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Taking a history of DEPRESSION

30/10/2007

Core symptoms of depression are: ---LOW MOOD


--- ANERGIA *(needed for diagnosis)
--- ANHEDONIA

* Must have 2/3 of these symptoms, one of which should be anhedonia

Physical changes in depressed patients:


MRI – Hippocampal atrophy in severely depressed patients (reversed with
antidepressants!)
fMRI -cognitive areas depressed, 5-HT neurones smaller and decreased function
compared to normal individuals.
- Upregulation of 5-HT receptors to compensate.

Statistics

* 1/6 people will have a severe depressive episode


* X2 risk of dying early
* 30% people with major (severe) depression actually get treated
* ECT – effective treatment for suicidal/psychotic, untreatable depression
* Deep Brain Stimulation (similar to PD treatment)
* Transcranial Magnetic

20ish clinical symptoms of depression

1. Sleep pattern change (typically EMW ->2hrs before normal)


2. Appetite change (typically ↓) Biological
3. Libido change (typically ↓) features

4. Low mood – consider diurnal variation in mood


5. Anergia - fatigue Core
6. Anhedonia features

7. Loss of concentration
8. Memory impairment Psychological
9. Psychomotor retardation features
10.Low self-esteem
11.Dichotomous thinking
12.Loss of confidence

13.Beck’s Cognitive Triad – helplessness, worthlessness,


hopelessness (world, self, future)

14.Hallucinations – typically auditory


(2nd person more common) – hostile, critical Psychotic
15.Delusions – nihilistic, persecutory, guilt features

16.Deliberate Self Harm/neglect Risk


17.Suicidal ideation assessment
ICD-10 Classification of depression

Time frame Mild (2, 2)


Symptoms Moderate (2, 3)
Function Severe ± Psychotic symptoms (2, 4)

Also! Older classification into


• Endogenous – depressed for no reason (=genetics?)
• Reactive – result of social circumstances 9e/g/ divorce, unemployment)

General Tips
NB. DO NOT SHAKE HANDS WITH – Depressed, manic, or OCD patients
Always enquire about sleep in detail e.g. when do you normally wake up?

Taking the History


1. Introduction, establish rapport etc
2. Ask open questions (e.g. I understand you’ve come to the GP today
because….could you just tell me a little more about that?)
3. Ask about ONSET (when did these problems start? Is there anything that
you can think of that might have triggered these feelings?)
4. Enquire about alterations in MOOD, ENERGY and INTEREST (core
symptoms)
a. Mood – How have you been feeling recently? Ask about diurnal
variation.
b. Anhedonia - Have you lost interest In doing things that you used to
enjoy?
c. Anergia- How do you find your energy nowadays?
5. Enquire about Physiological function
a. Sleep – Have you had any trouble getting off to sleep in the last few
weeks? Have you noticed any change in your sleeping patterns
recently? Do you wake up early in the mornings?)
b. Appetite/weight (what has your appetite been like recently? Has
there been a recent change in your weight?)
6. Elicit any of the patient’s concerns
a. Do you have any concerns about how you’ve been feeling recently?
b. I can see that this is really difficult for you – how have you been
coping with it all?!....NB. Could lead to ALCOHOL and related
issues!.
7. Ask about any triggers (e.g. relationships, family, work stressors)
a. Is there anything that you can think of that might have triggered
these feelings?
b. Have you been under pressure at hoem or at work?
c. Is there anyone at all that you feel you can talk to about this?
8. Ask about psychological symptoms
a. Anxiety – have there been times lately when you’ve fely very
anxious or frightened?)
b. Bipolar – have there been times (other occasions) when you’ve felt
the opposite e.g. elated, really happy?
c. Psychomotor retardation – have you noticed a change in your
movements and reactions recently? Do you seem to have slowed
down in your movements or have too little energy?)
d. Concentration - have you had any trouble concentrating on
things/work recently?
9. Assess suicidality
a. Do you feel that life is still worth living? Have there been any times
when you’ve just wished that you could end it all? Have you ever
acted on these feelings? What did you think that you actually might
do? HAVE YOU ACTUALLY TRIED IT?).

10.Ask about hopelesseness


a. How do you see the future?
b. Have you given up, or does there still seem to be some reason to
keep trying?
11.Elicit Past psych History
a. Aks what, when, duration of care, diagnosis, precipitants, treatment,
outcome
12.Elicit Past Medical History and any accidental injuries
13.Elicit Family Psych Hx
a. To your knowledge is there anyone in your family who has had to
see a psychiatrist/with mental illness?
14.Drug History
a. Specifically ask about ALCOHOL and substance misuse.
b. Allergies!

ABOVE ALL!
Show empathy and listen to the patient!
Always make use of REFLECTION (because it shows empathy and opens up to
new discussion)

Interviewing technique
All depends on your attitude towards the patient and towards depression (try to
empathise)
STRUCTURE – Have a skeleton framework

Minute 1: Just listen to the patient and be empathetic


Minute 2: Open Question – main ideas, concerns and expectations
Minute 3-4: clarifying questions – try to elicit symptoms to include differentials
(e.g. bipolar)
Minute 4-5: Scan for psychotic symptoms, risk factors and suicidal ideation
Minute 5-6: Family Hx, Drug Hx and regular medication -try to SUMMARISE