Topic 1 (Diagnosis of depression)

• Must last two weeks with symptoms present nearly everyday
• Episode cannot be contributed to substances such as alcohol or an organic illness.
• Loss of pleasure in activies usually found pleasurable
• Decreased energy
• Loss of self-esteem/confidence
• Unreasonable feelings of guilt
• Recurrent thoughts of death/suicide
• Inability to concentrate and more indecisiveness
• Changes in psychomotor activitive such as agitiation or lethargy
• Sleep disturbances
• Changes in appetite along with weight change (gain or loss)

Subtypes of depression disorder

• Major Depressive Disorder
  • Severe but short lived
  • Can be accompanied by symptoms such as delusions or hallucinations
  • Can be diagnosed as 'Major Depressive Episode with pyschotic symptoms'
• Dysthmyic Disorder
  • Less severe, but chronic
  • Longer than 2 years with less than 2 months without symptoms.
• Bipolar Disorder
  • Swings between two extremes of mania and depression
    • Mania is characterised by excessive, unreasonable elation and hyperactivity.
      • This can include needing little sleep, ideas of grandiose and disinhibition.
  • Change of moods can occur in cycles of days/weeks/months.

Paykel et al (2005)

• 5% of Europeans are experiencing clinical depression at any one time.

Angst (1999)

• 17% of the European population will experience depression at some point during their life.

Onset of depression normally occurs during 20-50 years, however there is a rise in major depressive disorders in those under the age of 20. This is because those aged 20-50 are subject to more stressors at work and with families. A rise in depression in those under the age of 20 could be a result of social media and exams.

Bipolar disorder is less common than major depression, it occurs in less than 10 per 1,000 people.

Keller et al (1984)

• Woman are twice as likely to be diagnosed with depression than men. This has historical bias.

Underlying causes

• Endogenus depression is caused by internal, biological mechanisms.
• Reactive depression is caused as a response to external stressors.
• This differentiation helps with treatement, but not diagnosis.

Types of symptoms

• Melancholic/Somatic Symptoms
  • Biological changes such as appetite changes, reduced sex drive, changes in sleep patterns, eg. 
  • It can be hard to identify if a person has melancholic depression as most people have some physical symptoms of depression.
  • Parker et al (1999) melancolic depression is associated with the more severe physical symptoms, poor response to placebo medication and good response to ECT.

Course of the disorder

• Seasonal Affective Disorder is when symptoms are apparent in the winter months.
• Brief Recurrent Depression is when episodes are short but frequent.

Validity of diagnosis criteria

• Not all subtypes of depression have being validated
  • Premenstrual dysphoria disorder shares some characteristics of depression, but also anxiety and very specific physical symotoms. It is only included in the appendix to help physicans investigate the validity of the syndrome.

Lack of reliable signs

• There is no objective measure to confirm the diagnosis of a mental disorder
• Experiences clinicians take a careful history from patients and consider the patient from many angles before deciding on a diagnosis.
• Body language and how the patient presents themselves is often a telling sign, depressed people often have low blink rate, furrowed eyebrows, bent shoulders and downward gaze.
  • Many people with depression will often try and avoid being diagnosed with depression and will try to conceal their low moods from people, this can make it harder to spot depression.

Who makes the diagnosis?

• Pyschiatrists treat people with mental disorders in hospitals and outpatient clinics.
• In the UK, people normally see their GP who refers them to a psychiatric if needed.
• Goldberg and Huxley (1992), about 50% of people displaying depressive symptoms when they see their GP are not diagnosed with depression.
  • GPs are not specialised in mental disorders and can miss key signs of depression.

• General sadness
  • People display sadness as an emotion as a normal reaction to life events.
  • Depression should only be diagnosed when the criteria is clearly met.
• Depression or anxiety?
  • Mild Depression can be difficult to distinguish from anxiety depression. It is important to diagnose the correct disorder as they have different treatments.
• Depression or dementia? (in older patients)
  • People with depression often perform badly on cognitive functioning tests.
  • A diagnosis of dprression rather than dementia can sometimes only be given when the patients mood improves and cogntivie functioning is restored.
• Depression and physical illness?
  • Sometimes depression is the side effect of phsyical illnesses such as hypothyroidism (the thyriod gland doesn't work properly). In these cases, depression disappears when the phsycial condition is treated.
• Depression in Children
  • Depression can often go undiagnosed because other problems such as conduct disorders are present, these can mask symptoms of depression.
  • Children can show different symptoms to adults; childhood depression is characterised by irritability. 

• Some argue that depressed and sad moods are normal reactions to human life and it is wrong to classify these moods as illnesses.
  • Others argue that depression can be extremely distressing and can lead to suicide so accurate diagnosis can lead to treatment and relief.
• Depression often appears alongside other mental disorders (co-morbidity).
  • Disorders found alongside depression include anxiety, schizophrenia, eating disorders and substance abuse.
    • The primary disorder must be identified and treated first, this can sometimes be difficult.
      • Maj (2005) suggested multi-axial classification system of the DSM encourages multiple diagnoses to be made when it is not appropriate to do so.
• Rates of major depression are twice as high in females that males (across culures).
  • Some have suggested this is a reflection on diagnosis practices rather than true gender differences.
  • It is more acceptable for women to ask for help and be seen with depression than it is for men.

• Clinicians should be aware of the patient's cultural and social background.
  • People from social minorities have a higher level of mental health disorders than others.
    • It is not clear whether this is a genetic vulnerability, psychosocial factors of being associated with being part of a social minority group, or misdiagnosis.
      • Clinicians could misinterpret cultural differences in behaviour and expression as symptoms of depresison.
• People from Eastern cultures place emphasis on the physical symptoms of depression.
  • Kua et al (1993) found 72% of people in China who presented with chest/adominal pains or headaches were later found to have a mental health problem.
  • Patients did not mention the emotional symptoms when first presented due to the stigma associated with emotional or mental weakness.