Mental state examination

Appearance (Figure 9.2). Depressive facies typically include downturned eyes, sagging of the corners of the mouth and, often, the presence of a vertical furrow between the eyebrows. The patient usually makes poor eye contact with the interviewer. There may be direct evidence of weight loss, with the patient appearing emaciated and perhaps dehydrated. Indirect evidence of recent weight loss may be clothes appearing to be too large. Evidence of poor self-care and general neglect may include an unkempt appearance, poor personal hygiene and dirty clothing.

Figure 9.2 • Features typically seen in patients suffering from a depressive episode.

Behaviour. Psychomotor retardation typically occurs.

Speech. This is slow, with long delays before answering questions.

Mood. This is characteristically low and sad, with feelings of hopelessness; the future seems bleak. Anxiety, irritability and agitation may also occur. The patient may complain of reduced energy and drive, and an inability to feel enjoyment. There is a loss of interest in normal activities and hobbies.

Thoughts. Pessimistic thoughts concerning the patient’s past, present and future occur. For example, minor misdemeanours in the past, such as taking home an office pencil many years ago, may be exaggerated out of all proportion and used as ‘proof’ that the patient is evil and undeserving of current status in life. The patient may suffer from delusions of poverty or illness. Suicidal thoughts may occur and should be ascertained. Homicidal thoughts may also be present. For example, a depressed mother may decide the future is equally bleak for her children and plan to kill them before committing suicide. Similarly, an elderly depressed man may persuade his wife to enter into a suicide pact.

Perceptions. In severe depressive episodes mood-congruent auditory hallucinations may occur. They are typically second person and derogatory in content. For example, the depressed patient may hear sentences such as ‘You are an evil, sinful man’; ‘You should die’.

Cognition. Poor concentration may lead the patient to think (mistakenly) that memory is also impaired. In elderly patients the presentation of depression may be very similar to that of dementia; this is known as (depressive) pseudodementia (see Chapter 20).

Depressive stupor

The patient exhibits features of stupor, being unresponsive, akinetic, mute and fully conscious. (Details of the differences between depressive stupor and neurological stupor are given in Chapter 5.) Following an episode of stupor the patient can recall the events that took place and the depressed mood at the time. Episodes of excitement may take place between episodes of stupor. Owing to effective treatment regimens now available, depressive stupor is only rarely seen.

Masked depression

Depressed patients may not always present with a depressed mood, but may instead present with somatic or other complaints. They may somatize their depressed mood owing to cultural factors (see Chapter 19), or indeed may not be able to articulate their emotions, as in the case of patients with severe learning disability (see Chapter 17) and elderly patients with dementia (see Chapter 20). In such cases, the presence of biological symptoms of depression is particularly helpful in making the diagnosis. In the case of learning disability, diurnal variation in abnormal behaviour may be observed and mirror diurnal variation in mood. The effective treatment of masked depression usually leads to a resolution of the somatic or other presentations.

Seasonal affective disorder (SAD)

In SAD there is a regular temporal relationship between the onset of depressive episodes and a particular time or season of the year. This often takes the form of untreated depressive episodes, commencing in the autumn or winter months and ending in the spring or summer months as the hours of daylight increase in each 24-hour cycle. The onset of bipolar disorders may also be seasonal. During depressive episodes, patients with SAD often exhibit carbohydrate craving, hypersomnia and weight gain; in these they differ from symptoms more typical of depression.

Cases in which there is a clearly distinguished seasonal psychosocial stressor, such as becoming depressed each winter because of regular winter unemployment, are excluded from the category of SAD.

Other types of depression

Agitated depression can occur in the elderly and is considered in Chapter 20. Neurotic depression or dysthymia is considered below. Another neurotic disorder, known as mixed anxiety and depressive disorder or anxiety depression, in which both anxiety and depressed mood are present but neither is clearly prominent, is considered in Chapter 10.

Hospitalization

Less severe depressive episodes can be treated by GPs in the community or by psychiatrists in outpatient clinics. However, patients suffering from severe episodes should be admitted to hospital. This may need to be compulsory if severe life-threatening features are present, such as a risk of suicide or poor intake of food and fluids.

Physical treatments

Pharmacotherapy. The mainstay of physical treatment is antidepressant medication. As detailed in Chapter 3, there are now available many antidepressants which are relatively safe in overdose, such as those belonging to the selective serotonin reuptake inhibitor (SSRI), serotonin–noradrenaline reuptake inhibitor (SNRI), noradrenaline reuptake inhibitor (NARI), reversible inhibitor of monoamine oxidase A (RIMA) and noradrenergic and specific serotonergic antidepressant (NaSSA) groups. (There is some evidence that many antidepressants may actually be only marginally more effective than placebos in treating depression. The reader is referred to the excellent book by Professor Irving Kirsch (see Further reading). It may not be a good idea to mention this in psychiatry examinations though.) Certain antidepressants, particularly SSRIs, may actually increase the risk of suicide. The 58^th edition (2009) of the British National Formulary (BNF) warns: ‘The use of antidepressants has been linked with suicidal thoughts and behaviour; children, young adults, and patients with a history of suicidal behaviour are particularly at risk. Where necessary, patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed.’

Electroconvulsive therapy (ECT). In the following relatively uncommon circumstances, ECT may be considered as a first-line treatment:

It may be considered in severe depression associated with:

Psychosurgery. In extremely rare cases, when all other treatments have failed, the extreme option of psychosurgery may be considered in severe chronic handicapping depression.

Phototherapy. For those patients suffering from SAD in whom the onset of depression is in the autumn or winter months, treatment with high-intensity light is possible.

Psychosocial treatments

Cognitive behavioural therapy (CBT). CBT has been found to be effective for mild to moderate depression. Unlike antidepressants, it clearly does not have any drug-related side-effects. Therefore, where eadily available, CBT should be considered as a first choice treatment in non-severe cases of depression. If a practitioner is not available, then CBT can be delivered in a self-help format, such as:

Other psychotherapies. A number of other different types of psychotherapy are available for mildly or moderately depressed patients or for patients who have recovered from severe depressive episodes. These include: group therapy; psychoanalytic psychotherapy; and, in the case of family or marital difficulties, family therapy and marital therapy. All can be used in combination with pharmacotherapy.

Increased activity and social contact. It is important not to allow depressed patients to withdraw totally from work and social activities. Instead, they should be encouraged gradually to increase such activities. Meeting other people and developing confiding relationships has a protective function in preventing relapse. Occupational therapy can be useful in enabling depressed inpatients to learn to cope with life skills such as cooking.