

<p>False</p> Signup and view all the answers

Reboxetine is a sedating antidepressant drug.

<p>False</p> Signup and view all the answers

Lithium has established efficacy as a sole treatment for unipolar depression.

<p>False</p> Signup and view all the answers

Lithium augmentation can produce a rapid amelioration of the depressed state within 48 hours.

<p>True</p> Signup and view all the answers

The effects of lithium augmentation are restricted to patients taking tricyclic antidepressants.

<p>False</p> Signup and view all the answers

Agomelatine may have a different mechanism of action, involving the activation of serotonin receptors.

<p>False</p> Signup and view all the answers

Trazodone and mirtazapine are safer than tricyclic antidepressants in overdose.

<p>True</p> Signup and view all the answers

Antidepressant drugs have similar clinical response rates in patients with dysthymia and major depression.

<p>True</p> Signup and view all the answers

Tricyclic antidepressants are more effective than SSRIs in the treatment of moderate depression.

<p>False</p> Signup and view all the answers

Antidepressants are effective in the treatment of minor depression.

<p>False</p> Signup and view all the answers

Lofepramine is a tricyclic antidepressant that is particularly hazardous in overdose.

<p>False</p> Signup and view all the answers

Venlafaxine is an SSRI that is more effective than tricyclic antidepressants in patients with more severe depressive states.

<p>False</p> Signup and view all the answers

Duloxetine is an SNRI that is more effective than SSRIs in the treatment of depression.

<p>False</p> Signup and view all the answers

Tricyclic antidepressants have a higher dropout rate due to side effects compared to SSRIs in short-term clinical trials.

<p>False</p> Signup and view all the answers

Anticonvulsants such as carbamazepine, valproate, and lamotrigine are not useful in the management of bipolar disorder.

<p>False</p> Signup and view all the answers

Lamotrigine has not been shown to have antidepressant effects in placebo-controlled trials in bipolar depressed patients.

<p>False</p> Signup and view all the answers

Atypical antipsychotic agents, used at low doses, are not of benefit when combined with antidepressants in non-psychotically depressed patients who have failed to respond to antidepressant treatment alone.

<p>False</p> Signup and view all the answers

The addition of atypical antipsychotic drugs to ineffective SSRI treatment does not result in clinical remission.

<p>False</p> Signup and view all the answers

Electroconvulsive therapy is not described in Chapter 25.

<p>False</p> Signup and view all the answers

Antipsychotic drugs are not combined with antidepressant drugs in the treatment of patients with depressive psychosis.

<p>False</p> Signup and view all the answers

The addition of olanzapine to antidepressant treatment does not result in clinical remission.

<p>False</p> Signup and view all the answers

Cognitive behaviour therapy is superior to a waiting list control in relieving depressive symptomatology, but it is not generally superior to other structured psychological treatments.

<p>True</p> Signup and view all the answers

Supportive psychotherapy is a type of therapy that focuses on the identification and resolution of current life difficulties, and it is less effective than problem-solving therapy in moderately depressed patients in primary care.

<p>False</p> Signup and view all the answers

Randomized trials suggest that problem-solving treatment is as effective as drug treatment in moderately depressed patients in primary care.

<p>False</p> Signup and view all the answers

Cognitive behaviour therapy is not effective as a sole treatment for patients with severe depression, and this view is supported by trial evidence.

<p>False</p> Signup and view all the answers

Behavioural activation is a type of therapy that uses the principles of operant conditioning to track the links between actions and emotional outcomes, and it is less effective than cognitive behaviour therapy in depression.

<p>False</p> Signup and view all the answers

Interpersonal therapy is less effective than antidepressant medication in depressed patients.

<p>False</p> Signup and view all the answers

The National Institute for Health and Clinical Excellence concluded that cognitive behaviour therapy is superior to drug treatment in moderately depressed outpatients.

<p>False</p> Signup and view all the answers

In severely depressed inpatients, ECT is probably inferior to antidepressant drug treatment in the short term.

<p>False</p> Signup and view all the answers

Delusions are not a feature that distinguishes patients who respond to full ECT from those who respond to placebo.

<p>False</p> Signup and view all the answers

Relapse rates are low in depressed patients who have not responded to full trials of medication and are treated with ECT.

<p>False</p> Signup and view all the answers

In major depression, psychotherapies have been extensively evaluated and are proven to be more effective than antidepressant medication.

<p>False</p> Signup and view all the answers

The overall response rate is about 30% for ECT and 20% for simulated treatment.

<p>False</p> Signup and view all the answers

Cognitive behaviour therapy is superior to other structured therapies such as interpersonal therapy in the management of mild to moderate depression.

<p>False</p> Signup and view all the answers

ECT is considered to be a relatively ineffective treatment for depressive disorders with marked weight loss, early-morning waking, retardation, and delusions.

<p>False</p> Signup and view all the answers

Couple therapy is not significantly more effective than a waiting list control.

<p>False</p> Signup and view all the answers

Dynamic psychotherapy aims to resolve underlying developmental conflicts and attendant life difficulties that are believed to be causing or maintaining the depressive disorder.

<p>True</p> Signup and view all the answers

More recent meta-analyses have shown that short-term psychodynamic therapy is less effective than cognitive behaviour therapy in depressed patients.

<p>False</p> Signup and view all the answers

The antidepressant effect of sleep deprivation is permanent and does not disappear after the next night’s sleep.

<p>False</p> Signup and view all the answers

Bright light treatment is usually given for a few minutes in the morning.

<p>False</p> Signup and view all the answers

Patients with ‘atypical’ depressive features such as overeating and oversleeping respond poorly to bright light treatment.

<p>False</p> Signup and view all the answers

The usual onset of the antidepressant effect of bright light is within 2–5 months.

<p>False</p> Signup and view all the answers

Lieverse et al. (2011) showed that bright light treatment is not effective in non-seasonal depression.

<p>False</p> Signup and view all the answers

The duration of exposure to bright light usually needs to be less than an hour.

<p>False</p> Signup and view all the answers

In patients with recurrent depression, maintenance antidepressant treatment for 1–2 years has been shown to lower the relapse rate from 78% to 18%.

<p>False</p> Signup and view all the answers

Cognitive therapy given during an acute phase of depression has been shown to lead to a less sustained improvement in depressive symptomatology compared to antidepressant drug treatment.

<p>False</p> Signup and view all the answers

Lithium carbonate has been shown to be highly effective in the prevention of recurrent unipolar depression.

<p>False</p> Signup and view all the answers

Maintenance treatment with cognitive therapy has been shown to be less effective in preventing relapse compared to maintenance medication.

<p>False</p> Signup and view all the answers

Mindfulness-based cognitive therapy (MBCT) has been shown to be less effective in lowering the risk of relapse in patients with recurrent depression compared to maintenance antidepressant treatment.

<p>False</p> Signup and view all the answers

Combining interpersonal therapy with medication in the treatment of the acute episode has been shown to increase relapse rates over the following 12 months.

<p>False</p> Signup and view all the answers

In patients who achieve remission from depression with interpersonal therapy as a sole treatment, continuation therapy has been shown to be unhelpful in preventing recurrence.

<p>False</p> Signup and view all the answers

Stopping antidepressants soon after a treatment response has been obtained is associated with a low risk of relapse.

<p>False</p> Signup and view all the answers

Continuing antidepressant treatment for 6 months past the point of remission doubles the relapse rate.

<p>False</p> Signup and view all the answers

Relapse refers to the worsening of symptoms after a period of complete recovery from a single episode of mood disorder.

<p>False</p> Signup and view all the answers

Treatment to prevent relapse should be called prophylactic or maintenance treatment.

<p>False</p> Signup and view all the answers

About two-thirds of patients who are withdrawn from medication will relapse during the next year.

<p>False</p> Signup and view all the answers

Involvement of the family in the management of depressive disorders is unlikely to improve the outcome.

<p>False</p> Signup and view all the answers

The majority of relapses occur in the last 6 months of the first year after medication withdrawal.

<p>False</p> Signup and view all the answers

Antidepressant drug treatment is indicated for patients with mild depressive conditions.

<p>False</p> Signup and view all the answers

Placebo-controlled studies have reached the conclusion that continuing antidepressant treatment for less than 6 months halves the relapse rate.

<p>False</p> Signup and view all the answers

Patients with severe depressive disorders can be treated at home if they have a supportive family.

<p>True</p> Signup and view all the answers

Work can provide a valuable distraction from depressive thoughts for patients with severe depression.

<p>False</p> Signup and view all the answers

Inpatient treatment is necessary for patients who live alone or whose families cannot care for them during the day.

<p>False</p> Signup and view all the answers

The risk of suicide is a key factor in determining the level of care and supervision required for a patient with a depressive disorder.

<p>True</p> Signup and view all the answers

Dysthymia is not an indication for antidepressant medication.

<p>False</p> Signup and view all the answers

Guidelines for a stepped-care approach to the management of depression have not been developed by the National Institute for Health and Clinical Excellence.

<p>False</p> Signup and view all the answers

Patients with a depressive disorder of moderate or greater severity may not require any treatment if they have a supportive family.

<p>False</p> Signup and view all the answers

A depressive disorder can be diagnosed simply based on the presence of prominent depressive symptoms.

<p>False</p> Signup and view all the answers

A patient's social resources are not an important consideration in the diagnosis of depressive disorder.

<p>False</p> Signup and view all the answers

The effects of the disorder on other people, such as family members, are not a significant consideration in the diagnosis of depressive disorder.

<p>False</p> Signup and view all the answers

A patient's history of previous mood disturbance is not an important factor in assessing the current disorder.

<p>False</p> Signup and view all the answers

The severity of a depressive disorder is solely determined by the presence of biological symptoms.

<p>False</p> Signup and view all the answers

Aetiology is not an important consideration in the diagnosis of depressive disorder.

<p>False</p> Signup and view all the answers

The risk of suicide is not a significant consideration in the diagnosis of depressive disorder.

<p>False</p> Signup and view all the answers

SSRIs are never used as a first-choice treatment for depression.

<p>False</p> Signup and view all the answers

Lofepramine is a sedating compound.

<p>False</p> Signup and view all the answers

Tricyclic antidepressants are commonly used as first-choice agents for patients with severe depression.

<p>False</p> Signup and view all the answers

Mirtazapine is used to treat patients who require concomitant sedation.

<p>True</p> Signup and view all the answers

Concomitant treatment with nonsteroidal anti-inflammatory drugs increases the risk of bleeding with SSRIs.

<p>True</p> Signup and view all the answers

The dosage and precautions for antidepressant drugs are described in Chapter 25.

<p>True</p> Signup and view all the answers

Amitriptyline is a commonly used first-choice agent for treating depression.

<p>False</p> Signup and view all the answers

The choice of antidepressant drug should be made without considering the patient's medical history and potential side effects.

<p>False</p> Signup and view all the answers

In patients with moderate to severe depression, adding cognitive behaviour therapy to antidepressant medication is unhelpful.

<p>False</p> Signup and view all the answers

If a depressive disorder does not respond within a reasonable time to a chosen combination of antidepressant drugs, graded activity, and psychological treatment, switching to a different antidepressant is the first step.

<p>False</p> Signup and view all the answers

SSRIs have a clear dose–response relationship.

<p>False</p> Signup and view all the answers

Switching from an SSRI to a different class of drug has been shown to be significantly better in terms of remission rate than switching to a second SSRI.

<p>False</p> Signup and view all the answers

If a patient does not respond to one antidepressant, the next step is to increase the dose of the same medication.

<p>False</p> Signup and view all the answers

Couple therapy is not a helpful addition in depressed patients where problems with a partner are playing a role in maintaining the disorder.

<p>False</p> Signup and view all the answers

Therapy directed towards self-examination is particularly helpful in patients with severe depression.

<p>False</p> Signup and view all the answers

In patients with recurrent depressive disorders, therapy directed towards self-examination may be offered during acute episodes.

<p>False</p> Signup and view all the answers

ECT is usually considered as a first-line treatment of depression.

<p>False</p> Signup and view all the answers

The therapeutic effect of antidepressant drugs is usually faster than that of ECT.

<p>False</p> Signup and view all the answers

Patients who refuse to drink enough fluid to maintain an adequate output of urine are candidates for ECT.

<p>True</p> Signup and view all the answers

Patients with depressive psychosis respond better to ECT than to a combination of an antidepressant drug and an antipsychotic drug.

<p>False</p> Signup and view all the answers

The patient should be encouraged to engage in activities that they are likely to fail at due to slowness or poor concentration.

<p>False</p> Signup and view all the answers

Psychotherapy can be used as the sole therapy for patients with severe depression with melancholic features.

<p>False</p> Signup and view all the answers

The therapeutic response to psychotherapy is usually faster than that to antidepressant drugs.

<p>False</p> Signup and view all the answers

The more structured therapies such as interpersonal therapy and cognitive behaviour therapy have a weaker evidence base with regard to the treatment of moderate to severe depression.

<p>False</p> Signup and view all the answers

Aripiprazole is more likely to cause metabolic side effects than other atypical antipsychotics.

<p>False</p> Signup and view all the answers

The combination of lithium with SSRIs is contraindicated due to the risk of 5-HT neurotoxicity.

<p>False</p> Signup and view all the answers

The aim of lithium augmentation is to obtain a lithium concentration within the range of 1.0-1.5 mmol/l.

<p>False</p> Signup and view all the answers

Risperidone is less likely to cause weight gain compared to olanzapine and quetiapine.

<p>False</p> Signup and view all the answers

Lithium augmentation is usually not well tolerated in depressed patients.

<p>False</p> Signup and view all the answers

About 20% of depressed patients will show a useful response to lithium augmentation over 1-3 weeks.

<p>False</p> Signup and view all the answers

The discontinuation rate due to adverse effects is significantly lower with atypical antipsychotics than with placebo.

<p>False</p> Signup and view all the answers

The combination of lithium with MAOIs or clomipramine is not effective in depressed patients who are otherwise refractory to treatment.

<p>False</p> Signup and view all the answers

SSRIs are usually combined with serotonergic agents like bupropion in combination treatment.

<p>False</p> Signup and view all the answers

When switching between agents with different pharmacological properties, cross-tapering can be employed.

<p>True</p> Signup and view all the answers

Amitriptyline is slightly less effective than SSRIs in patients with severe depression.

<p>False</p> Signup and view all the answers

The evidence for combination treatment with antidepressants is abundant and well-documented.

<p>False</p> Signup and view all the answers

Combination of a tricyclic antidepressant with SSRIs is a recommended approach.

<p>False</p> Signup and view all the answers

Antipsychotic drugs are not useful in non-psychotic resistant depression except at high doses.

<p>False</p> Signup and view all the answers

Atypical antipsychotic drugs are used in high doses to augment SSRIs in nonpsychotic depression.

<p>False</p> Signup and view all the answers

In patients with psychotic depression, it is usually best to prescribe a combination treatment of antidepressant and antipsychotic medication.

<p>True</p> Signup and view all the answers

The addition of tri-iodothyronine (T3) to ineffective tricyclic antidepressant treatment has consistently shown to be highly effective in all studies.

<p>False</p> Signup and view all the answers

Tri-iodothyronine (T3) is typically started at a dose of 20 μg daily and increased to 40 μg after 1 week if tolerance is good.

<p>False</p> Signup and view all the answers

The use of ECT is contraindicated in patients with evidence of cardiovascular disease.

<p>True</p> Signup and view all the answers

The response to ECT is not affected by medication resistance.

<p>False</p> Signup and view all the answers

Tri-iodothyronine (T3) augmentation is only effective in treating depressive disorders with underlying thyroid activity.

<p>False</p> Signup and view all the answers

The addition of tri-iodothyronine (T3) to antidepressant treatment is always associated with severe side effects.

<p>False</p> Signup and view all the answers

ECT is only beneficial in patients who have not responded to antidepressant drugs and have no psychotic features.

<p>False</p> Signup and view all the answers

The efficacy of tri-iodothyronine (T3) augmentation is established for all types of antidepressant drugs.

<p>False</p> Signup and view all the answers

Among patients who have had three episodes of major depression, the likelihood of another episode is 80%.

<p>False</p> Signup and view all the answers

Lithium is a first choice medication for long-term maintenance treatment of recurrent depression in most patients.

<p>False</p> Signup and view all the answers

In patients with prolonged depression, it is particularly important to watch carefully for suicidal intentions.

<p>True</p> Signup and view all the answers

Maintenance treatment should be considered if a patient has had one previous episode of depression within a 5-year period.

<p>False</p> Signup and view all the answers

Cognitive behaviour therapy is only effective in lowering the risk of relapse in patients with no residual depressive symptomatology.

<p>False</p> Signup and view all the answers

A study found that cognitive behaviour therapy was less effective than treatment as usual in bringing about a therapeutic response.

<p>False</p> Signup and view all the answers

General practitioners do not play a key role in the long-term monitoring of patients with depressive disorders.

<p>False</p> Signup and view all the answers

Annual monitoring of body weight, blood pressure, glucose, and lipids is not recommended for patients with depressive disorders.

<p>False</p> Signup and view all the answers

The relapse rate in the year after ECT may be as low as 20%.

<p>False</p> Signup and view all the answers

A randomized study found post-ECT prophylaxis with a combination of lithium and nortriptyline to be less effective than maintenance ECT in sustaining remission.

<p>False</p> Signup and view all the answers

The choice of antidepressant medication is not influenced by the patient's response in the acute or continuation phase of treatment.

<p>False</p> Signup and view all the answers

After recovery, the patient should be followed up for several weeks by the psychiatric team or general practitioner.

<p>False</p> Signup and view all the answers

Lithium does not have a specific effect on lowering the risk of suicidal behaviour in patients with mood disorders.

<p>False</p> Signup and view all the answers

If residual symptoms are still present, it is safer to withdraw medication.

<p>False</p> Signup and view all the answers

Psychotherapy is not helpful in readjusting lifestyle to reduce the risk of further depressive episodes.

<p>False</p> Signup and view all the answers

Community nurses and nurse therapists do not play a valuable role in delivering treatment for depressive disorders.

<p>False</p> Signup and view all the answers

Newer antidepressant drugs are not better tolerated in the longer term than older antidepressant drugs.

<p>False</p> Signup and view all the answers

A mild depressive episode requires at least three symptoms of A and two symptoms of B.

<p>False</p> Signup and view all the answers

The severity of symptoms and degree of functional impairment are not considered in the classification of depressive episodes.

<p>False</p> Signup and view all the answers

All three symptoms of A are required for a severe depressive episode, but only three symptoms of B are required.

<p>False</p> Signup and view all the answers

Reduced concentration is a symptom of A in the ICD-10 classification.

<p>False</p> Signup and view all the answers

The ICD-10 classification provides a clear distinction between moderate and mild depressive episodes.

<p>True</p> Signup and view all the answers

According to the ICD-10, at least three of the symptoms listed are required to make a diagnosis of depression 'with somatic features'

<p>False</p> Signup and view all the answers

In DSM-5, the diagnosis of depression 'with melancholic features' requires either 'loss of interest' or 'lack of emotional reactivity' to be present

<p>True</p> Signup and view all the answers

Weight loss of 3% or more of body weight in the last month is a diagnostic criterion for depression 'with somatic features' in ICD-10

<p>False</p> Signup and view all the answers

Early-morning waking (2 hours or more before usual time) is a diagnostic criterion for depression 'with melancholic features' in DSM-5

<p>True</p> Signup and view all the answers

Marked loss of appetite is a diagnostic criterion for depression 'with melancholic features' in both ICD-10 and DSM-5

<p>True</p> Signup and view all the answers

What is the classification term used for a depressive episode that is characterized by a lack of energy and depression?

<p>Atypical depression</p> Signup and view all the answers

What is the DSM-5 classification term used for a depressive disorder that is characterized by persistent depressive symptoms that have persisted for at least 1 year?

<p>Persistent Depressive Disorder (Dysthymia)</p> Signup and view all the answers

What is the ICD-10 classification term used for a depressive disorder that is characterized by recurrent episodes of depression?

<p>Recurrent depressive disorder</p> Signup and view all the answers

What is the classification term used for a depressive disorder that is characterized by brief episodes of depression?

<p>Recurrent brief depression</p> Signup and view all the answers

What is the ICD-10 classification term used for a depressive disorder that is characterized by mild depressive symptoms?

<p>Mild depressive episode</p> Signup and view all the answers

The DSM-5 includes a specifier 'with peripartum onset' for depressive disorders.

<p>True</p> Signup and view all the answers

The ICD-10 classification provides a clear distinction between mild and moderate depressive disorders.

<p>True</p> Signup and view all the answers

Depressive cognitions in patients with severe depressive episode are limited to feelings of worthlessness and pessimism.

<p>False</p> Signup and view all the answers

Agitated depression is a condition that is seen more commonly among middle-aged and elderly patients than among younger individuals.

<p>True</p> Signup and view all the answers

In DSM-5, Persistent Depressive Disorder (Dysthymia) requires symptoms to have persisted for at least 2 years.

<p>False</p> Signup and view all the answers

The hypothalamic-pituitary-adrenal axis is studied in the context of genetic epidemiology.

<p>False</p> Signup and view all the answers

Neurogenesis, neurotropins, and synaptic plasticity are related to neuropsychology and brain imaging.

<p>False</p> Signup and view all the answers

Cognitive style is investigated in the context of early environment.

<p>True</p> Signup and view all the answers

Monoamines are related to psychological investigations.

<p>False</p> Signup and view all the answers

Personality is investigated in the context of genetic epidemiology.

<p>False</p> Signup and view all the answers

What is the primary genetic contribution to mood disorders?

<p>Multiple genes of small individual effect</p> Signup and view all the answers

How do adverse early life experiences affect development?

<p>They shape personality and limit subsequent attachment behavior</p> Signup and view all the answers

What triggers depressive disorders in people who lack social support?

<p>Current life events</p> Signup and view all the answers

What is associated with changes in the activity of monoamine neurons and the HPA axis?

<p>Depressive disorders</p> Signup and view all the answers

What may involve a loss of synaptic plasticity and dendrite formation?

<p>The neurobiology of episodes of depression</p> Signup and view all the answers

What suggests persistent biological vulnerability in mood disorders?

<p>Structural and functional brain abnormalities</p> Signup and view all the answers

Freud suggested that melancholia results from the loss of a loved one through death.

<p>False</p> Signup and view all the answers

Depressed patients often appear to be critical of others, according to Freud's theory.

<p>False</p> Signup and view all the answers

Freud's theory proposes that depression occurs when feelings of love and hostility are present at the same time, but not simultaneously.

<p>False</p> Signup and view all the answers

Melanie Klein believed that weaning represents a significant symbolic gain for the infant.

<p>False</p> Signup and view all the answers

According to Melanie Klein, 'depressive anxiety' leads to attempts at revenge and hatred towards others.

<p>False</p> Signup and view all the answers

Freud's theory of depression is based on the idea that the patient's feelings of love are redirected against themselves as self-reproach.

<p>True</p> Signup and view all the answers

Freud's paper 'Mourning and melancholia' was published in 1915.

<p>False</p> Signup and view all the answers

Freud's theory of depression suggests that the patient's feelings of hostility are redirected against the loved one as self-reproach.

<p>False</p> Signup and view all the answers

Melanie Klein's theory is based on the idea that the infant's feelings of love and hostility are present at the same time.

<p>False</p> Signup and view all the answers

Freud's theory of depression proposes that the patient's feelings of love are redirected against the therapist as transference.

<p>False</p> Signup and view all the answers

Decreased plasma tryptophan is a evidence of abnormalities in noradrenaline activity in depression

<p>False</p> Signup and view all the answers

Decreased brain 5-HT reuptake sites are only detected by PET

<p>False</p> Signup and view all the answers

Clinical relapse after α-methyl-para-tyrosine (AMPT) is a evidence of abnormalities in dopamine activity in depression

<p>True</p> Signup and view all the answers

Decreased homovanillic acid (HVA) levels in cerebrospinal fluid is a evidence of abnormalities in 5-HT activity in depression

<p>False</p> Signup and view all the answers

Blunted 5-HT neuroendocrine responses is a evidence of abnormalities in noradrenaline activity in depression

<p>False</p> Signup and view all the answers

Immune changes in depression include increased natural killer cell activity.

<p>False</p> Signup and view all the answers

Induction of indoleamine 2,3-dioxygenase is an immune change associated with depression.

<p>True</p> Signup and view all the answers

Increases in positive acute phase proteins are a characteristic of depression.

<p>True</p> Signup and view all the answers

Decreased inflammatory cytokine levels, such as IL-6 and TNFα, are associated with depression.

<p>False</p> Signup and view all the answers

Lowered proliferative responses of lymphocytes to mitogens are a characteristic of depression.

<p>True</p> Signup and view all the answers

Dorsolateral and dorsomedial prefrontal cortex are associated with impaired voluntary regulation of emotion in depressed patients.

<p>False</p> Signup and view all the answers

The anterior cingulate is associated with abnormal emotional processing in depressed patients.

<p>False</p> Signup and view all the answers

The ventral striatum is associated with impaired incentive behavior in depressed patients.

<p>True</p> Signup and view all the answers

The amygdala is associated with impaired attentional processes in depressed patients.

<p>False</p> Signup and view all the answers

Psychomotor disturbances are associated with dorsolateral and dorsomedial prefrontal cortex in depressed patients.

<p>False</p> Signup and view all the answers

Amitriptyline is an antidepressant drug that is known to have no anticholinergic effects.

<p>False</p> Signup and view all the answers

All SSRIs have a similar toxicity profile in overdose.

<p>False</p> Signup and view all the answers

Mirtazapine is an antidepressant drug that is known to cause marked sedation and weight gain.

<p>True</p> Signup and view all the answers

Reboxetine is an antidepressant drug that is known to cause no anticholinergic effects and no sedation.

<p>True</p> Signup and view all the answers

Venlafaxine is an antidepressant drug that has a low toxicity profile in overdose.

<p>False</p> Signup and view all the answers

What is an important aspect of improving the outcome of depression treatment?

<p>Involving the patient's family</p> Signup and view all the answers

What is a common question asked by patients with a first episode of moderate to severe depression?

<p>Can I recover?</p> Signup and view all the answers

What is a key aspect of depression that patients and families often want to know?

<p>What is wrong with me?</p> Signup and view all the answers

What is a common feeling experienced by patients with depression?

<p>Guilt</p> Signup and view all the answers

What is a consideration in the management of depression?

<p>Whether the patient should continue working</p> Signup and view all the answers

What has been developed by the National Institute for Health and Clinical Excellence (2009a)?

<p>Guidelines for a stepped-care approach to depression management</p> Signup and view all the answers

What is recommended for patients with persistent mild depressive symptoms that do not respond to exercise programmes and sleep hygiene?

<p>All of the above</p> Signup and view all the answers

What is the recommended treatment for patients who present with moderate or severe depression?

<p>A combination of antidepressant medication and a high-intensity psychological intervention</p> Signup and view all the answers

How long should patients who respond to antidepressant medication continue treatment?

<p>At least 6 months</p> Signup and view all the answers

What is recommended for patients who have relapsed despite antidepressant treatment?

<p>Cognitive behaviour therapy or mindfulness-based cognitive therapy</p> Signup and view all the answers

What should patients at high risk of relapse be advised to do?

<p>Continue antidepressant treatment for 2 years</p> Signup and view all the answers

What should be considered for patients who are well but who have experienced three or more previous episodes of depression?

<p>Mindfulness-based cognitive therapy</p> Signup and view all the answers

What is the primary focus of the treatment plan for depression?

<p>Collaborative exercise between patient and clinical team</p> Signup and view all the answers

Who should be involved in discussions about the nature of depression and treatment plan?

<p>The patient's family members</p> Signup and view all the answers

What is the aim of involving the family in discussions about depression and treatment plan?

<p>To improve mutual communication and support</p> Signup and view all the answers

What is recommended for patients with short-lived mild depression who may recover quickly without treatment?

<p>Early review ('active monitoring')</p> Signup and view all the answers

What is not recommended for the treatment of mild depression?

<p>Antidepressants</p> Signup and view all the answers

What is recommended for patients with persistent mild depression?

<p>Guided self-help programme based on cognitive behaviour therapy</p> Signup and view all the answers

In treating resistant depression, adding an atypical antipsychotic drug to an SSRI is a recommended treatment option.

<p>True</p> Signup and view all the answers

MAOIs are not effective in combination with lithium.

<p>False</p> Signup and view all the answers

ECT is a pharmacological treatment option for resistant depression.

<p>False</p> Signup and view all the answers

Adding mirtazapine to an SSRI is an example of an antidepressant combination.

<p>True</p> Signup and view all the answers

Increasing the dose of an antidepressant is only recommended if the patient has depressive psychosis.

<p>False</p> Signup and view all the answers

Study Notes

Depressive Disorders

  • Depressive disorders are a group of psychiatric syndromes characterized by depressed mood, negative thinking, lack of enjoyment, reduced energy, and slowness.
  • The central features of depressive disorders are:
    • Depressed mood
    • Negative thinking
    • Lack of enjoyment
    • Reduced energy
    • Slowness
  • Depressed mood is usually the most prominent symptom, but not always.

Clinical Features of Severe Depression

  • A severe depressive episode is characterized by:
    • Low mood
    • Lack of enjoyment (anhedonia)
    • Negative thinking
    • Reduced energy
    • Decreased social and occupational functioning
  • Appearance:
    • Neglected dress and grooming
    • Facial features: downturned mouth corners, vertical furrowing of the brow
    • Reduced blinking rate
    • Bent shoulders, inclined head, and downward gaze
    • Reduced gestures and movements
  • Mood:
    • Pervasive misery
    • Unimproved by pleasant circumstances
    • Experienced as different from ordinary sadness
    • Often worse in the morning, improving as the day progresses (diurnal variation of mood)
  • Depressive cognitions:
    • Negative thoughts (worthlessness, pessimism, guilt)
    • Feelings of guilt often take the form of unreasonable self-blame
    • Pessimistic thoughts concern future prospects
    • Gloomy preoccupations may progress to thoughts of suicide
  • Lack of interest and enjoyment (anhedonia):
    • No enthusiasm for activities and hobbies
    • No pleasure in everyday things
    • Withdrawal from social encounters
  • Reduced energy:
    • Lethargic, find everything an effort, leaving tasks unfinished
    • Attribution to physical illness
  • Psychomotor changes:
    • Psychomotor retardation: slow walking, acting, and speaking
    • Agitation: restlessness, inability to relax, pacing
  • Biological symptoms:
    • Sleep disturbance (early-morning waking, delay in falling asleep, waking during the night)
    • Loss of appetite, weight, and libido
    • Constipation, loss of interest in activities
    • Amenorrhoea in women
  • Other features:
    • Depersonalization
    • Obsessional symptoms
    • Panic attacks
    • Dissociative symptoms (rare)
    • Complaints of poor memory, which can be severe

Psychotic Depression

  • Psychotic depression is a severe depressive disorder characterized by:
    • Delusions and hallucinations
    • Complete loss of function in social and occupational spheres
    • Inattention to basic hygiene and nutrition
    • Impaired insight
    • Delusions of worthlessness, guilt, ill health, and poverty
    • Hallucinations may be mood-congruent or mood-incongruent

Clinical Variants of Depressive Disorders

  • Agitated depression:
    • Prominent agitation
    • More common among middle-aged and elderly patients
  • Retarded depression:
    • Prominent psychomotor retardation
    • No evidence that it represents a separate syndrome
    • May predict a good response to electroconvulsive therapy (ECT)

Depressive Stupor

  • In severe depressive disorder, patients may exhibit depressive stupor, characterized by extreme slowing of movement and poverty of speech.
  • Patients may become motionless and mute, with impaired recall of events during the stupor state.
  • Kraepelin described patients in depressive stupor as lying mute in bed, giving no answers, and showing no defensive response to pinprick.
  • Today, it is believed that patients can recall nearly all events that took place during the period of stupor upon recovery.
  • Depressive stupor may be accompanied by catatonic motor disturbances.

Atypical Depression

  • Atypical depression is characterized by variably depressed mood with mood reactivity to positive events.
  • Additional symptoms include overeating and oversleeping, extreme fatigue and heaviness in the limbs, and pronounced anxiety.
  • Patients often have a lifelong tendency to react exaggeratedly to perceived or real rejection.
  • Atypical depression typically has an earlier onset of illness and a more chronic course.
  • Recognition of atypical depression is important, as patients may be mismanaged due to their interpersonal sensitivity.
  • Historically, atypical depression has been associated with poor response to tricylic antidepressants, but better response to monoamine oxidase inhibitors (MAOIs).

Mixed Depression

  • Mixed depression is characterized by symptoms of depression, accompanied by symptoms typically seen in mania.
  • Common symptoms include irritable mood, mood lability, distractibility, agitation, and impulsivity.
  • Mixed depression is more common in patients with a family history of bipolar disorder.
  • Patients with mixed depression are more likely to develop bipolar disorder in the future.

Mild Depressive States

  • Mild depressive disorders present with similar symptoms to severe depression, but with less intensity.
  • Additional symptoms may include anxiety, phobias, obsessional symptoms, and dissociative symptoms.
  • Mild depressive disorders often involve sleep disturbances, but not early-morning waking, and may include difficulty falling asleep or waking during the night.
  • Biological features like poor appetite, weight loss, and low libido are typically absent.
  • Mild depressive disorders can be challenging to classify and may merge into minor mood disorders.

Minor Anxiety–Depressive Disorders

  • Minor anxiety–depressive disorders involve a mix of anxiety and depressive symptoms that do not meet criteria for a specific disorder.
  • Symptoms may include fatigue, anxiety, depression, irritability, poor concentration, insomnia, somatic symptoms, and bodily preoccupation.
  • These disorders are common in primary care and may cause significant distress and impairment.
  • Cultural variations in the clinical presentation of depressive states exist, but sadness, joylessness, anxiety, and lack of energy are common symptoms across cultures.

Classification of Depressive Disorders

  • There is no general agreement on the best method of classifying depressive disorders.
  • Approaches have been tried based on:
    • Presumed aetiology (causes)
    • Symptomatic picture (symptoms)
    • Course (development and progression)

Classification by Presumed Aetiology

  • Historical distinction between endogenous depression (caused by internal factors) and reactive depression (caused by external factors) is no longer used.
  • Neither ICD-10 nor DSM-5 contains categories of reactive or endogenous depression.

Classification by Symptomatic Picture

  • Melancholic depression:
    • Characterized by "biological" symptoms such as loss of appetite, psychomotor changes, weight loss, constipation, reduced libido, amenorrhoea, and early-morning waking.
    • Associated with:
      • More severe symptomatology
      • Family history of depression
      • Poor response to placebo medication
      • Possibly better response to tricyclic antidepressants than selective serotonin reuptake inhibitors (SSRIs)
      • More evidence of neurobiological abnormalities
  • Psychotic depression:
    • Characterized by severe depression with psychotic features.
    • Requires treatment with antidepressant medication and antipsychotic drugs.
  • Non-melancholic depression:
    • Includes mild depressive episodes and atypical depression.
    • Characterized by:
      • Anxiety
      • Hostility
      • Phobias
      • Obsessional symptoms

Classification by Course

  • Unipolar and bipolar disorders:
    • Mood disorders are characteristically recurrent.
    • Kraepelin's classification of manic-depressive psychosis is no longer used.
  • Seasonal affective disorder:
    • Characterized by depressive episodes that occur at the same time every year.
    • Associated with:
      • Hypersomnia
      • Increased appetite
      • Afternoon slump in energy levels
    • Treatment includes exposure to bright artificial light.

Recurrent Brief Depression

  • Characterized by:
    • Recurrent depressive episodes of short duration (typically 2-7 days)
    • No apparent link to the menstrual cycle in female sufferers
    • Associated with:
      • Suicidal behavior
      • Personal distress
      • Social and occupational impairment
    • Treatment is often with antidepressant medication, but its value is questionable.

Classification in DSM-5 and ICD-10

  • Both systems contain categories for:
    • Single episodes of mood disorder
    • Recurrent episodes
    • Milder but persistent depressive states (dysthymia)
  • Differences between DSM-5 and ICD-10:
    • DSM-5 includes mood disorders secondary to a medical condition
    • ICD-10 classifies these conditions as mood disorders under "Organic Mental Disorders"
  • Both systems allow for the diagnosis of:
    • Recurrent brief depression
    • Atypical depression

Aetiology of Depression

  • The aetiology of depression is a complex phenomenon, with multiple approaches to understanding its causes, including genetic, environmental, and psychological factors.
  • Family and twin studies have shown that depression tends to run in families, with a threefold increased risk in first-degree relatives.
  • Environmental influences, such as childhood experiences and current life difficulties, also play a significant role in the development of depression.

Genetic Causes

  • Twin studies have found that the concordance rate for depressive disorders is higher in monozygotic twins (45%) than in dizygotic twins (20%).
  • The heritability of major depression is estimated to be around 37%, which is lower than that of bipolar disorder or schizophrenia.
  • Genetic factors may interact with environmental factors to contribute to the development of depression.
  • The mode of inheritance of depression is likely to be polygenic, involving the combined action of multiple genes with small effects.

Molecular Genetics

  • The monoamine theory of depression suggests that allelic variations in genes involved in monoamine synthesis or metabolism may contribute to the risk of mood disorders.
  • Association studies have identified several candidate genes, including the serotonin transporter gene, but the results have been inconsistent.
  • Genome-wide association studies (GWAS) have not yet identified any convincingly replicated loci for depression.
  • A recent whole genome sequencing study identified two replicated genetic markers for severe recurrent depression in a Han Chinese population.

Personality

  • Certain personality traits, such as high levels of premorbid anxiety, may be associated with an increased risk of depression.
  • Aspects of personality, such as cognitive style, may influence the way people respond to adverse circumstances, making them more likely to develop depressive disorders.
  • Neuroticism, as measured by the Eysenck Personality Questionnaire, is associated with an increased risk of depression, and may share common genes with major depression.

Early Environment

  • Parental deprivation, particularly parental separation, may be a risk factor for depression in later life.
  • Gross disruption of parent-child relationships, such as physical or sexual abuse, is also a risk factor for depression.
  • Subtle differences in parental style, such as non-caring or overprotective parenting, may also contribute to the development of depression.
  • Mothers with postnatal depression may manifest a rearing style that is characterized by neglect and emotional indifference, which may increase the risk of depression in their children.

Precipitating Factors

  • Recent life events, such as adverse life events, may precipitate depression in susceptible individuals.
  • The association between life events and depression is not coincidental, and is not specific to depression.
  • Methodologically reliable research has shown that there is a sixfold excess of adverse life events in the months before the onset of depressive disorder.
  • Life events are important antecedents of all forms of depression, but appear to be relatively less important in established melancholic-type disorders and where there is a strong family history of depression.

Vulnerability Factors and Life Difficulties

  • Poor social support, measured as lack of intimacy or social integration, is associated with an increased risk of depression.
  • The mechanism of this association is unclear, and may be due to a lack of opportunities to confide, distorted perception of intimacy, or other factors.
  • The effects of physical illness, such as Cushing's disease, can also contribute to the development of depression.
  • Organic mood disorders, such as those caused by brain disease or certain infections, may provide clues to the aetiology of depression.

Psychological Approaches to Aetiology

  • Cognitive theories propose that depressive disorders are caused by negative views of the self, the world, and the future, which are maintained by illogical ways of thinking, such as:
    • Arbitrary inference
    • Selective abstraction
    • Overgeneralization
    • Personalization
  • These negative views are often established early in life, usually through childhood adversity, and affect how a person responds to stress and adversity
  • Schemas can become activated by matching life experiences, increasing the risk of depression

Neurobiological Approaches to Aetiology

  • Depressive disorders must ultimately be mediated through changes in brain neurochemistry and circuitry involved in emotional regulation
  • Monoamine neurotransmitters, particularly noradrenaline and 5-hydroxytryptamine (5-HT), play an important role in the actions of effective antidepressant drugs
  • Monoamine pathways innervate cortical and subcortical brain regions involved in mood regulation
  • Recent studies have used structural and functional imaging techniques to identify changes in neural circuitry associated with depressive disorders
  • Mood disorders are associated with distinct and persistent neuropathological changes in relevant brain regions

The Monoamine Hypothesis

  • The monoamine hypothesis suggests that depressive disorder is due to an abnormality in a monoamine neurotransmitter system at one or more sites in the brain
  • Three monoamine transmitters have been implicated: serotonin (5-HT), noradrenaline, and dopamine
  • The hypothesis has been tested through the study of:
    • Biochemistry of neurotransmitters in patients with mood disorders
    • Effects of selective drugs on measurable indices of monoamine system function
    • Pharmacological properties shared by antidepressant drugs

5-HT Function

  • Plasma tryptophan levels are decreased in untreated depressed patients, particularly in those with melancholic depression
  • Studies of cerebrospinal fluid (CSF) have found inconsistent evidence of a consistent reduction in CSF concentrations of 5-hydroxyindoleacetic acid (5-HIAA) in depressed patients
  • Post-mortem brain studies have found little consistent evidence of lowered brain concentrations of 5-HT or 5-HIAA in depressed patients
  • Neurochemical brain imaging studies have found evidence of decreased 5-HT1A receptor binding throughout cortical and subcortical regions
  • Neuroendocrine tests have found blunted 5-HT-mediated endocrine responses in depressed patients
  • Tryptophan depletion studies have found that lowering brain 5-HT function can induce depressive symptoms in vulnerable individuals

Noradrenaline Function

  • There is no consistent evidence of changes in brain or CSF concentrations of noradrenaline or its major metabolite, 3-methoxy-4-hydroxy-phenylethylene glycol (MHPG), in depressed patients
  • Neuroendocrine tests have found blunted growth hormone responses to clonidine in depressed patients
  • Catecholamine depletion studies have found that lowering brain catecholamine function can induce depressive symptoms in vulnerable individuals

Dopamine Function

  • Dopamine neurons in the mesolimbic system play a key role in incentive behavior and reward
  • Abnormalities in dopamine function may be involved in the pathophysiology of depression
  • CSF levels of homovanillic acid (HVA) are consistently low in depressed patients
  • Some brain imaging studies have found increased binding of dopamine D2/D3 receptors in striatal regions
  • Regional reductions in dopamine D1 receptors have been reported in some studies

Dexamethasone Suppression Test

  • The dexamethasone suppression test is used to study depressed patients, suppressing cortisol levels by inhibiting ACTH release at the pituitary level.
  • About 50% of depressed inpatients do not show normal suppression of cortisol secretion after administering 1 mg of dexamethasone.
  • Dexamethasone non-suppression is more common in depressed patients with melancholia.
  • Abnormalities in the dexamethasone suppression test are not exclusive to mood disorders, also reported in mania, chronic schizophrenia, and dementia.

Glucocorticoid Receptor Hypothesis

  • The glucocorticoid receptor hypothesis suggests that dysfunction of the HPA axis and depressive syndrome are linked to genetic or acquired defects of glucocorticoid receptors.
  • Antidepressant medication increases expression of glucocorticoid receptors, which may be a therapeutic mechanism to normalize excessive HPA axis activity.
  • HPA axis changes in depressed patients are generally regarded as state abnormalities, remitting when the patient recovers.

Corticotropin-Releasing Hormone (CRH) and Depression

  • CRH has a neurotransmitter role in limbic regions, regulating biochemical and behavioral responses to stress.
  • Administration of CRH to animals produces changes in neuroendocrine regulation, sleep, and appetite similar to those found in depressed patients.
  • CRH levels may be increased in the CSF of depressed patients, suggesting a possible role in the pathophysiology of depression.
  • Non-peptide antagonists of CRH receptors may have value as antidepressant agents.

Thyroid Function and Depression

  • Circulating plasma levels of free thyroxine are normal in depressed patients, but levels of free triiodothyronine may be decreased.
  • About 25% of depressed patients have a blunted thyrotropin-stimulating hormone (TSH) response to intravenous thyrotropin-releasing hormone (TRH).
  • Abnormalities in thyroid function are not specific to depression, also found in alcoholism and panic disorder.

Depression and the Immune System

  • Patients with depression manifest various disturbances of immune function, including decreased cellular immune responses and immune activation.
  • Changes in immune regulation may play a role in HPA axis dysfunction in depression.
  • Cytokines can induce expression of the tryptophan-metabolizing enzyme indoleamine 2,3-dioxygenase, which lowers tryptophan levels and puts vulnerable individuals at risk of depression.

Sleep Changes in Depression

  • Disturbed sleep is characteristic of depression, with abnormalities in sleep architecture, including impaired sleep continuity and duration, decreased deep sleep, and increased REM sleep.
  • Decreased REM sleep latency may persist in recovered depressed patients, indicating a vulnerability to relapse.
  • Many effective antidepressant drugs decrease REM sleep time and latency, and both total sleep deprivation and selective REM sleep deprivation can produce temporary alleviation of mood in depressed patients.

Brain Imaging in Mood Disorders

  • Structural brain imaging studies have found abnormalities in patients with depression, including enlarged lateral ventricles, decreased hippocampal volume, and decreased grey matter volume in anterior brain areas.
  • The neurotrophic hypothesis of depression suggests that stress and cortisol hypersecretion can lead to atrophy and death of neurons and downregulation of adult neurogenesis.
  • Functional brain imaging studies have shown abnormalities in cerebral blood flow and metabolism, supporting a circuitry model of mood disorders.

Neuropsychological Changes in Mood Disorders

  • Patients with acute depression and mania show poor performance on various measures of neuropsychological function, including attention, learning, memory, and executive function.
  • Cognitive impairments resolve as the mood disorder remits, but may persist in euthymic patients with recurrent depression.
  • Depression is clinically associated with negative biases in the processing of emotional information, which can be reversed by antidepressant medication.

Conclusions

  • The predisposition to develop depressive disorders has a significant genetic contribution.
  • Adverse early experiences, such as parental conflict or abuse, may play a part in shaping features of personality that determine vulnerability to depression.
  • The precipitating causes of mood disorders include stressful life events and certain physical illnesses, which can be modified by background factors, such as personality, early life experiences, and genetic inheritance.
  • Two kinds of pathophysiological mechanisms have been proposed to explain how precipitating events lead to depressive disorders: psychological and neurobiological mechanisms.

Major Depression

  • 10% of patients who present with a depressive disorder will eventually have a manic illness, and these patients are more likely to have a family history of mania or to show brief, mild manic mood swings during antidepressant treatment.
  • The age of onset of major depression varies widely and can occur at any point in the lifespan, with about half of all cases occurring before the age of 21.
  • The average length of a depressive episode is about 6 months, but around 25% of patients have episodes that last for more than 1 year, and around 10–20% develop a chronic unremitting course.
  • About 80% of patients with major depression will experience further episodes, and over a 25-year follow-up, patients with recurrent major depression experience on average about four further episodes.
  • The interval between episodes becomes progressively shorter, and about 50% of depressed patients do not achieve complete symptom remission between episodes, experiencing continuing subsyndromal depressive symptomatology of fluctuating severity.

Dysthymia

  • Dysthymia is a chronic disorder that lasts for many years, but about 50% of outpatients may be expected to show a clinical recovery over a 5-year follow-up.
  • Some patients with dysthymia develop major depression (so-called double depression), while some patients who originally present with major depression subside into dysthymia.

Minor Depressive Disorders

  • Minor depressive disorders are depressive disorders that do not meet threshold criteria for major depression, even of mild severity.
  • These conditions show a recurrence rate similar to that of major depression, and patients who meet the criteria for minor depression at one point in follow-up may then subsequently be diagnosed as suffering from major depression, and vice versa.

Mortality of Depressive Disorders

  • Mortality is significantly increased in patients with depression, largely due to suicide, accidents, cardiovascular disease, and comorbid substance misuse.
  • The standardized mortality ratio in mood disorders is about twice that found in the general population, and there is now compelling evidence that depressive disorders increase the risk of general medical conditions such as diabetes and cardiovascular disease.
  • Treatment lowers the mortality in patients with depression, and rates of suicide in patients with depression are at least 15 times higher than those in the general population.

Prognostic Factors

  • The best predictor of the future course is the history of previous episodes, and the risk of recurrence is much higher in individuals with a history of several previous episodes.
  • Other factors that predict a higher risk of future episodes include incomplete symptomatic remission, early age of onset, poor social support, poor physical health, comorbid substance misuse, and comorbid personality disorder.

The Acute Treatment of Depression

  • Antidepressant drugs are effective in the acute treatment of major depression, with the largest effects relative to placebo seen in patients with major depression whose symptoms are of at least moderate severity.
  • Short-term response rates in controlled trials are about 50% for patients on active treatment, and about 30% for those on placebo, with the number needed to treat (NNT) being between 5 and 7.
  • In terms of efficacy, there is little to choose between the various antidepressants, although some are better than others in certain defined situations.

Tricyclic Antidepressants

  • Tricyclic antidepressants have been extensively compared with placebo in both inpatients and outpatients with major depression, and are clearly more effective than placebo in all but the most severely depressed patients.
  • There is little evidence that tricyclic antidepressant drugs differ from one another in clinical efficacy, but they do differ in terms of their side effect profile.

Selective Serotonin Reuptake Inhibitors and Serotonin and Noradrenaline Reuptake Inhibitors

  • SSRIs have undergone extensive trials both against placebo and against comparator antidepressants, and are as effective as tricyclic antidepressants in the broad range of depressed patients.
  • Venlafaxine, a serotonin and noradrenaline reuptake inhibitor (SNRI), appears to be slightly more effective than SSRIs in patients with more severe depressive states.

Monoamine Oxidase Inhibitors

  • MAOIs are effective antidepressants and of equal therapeutic activity to tricyclic antidepressants for moderate to severe depressive disorders, particularly with melancholic features.
  • However, MAOIs are liable to cause dangerous reactions with other drugs and some foods, and for this reason they are not recommended as first-line antidepressant drugs.

Anticonvulsants in Bipolar Disorder

  • Anticonvulsants such as carbamazepine, valproate, and lamotrigine are useful in managing bipolar disorder and can prevent episodes of major depression.
  • Lamotrigine has shown antidepressant effects in placebo-controlled trials in bipolar depressed patients, particularly those with higher levels of symptomatology.

Atypical Antipsychotic Drugs

  • Atypical antipsychotic agents, used at relatively low doses, can be beneficial when combined with antidepressants in non-psychotically depressed patients who have failed to respond to antidepressant treatment alone.
  • A meta-analysis of trials involving 3500 patients found that the addition of drugs such as aripiprazole, quetiapine, and risperidone to ineffective SSRI treatment resulted in clinical remission (NNT = 9).

Electroconvulsive Therapy (ECT)

  • ECT is more effective than simulated ECT in patients with major depression, with a response rate of about 70% for ECT and 40% for simulated treatment (NNT = 3–4).
  • ECT is probably superior to antidepressant drug treatment in severely depressed inpatients, at least in the short term.
  • Delusions and retardation are features that distinguish patients who respond to full ECT from those who respond to placebo.

Psychological Treatments

  • Psychotherapies can be employed as alternatives to antidepressant medication or as adjuncts.
  • Specific psychotherapies are somewhat more effective than treatment as usual in the management of mild to moderate depression, particularly in primary care.
  • Structured treatments such as cognitive behavior therapy do not appear to be superior to other structured therapies such as interpersonal therapy.

Supportive Psychotherapy and Problem-Solving

  • Supportive psychotherapy focuses on identifying and resolving current life difficulties, and using the patient's strengths and available coping resources.
  • Problem-solving treatment is better than treatment as usual in moderately depressed patients in primary care.

Cognitive Behavior Therapy (CBT)

  • CBT aims to help patients modify their ways of thinking and acting in relation to life situations and depressive symptoms.
  • CBT is superior to a waiting list control in relieving depressive symptomatology, and is as effective as pharmacological treatment in moderately depressed outpatients.
  • Combined CBT and pharmacological treatment is better than pharmacological treatment alone.

Behavioral Activation

  • Behavioral activation uses the principles of operant conditioning to assist patients in engaging in behaviors that will lead to a positive effect on mood.
  • A recent meta-analysis of 26 randomized trials of behavioral activation in depression showed that the technique was superior to control procedures.

Interpersonal Psychotherapy

  • Interpersonal therapy is a systematic and standardized treatment approach to personal relationships and life problems.
  • It is more effective than placebo with clinical management and GP treatment as usual, and is as effective as antidepressant medication.

Couple Therapy

  • Couple therapy aims to understand the nature of interactions between the patient and their partner and modify them to make the relationship more mutually supportive.
  • It is significantly more effective than a waiting list control and as effective as cognitive behavior therapy.

Dynamic Psychotherapy

  • Dynamic psychotherapy aims to resolve underlying developmental conflicts and attendant life difficulties that are believed to be causing or maintaining the depressive disorder.
  • It has been shown to have equivalent benefit in depressed patients for short-term psychodynamic therapy compared to other psychotherapies.

Other Treatments

  • Sleep deprivation can bring about rapid short-term changes in mood, but the alleviation of depressed mood is nearly always temporary.
  • Bright light treatment has been shown to be effective in treating winter depression, with an onset of antidepressant effect within 2–5 days.
  • Bright light treatment may also be effective in non-seasonal depression, particularly in elderly people with depression.

Relapse and Recurrence of Mood Disorders

  • Mood disorders often recur, and if left untreated, have a poor long-term prognosis
  • There is an increasing emphasis on long-term management, including prevention of relapse and recurrence
  • Relapse refers to the worsening of symptoms after an initial improvement during treatment, whereas recurrence refers to a new episode after a period of complete recovery

Prevention of Relapse and Recurrence

  • Treatment to prevent relapse is called continuation treatment, and treatment to prevent recurrence is called prophylactic or maintenance treatment
  • Continuation therapy for 6 months past the point of remission halves the relapse rate
  • Treatment should be at the originally effective dose of medication if possible
  • Continuation of antidepressant treatment for longer than 6 months confers little extra benefit, except in the elderly, where continuation therapy for 12 months is more appropriate

Maintenance Treatment

  • Maintenance antidepressant treatment can substantially reduce relapse rates
  • Lithium carbonate has also been used in the prevention of recurrent unipolar depression, but the overall evidence for its efficacy is less robust
  • Maintaining the dose of medication at the level that was required to achieve remission appears most effective in prophylaxis if tolerability permits
  • Lithium together with the antidepressant appears worthwhile in some patients

Cognitive Therapy

  • Cognitive therapy given during an acute phase of depression leads to a more sustained improvement in depressive symptomatology and lessens the risk of subsequent relapse compared to antidepressant drug treatment
  • Cognitive behavioural therapy continued (or started) after remission prevents relapse, perhaps to a greater extent than maintenance medication
  • Mindfulness-based cognitive therapy (MBCT) integrates cognitive behaviour therapy with meditation techniques and is as effective as maintenance antidepressant treatment in preventing relapse

Interpersonal Therapy

  • Combining interpersonal therapy with medication in the treatment of the acute episode appears to decrease relapse rates over the following 12 months
  • The effect of continuation treatment with combined interpersonal therapy and medication has also been studied in older depressed patients
  • Continuation therapy with interpersonal therapy as a sole treatment prevents recurrence

Assessment of Depressive Disorders

  • The aims of assessment are to decide whether the diagnosis is depressive disorder, judge the severity of the disorder, form an opinion about the causes, assess the patient's social resources, and gauge the effect of the disorder on other people
  • Diagnosis depends on thorough history-taking and examination of the physical and mental state
  • Particular care should be taken not to overlook a depressive disorder in patients who do not complain spontaneously of being depressed ('masked depression')

Management of Depressive Disorders

  • The first question concerns the level of care and supervision that may be required, which depends on the severity of the disorder and the quality of the patient's social resources
  • Patients who live alone, or whose families cannot care for them during the day, may need intensive community treatment or day-patient care
  • Involvement of the family wherever possible is likely to improve the outcome
  • The need for antidepressant drug treatment should be considered, particularly for patients with a major depressive syndrome of at least moderate severity

Choice and Use of Antidepressant Drugs

  • SSRIs are the usual first choice for antidepressant treatment, unless the patient has done well previously with a different agent.
  • Lofepramine, a tricyclic antidepressant, is another option with a different side effect profile.
  • Mirtazapine may be considered if the patient needs concomitant sedation or if there are relative contraindications to the use of SSRIs.

Dosage and Precautions

  • The dosage of antidepressant drugs should be as prescribed, and the patient should be warned about the effects of taking alcohol.
  • Patients should be advised about driving, particularly that they should not drive while experiencing sedative side effects or any other effects that might impair their performance in an emergency.

Electroconvulsive Therapy (ECT)

  • ECT is rarely part of first-line treatment of depression and is usually considered only for patients who have already been admitted to hospital.
  • ECT is indicated for patients who refuse to drink enough fluid to maintain adequate urine output, those who present a highly dangerous suicidal risk, or those suffering extreme distress.

Activity

  • Suitable activity should be considered for every patient to prevent social withdrawal and deprivation of social stimulation and rewarding experiences.
  • The type and amount of activity should be tailored to the individual patient and adjusted as the illness runs its course.

Psychotherapy

  • The appropriate kind of psychological treatment should be decided in each case, taking into account the patient's preferences and the availability of suitably trained therapists.
  • Cognitive behaviour therapy (CBT) and interpersonal therapy are evidence-based treatments for moderate to severe depression.
  • CBT can be added to antidepressant medication to enhance therapeutic response.

Failure to Respond to Initial Treatment

  • If a depressive disorder does not respond to initial treatment, the plan should be reviewed, and the patient's medication adherence and diagnosis should be reassessed.
  • The treatment plan can be adjusted by increasing the dose of antidepressant medication, switching to a different medication, or adding another medication.

Switching Antidepressant Medications

  • If a patient does not respond to one antidepressant, the first step is usually to stop the first medication and try another.
  • Switching to a different class of drug (e.g., from SSRI to mirtazapine or venlafaxine) may be marginally better than switching to a second SSRI.

Combination Treatment

  • Combination strategies aim to supplement the antidepressant effect of an ineffective or partially effective medication with another antidepressant agent.
  • The evidence for combination treatment is limited, but it is endorsed in case series and expert reviews.

Augmentation of Antidepressant Drug Treatment

  • Augmentation therapy involves adding a second compound to the antidepressant to enhance therapeutic response.
  • Antipsychotic drugs, lithium, and other agents can be used for augmentation therapy.
  • The evidence for augmentation therapy is limited, and the approach should be used with caution due to the increased risk of adverse effects.

Lithium Augmentation

  • Lithium can be effective in the treatment of resistant depression, and about 50% of depressed patients will show a useful response over 1–3 weeks.
  • Lithium can be added to any primary antidepressant medication with good effect, although combination with SSRIs and venlafaxine should be undertaken with caution.

Tri-iodothyronine (T3) Augmentation

  • T3 can be added to ineffective tricyclic antidepressant treatment to bring about a clinical response, even in patients with normal thyroid activity
  • Dose of 20-40 μg daily, starting with 10 μg and increasing to 20 μg after 1 week if tolerated
  • Mild side effects, including tremor and sweating, but not recommended for patients with cardiovascular disease

Electroconvulsive Therapy (ECT)

  • Considered for severe depression that persists despite antidepressant treatment
  • ECT is more effective than drugs in severe depressions, particularly when psychotic features are present
  • Meta-analysis suggests that medication resistance lowers the response rate to ECT (48% vs 65%)
  • Relapse rate in the year after ECT can be as high as 50% if patients continue on the same antidepressant medication

Post-ECT Prophylaxis

  • Combination of lithium and nortriptyline or maintenance ECT can be effective in sustaining remission
  • However, relapse rate is still high, with around 50% of patients relapsing in 6 months

Continuing Support and Other Measures

  • Continuing support is essential for patients who do not respond to treatment
  • Reassurance and discussion of problems contributing to depression can be helpful
  • Structured psychotherapies, such as cognitive behaviour therapy, can be effective in bringing about a therapeutic response
  • Watching for suicidal intentions is important, particularly in patients with prolonged depression
  • Other treatment approaches, such as deep brain stimulation and neurosurgery, can be considered for severe symptoms and longstanding refractory illness

Prevention of Relapse and Recurrence

  • Following recovery, patients should be followed up for several months by the psychiatric team or general practitioner
  • Antidepressant medication should usually be continued for about 6 months and then gradually withdrawn over several weeks
  • Watching for signs of discontinuation reactions or relapse is important
  • Involving relatives in the plan can be helpful
  • Maintenance treatment should be considered for patients with a history of recurrence, particularly if there is a family history of recurrent major depression

Maintenance Treatment

  • Long-term maintenance treatment may be necessary due to the high recurrence rate of major depression (90% in patients with three previous episodes)
  • Factors to consider include the likely impact of recurrence, previous response to drug treatment, and the patient's view of long-term drug treatment
  • Choice of medication depends on response in the acute or continuation phase of treatment
  • Lithium can be effective for long-term maintenance treatment of recurrent depression, particularly in patients with a history of manic episodes

Criteria for Depressive Episode in ICD-10

  • A Depressed Mood is a necessary criterion for a depressive episode
  • Loss of Interest and Enjoyment is another essential criterion for a depressive episode
  • Reduced Energy and Decreased Activity is the third criterion for a depressive episode

Additional Criteria

  • Reduced Concentration is a symptom of a depressive episode
  • Reduced Self-Esteem and Confidence is a symptom of a depressive episode
  • Ideas of Guilt and Unworthiness are a symptom of a depressive episode
  • Pessimistic Thoughts are a symptom of a depressive episode
  • Ideas of Self-Harm are a symptom of a depressive episode
  • Disturbed Sleep is a symptom of a depressive episode
  • Diminished Appetite is a symptom of a depressive episode

Classification of Depressive Episodes

  • Mild Depressive Episode: at least two symptoms from A and at least two symptoms from B
  • Moderate Depressive Episode: at least two symptoms from A and at least three symptoms from B
  • Severe Depressive Episode: all three symptoms from A and at least four symptoms from B
  • Severity of symptoms and degree of functional impairment also guide classification of depressive episodes

Multifactorial Origin of Mood Disorders

  • Mood disorders have a multifactorial origin, involving genetic, environmental, and psychological factors.
  • Multiple genes with small individual effects contribute to mood disorders.
  • Genetic contributions can affect mood disorders directly through cortical circuitry modification or indirectly through personality and psychological coping mechanisms.

Early Life Experiences and Mood Disorders

  • Adverse early life experiences shape personality and limit subsequent attachment behavior and social support access.
  • Early life experiences can affect the development of the hypothalamic–pituitary–adrenal (HPA) axis and neurobiological responses to stress in adulthood.

Triggering Factors and Vulnerability

  • Depressive disorders are often triggered by current life events, particularly in individuals lacking social support.
  • The impact of life events is modified by early life experience, personality, and genetic inheritance.
  • The interaction of these factors determines an individual's resilience or vulnerability to a life event and subsequent risk of clinical mood disturbance.

Neurobiology of Depression

  • The neurobiology of depression episodes is associated with changes in monoamine neurons and HPA axis activity.
  • These changes modify the activity of neural circuitry involved in emotional regulation.
  • At a cellular level, depression may involve a loss of synaptic plasticity and dendrite formation.

Brain Abnormalities in Mood Disorders

  • Structural and functional brain abnormalities in mood disorders suggest persistent biological vulnerability.
  • This vulnerability is likely produced by genetic inheritance or early developmental factors.

Psychoanalytical Theory of Depression

  • Sigmund Freud's paper "Mourning and Melancholia" (1917) highlights the similarities between mourning and depressive disorders, suggesting a common cause.
  • Freud proposes that melancholia results from a loss of an "object" (an internal representation or abstraction), not just a physical loss, due to the absence of actual loss in some depressed patients.
  • Depressed patients often exhibit self-criticism, which Freud believes is a disguised accusation of someone else they feel affection for, indicating ambivalence (love and hostility simultaneously).

Object Relations and Depression

  • Melanie Klein develops Freud's ideas, suggesting that weaning (loss of the breast) represents a significant symbolic loss for the infant, leading to feelings of remorse and guilt.
  • In normal development, this "depressive anxiety" motivates attempts at reparation and concern for others.
  • Failure to navigate this process can result in depressive reactions to future losses.

Attachment Theory and Depression

  • John Bowlby's work shows that the main caregiver's rearing abilities play a crucial role in shaping the infant's secure emotional attachment.
  • Secure attachment is essential for developing satisfactory interpersonal relationships, and insecure attachments can increase the risk of adult psychopathology, including depression.

Abnormalities in Monoamine Activity in Depression

  • 5-HT (Serotonin) shows decreased plasma tryptophan levels in individuals with depression
  • Blunted 5-HT neuroendocrine responses are observed in depressed individuals
  • Decreased brain 5-HT1A receptor binding is evident in Positron Emission Tomography (PET) scans
  • Decreased brain 5-HT reuptake sites are seen in Single Photon Emission Computed Tomography (SPET) and PET scans
  • Clinical relapse occurs after tryptophan depletion, suggesting a link between 5-HT and depression

Noradrenaline Abnormalities in Depression

  • Blunted noradrenaline-mediated growth hormone release is observed in depressed individuals
  • Clinical relapse occurs after administration of α-methyl-para-tyrosine (AMPT), indicating noradrenaline's role in depression

Dopamine Abnormalities in Depression

  • Decreased homovanillic acid (HVA) levels are seen in cerebrospinal fluid of depressed individuals
  • Clinical relapse occurs after administration of α-methyl-para-tyrosine (AMPT), suggesting dopamine's involvement in depression

Immune Changes in Depression

  • Lymphocytes exhibit lowered proliferative responses to mitogens
  • Natural killer cell activity is decreased
  • Levels of positive acute phase proteins are increased
  • Inflammatory cytokine levels are elevated, including:
    • IL-6 (interleukin 6)
    • TNFα (tumor necrosis factor alpha)
  • Indoleamine 2,3-dioxygenase is induced

Neuropsychological Correlates of Depression

  • Dorsolateral prefrontal cortex: Altered cerebral perfusion and metabolism are associated with cognitive dysfunction, particularly executive dysfunction, in depressed patients.
  • Dorsomedial prefrontal cortex: Impaired voluntary regulation of emotion is linked to altered cerebral perfusion and metabolism in this region.
  • Medial prefrontal cortex: Abnormal emotional processing is correlated with altered cerebral perfusion and metabolism in this region.
  • Anterior cingulate: Impaired attentional processes and altered emotional salience are associated with altered cerebral perfusion and metabolism in this region.
  • Amygdala: Abnormal emotional processing is linked to altered cerebral perfusion and metabolism in this region.
  • Ventral striatum: Impaired incentive behavior and psychomotor disturbances are correlated with altered cerebral perfusion and metabolism in this region.

Pharmacological Treatments for Resistant Depression

  • Maximizing antidepressant dosage to the highest tolerable level is a treatment option.
  • Adding an antipsychotic drug is recommended for patients with depressive psychosis.
  • Switching to a different class of antidepressant, such as venlafaxine or tricyclic antidepressants, may be effective.
  • Combining antidepressants, such as an SSRI with mirtazapine, or venlafaxine with mirtazapine, is a potential treatment strategy.
  • Adding an atypical antipsychotic drug to an SSRI or venlafaxine may improve treatment outcomes.
  • Lithium can be added to antidepressant drug treatment to enhance its effectiveness.
  • Monoamine oxidase inhibitors (MAOIs) can be used in combination with lithium to treat resistant depression.
  • Electroconvulsive therapy (ECT) is a treatment option for severe cases of resistant depression.

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This chapter focuses on depressive disorders, distinguishing them from normal feelings of unhappiness and symptoms of other disorders. Learn about the central features of these syndromes.

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