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Major depressive episode

Clinical Discipline(s)/Organ System(s)
Psychiatry/Health Psychology, General Practice
Progress Test Topic(s)
Mental health
Description
You have a regular patient at your practice, an 87 year old NZ European widow and retired school principal, whom you see about every three months. She has a history of controlled hypertension. She has two adult children who live overseas and with whom she has occasional contact. She presents with complaints of initial, middle and terminal insomnia, progressive weight loss, memory and concentration difficulties, and worry over the past six months. She relates these changes to her dog’s recent serious illness, but notes the dog survived. She adds that if her dog died she'd have little to live for. She denies being depressed claiming she 'doesn't agree with depression - I have no time for self-pity!' She reports drinking 2-3 glasses of sherry at night. She is very worried about 'electric shock therapy' which she hears that doctors use to treat 'old people with problems' because she considers it 'torture'.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Physiological changes associated with ageing
   - DSM-IV diagnostic criteria for psychiatric disease
   - Current biopsychosocial theories of the aetiology of depression in older people
   - Current biopsychosocial theories of alcohol dependence in older people
   - Stages of sleep and sleep disturbances
   - Pathophysiology of Huntington disease, Parkinson's disease and multiple sclerosis
   - Pharmacology of selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and hypnosedatives
Clinical and Communication Skills 
   - Elicit a history of depression from an older patient and/or collateral history from a caregiver/family/whānau member
   - Perform a mental state examination of an older patient with depression; recognise psychomotor variations of depression (i.e. psychomotor retardation and agitation)
   - Conduct a Montreal Cognitive Assessment (MOCA) to screen for cognitive impairment
   - Perform a functional assessment (e.g. activities of daily living independence)
   - Recognise the biological symptoms of depression and identify the risk factors for depression
   - Interpret relevant investigations: electrolytes, hormonal screening, toxicology screen,imaging
   - Identify barriers to the diagnosis of depression, i.e. the role of stigma
   - Differential diagnosis of depression in an older person
   - Differential diagnosis of insomnia in an older person
   - Management of depression in older people: pharmacological and psychosocial approaches, electroconvulsive therapy (ECT)
   - Management of insomnia: pharmacological and psychosocial methods, notably sleep hygiene
   - Indications and preparations(including consent/second opinion) for ECT; side-effects of ECT
   - Perform a risk assessment for harm to self or others; assess suicide and neglect risk; identification and analysis of risk and protective factors for suicide and self-harm
   - Criteria for referral to psychiatric services
   - Role of the GP in managing depression
   - Prognosis of depression
Personal and Professional Skills 
   - Non-judgemental approach to mental illness and demonstrate empathy
   - Awareness of social impact of mental illness e.g. stigma
   - Discuss public perceptions of treatment: ECT and how these are best managed
Hauora Māori 
   - Appropriate engagement and consultation with whānau
   - Evidence of differential management of depression, with Māori less likely than non-Māori to be prescribed antidepressant medication
   - Consideration of access to cultural/spiritual support for patient and whānau
Population Health 
   - Epidemiology of depression and alcohol abuse in older people
   - Pharmacoepidemiology of antidepressants and hypnosedatives
Conditions to be considered relating to this scenario
Common
major depressive disorder, hypothyroidism, Cushing's syndrome, steroid use, drugs (beta-blockers, calcium channel blockers, substance abuse), obstructive sleep apnoea, alcohol and other hypnosedative abuse/dependence, schizoaffective disorder, schizophrenia, Wernicke-Korsakoff syndrome, hyperthyroidism, Parkinson's disease, dementia, adjustment disorder, dysthymic disorder, bipolar affective disorder, generalised anxiety disorder, post-traumatic stress disorder, obsessive-compulsive personality disorder, borderline personality disorder, stroke, chronic fatigue syndrome
Less common but 'important not to miss'
systemic lupus erythematosus (SLE), Lyme disease, HIV, Addison's disease, central nervous system neoplasia (primary and secondary), multiple sclerosis, Huntington's disease
Uncommon
prolactinoma, acute intermittent porphyria, anorexia nervosa, bulimia nervosa