Mental Health
Question 34 of 180
A 54 year old man presents to the Emergency Department seeking help for his low mood. He tells you his mood has been declining over the past 3 months. In the last week he has been having suicidal thoughts. Which of the following is NOT a typical feature of depression?
Answer:
Depression is defined in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the presence of at least five out of a possible nine defining symptoms, present for at least 2 weeks, of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.- Persistently low mood
- Loss of pleasure or interest in normal activities
- Disturbed sleep (decreased or increased compared to usual).
- Decreased or increased appetite and/or weight.
- Fatigue/loss of energy.
- Agitation or slowing of movements.
- Poor concentration or indecisiveness.
- Feelings of worthlessness or excessive or inappropriate guilt.
- Suicidal thoughts or acts.
Depression
Mental Health
Last Updated: 12th February 2021
Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.
Risk factors
The cause of depression is unknown, but is likely to result from a complex interaction of biological, psychological, and social factors. Factors that may increase the risk of depression include:
- Chronic comorbidities (such as diabetes mellitus, chronic obstructive pulmonary disease, cardiovascular disease and especially people with chronic pain syndromes).
- Medicines (for example, corticosteroids).
- Female gender.
- Older age.
- Recent childbirth.
- Psychosocial issues such as divorce, unemployment, poverty, homelessness.
- Personal history of depression.
- Genetic and family factors — a family history of depressive illness.
- Adverse childhood experiences (for example, poor parent-child relationship, physical or sexual abuse).
- Personality factors (for example, neuroticism).
- A past head injury, including hypopituitarism following trauma.
Clinical features
Depression is defined in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the presence of at least five out of a possible nine defining symptoms, present for at least 2 weeks, of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Persistently low mood
- Loss of pleasure or interest in normal activities
- Disturbed sleep (decreased or increased compared to usual).
- Decreased or increased appetite and/or weight.
- Fatigue/loss of energy.
- Agitation or slowing of movements.
- Poor concentration or indecisiveness.
- Feelings of worthlessness or excessive or inappropriate guilt.
- Suicidal thoughts or acts.
Depression questionnaires can be helpful in detecting depression and in assessing severity, but should not be used alone to determine the presence of depression which needs treatment. The severity of depression is determined by both the number and severity of symptoms, as well as the degree of functional impairment.
Differential diagnosis
- Grief reaction
- Anxiety disorders
- Bipolar disorder
- Premenstrual dysphoric disorder
- Neurological conditions, such as Parkinson's disease, multiple sclerosis, dementia
- Substances and adverse drug effects
- Hypothyroidism
- Obstructive sleep apnoea syndrome
Complications
- Exacerbation of the pain, disability, and distress associated with a range of physical diseases.
- Reduced quality of life for the person and their families.
- Increased morbidity and mortality in a range of comorbid conditions including coronary heart disease and diabetes mellitus.
- Increased risk of suicide and self-harm
- Suicide is the main cause of the increased mortality of depression and is commonest in those with comorbid physical and mental illness.
- Two-thirds of people who attempt suicide are experiencing depression.
- There is a four-times higher risk of suicide in depressed people compared with the general population, and the risk of suicide is nearly 20-times higher in the most severely ill.
- Impaired ability to function normally, which may result in:
- Limited ability to carry out activities of daily life.
- Employment problems – for example, due to loss of productivity, or absenteeism.
- Neglect of dependants.
- Family problems and relationship break-ups.
- Increased risk of substance abuse.
Risk assessment
- When assessing the risk of suicide, ask the person:
- Do you have thoughts about death or suicide?
- Do you feel that life is not worth living?
- Have you made a previous suicide attempt?
- Is there a family history of suicide?
- If the answer to any of these questions is yes, ask about their plans for suicide:
- Have you considered a method?
- Do you have access to the materials?
- Have you made any preparations (for example, written a note)?
- Also ask about any protective factors (including coping strategies, supportive relationships, dependent children, religious beliefs), for example:
- What keeps you from harming yourself?
- Is there anything that would make life worth living?
- Identify risk factors that increase the risk of suicide — these include:
- Previous suicide attempts or self-harm. Consider history and frequency of any past self-harm, medical seriousness, use of violent methods, evidence of planning, such as suicide note or changes to will, and precautions taken to prevent rescue.
- Active mental illness.
- Family history of mental disorder, suicide or self-harm.
- Low socioeconomic status.
- Male gender.
- Being unemployed.
- Physical health problems.
- Living alone.
- Being unmarried.
- Abusive or violent relationships.
- Drug/alcohol dependence.
- Feelings of hopelessness.
- Exposure to suicidal behaviour.
- High risk groups include:
- Young and middle-aged men.
- People in contact with the criminal justice system.
- Specific occupational groups, for example, doctors, nurses, veterinary workers, farmers, agricultural workers.
- If there is a risk of self-harm or suicide:
- Assess whether the person has adequate social support and is aware of sources of help.
- Assess whether there are any dynamic risk factors that can be treated (for example, mental illness, use of alcohol or illicit drugs).
- Arrange help appropriate to the level of risk.
- Advise the person to seek further help if the situation deteriorates.
- Assess for any safeguarding concerns in children, young people, or vulnerable adults dependent for their care on the person presenting with an episode of self-harm.
- If a person with depression presents considerable immediate risk to themselves or others, refer them urgently to specialist mental health services.
- If the person is considered at low risk, discuss and/or create a safety plan with them, detailing steps they should take if their situation deteriorates.
Bipolar affective disorder
Bipolar disorder (also known as bipolar affective disorder or manic depressive disorder) is a serious long-term mental illness, which is usually characterised by episodic depressed and elated moods and increased activity (hypomania or mania):
- Manic episode
- A manic episode is a distinct period during which there is abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by at least three additional symptoms, and which is severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalisation, or includes psychotic features such as delusions or hallucinations. Additional symptoms include:
- Increased energy or activity, restlessness, and a decreased need for sleep.
- Pressure of speech or incomprehensible speech.
- Flight of ideas or racing thoughts.
- Distractibility, poor concentration.
- Increased libido, disinhibition, and sexual indiscretions.
- Extravagant or impractical plans.
- Psychotic symptoms: delusions (usually grandiose) or hallucinations (usually voices).
- A manic episode is a distinct period during which there is abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by at least three additional symptoms, and which is severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalisation, or includes psychotic features such as delusions or hallucinations. Additional symptoms include:
- Hypomanic episode
- A hypomanic episode is similar to a manic episode except that a diagnosis only requires that symptoms have lasted for 4 days, the episode is not severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalisation, and there are no psychotic features.
- Depressive episode
- A depressive episode is a period of at least 2 weeks during which there is either depressed mood, loss of energy, or loss of interest or pleasure in nearly all activities, accompanied by at least four additional symptoms.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
