Depressed Mood

Introduction

Depressed mood is a crucial topic for the MCCQE1 exam and a common presentation in Canadian primary care settings. This comprehensive guide will help you prepare for questions related to depressed mood on the MCCQE1, with a focus on Canadian guidelines and practices.

Epidemiology in Canada

Understanding the prevalence and impact of depressed mood in Canada is essential for MCCQE1 preparation:

• Approximately 11% of Canadian adults experience major depressive disorder in their lifetime
• Depression affects about 5.4% of the Canadian population annually
• Women are 1.5 times more likely than men to experience depression
• The economic burden of depression in Canada is estimated at $32.3 billion annually

Diagnostic Criteria

For MCCQE1 preparation, it's crucial to know the diagnostic criteria for Major Depressive Disorder (MDD) according to the DSM-5:

1. Depressed mood
2. Diminished interest or pleasure
3. Significant weight loss/gain or appetite changes
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Diminished ability to concentrate
9. Recurrent thoughts of death or suicidal ideation

Canadian Guidelines for Depression Management

The Canadian Network for Mood and Anxiety Treatments (CANMAT) provides guidelines for managing depression in Canada. Here's a summary of the stepped-care approach:

Pharmacological Management

Understanding antidepressant medications is crucial for MCCQE1 success. Here's a table summarizing key antidepressants used in Canada:

Non-pharmacological Interventions

Canadian guidelines emphasize the importance of non-pharmacological interventions:

1. Cognitive Behavioral Therapy (CBT): First-line treatment in Canada, especially for mild to moderate depression
2. Interpersonal Therapy (IPT): Effective for depression related to interpersonal issues
3. Mindfulness-Based Cognitive Therapy (MBCT): Increasingly used in Canada for relapse prevention
4. Exercise: Recommended as an adjunct treatment in Canadian guidelines
5. Light Therapy: Particularly for Seasonal Affective Disorder, common in northern Canadian regions

Special Populations

Perinatal Depression

• Affects up to 13% of Canadian women during pregnancy and postpartum
• Screening recommended using the Edinburgh Postnatal Depression Scale (EPDS)
• SSRIs are generally considered safe during pregnancy and breastfeeding in Canada

Elderly Depression

• Often underdiagnosed in Canadian seniors
• May present atypically with more somatic complaints
• Consider drug interactions and lower starting doses in this population

Indigenous Populations

• Higher rates of depression in Indigenous communities in Canada
• Culturally appropriate interventions and community-based programs are essential
• Understand the impact of intergenerational trauma and social determinants of health

Suicide Risk Assessment

A critical skill for Canadian physicians and a high-yield topic for MCCQE1:

1. Ask directly about suicidal thoughts
2. Assess risk factors (previous attempts, substance abuse, chronic illness)
3. Evaluate protective factors (social support, religious beliefs)
4. Determine suicide plan and access to means
5. Assess impulsivity and judgment

Canadian Resources for Depression

• Canadian Mental Health Association (opens in a new tab)
• Mood Disorders Society of Canada (opens in a new tab)
• Centre for Addiction and Mental Health (CAMH) (opens in a new tab)

Key Points to Remember for MCCQE1

• 🇨🇦 Know Canadian epidemiology and economic burden of depression
• 📊 Memorize DSM-5 diagnostic criteria for Major Depressive Disorder
• 💊 Understand first-line treatments in Canada (SSRIs, SNRIs, CBT)
• 🩺 Be familiar with CANMAT guidelines for depression management
• 🤰 Recognize special considerations for perinatal, elderly, and Indigenous populations
• 🆘 Master suicide risk assessment and know provincial Mental Health Act criteria

Sample MCCQE1-Style Question

A 32-year-old woman presents to her family physician with a 3-month history of persistent low mood, decreased interest in usual activities, and difficulty sleeping. She reports feeling worthless and has lost 5 kg unintentionally. She denies any suicidal thoughts. Physical examination and routine blood work are unremarkable. Which of the following is the most appropriate next step in management?

• A. Start sertraline 50 mg daily
• B. Refer for cognitive behavioral therapy
• C. Prescribe trazodone for insomnia
• D. Order thyroid function tests
• E. Recommend light therapy

Explanation

The correct answer is:

• A. Start sertraline 50 mg daily

This patient meets the diagnostic criteria for Major Depressive Disorder (MDD) based on her symptoms lasting for more than two weeks and including depressed mood, anhedonia, sleep disturbance, weight loss, and feelings of worthlessness. According to Canadian guidelines (CANMAT), first-line treatments for MDD include both antidepressants (particularly SSRIs) and psychotherapy.

While cognitive behavioral therapy (option B) is also a first-line treatment, in the Canadian healthcare system, access to psychotherapy may have longer wait times. Therefore, starting an SSRI like sertraline is an appropriate initial step that can be implemented immediately by the family physician.

Option C (trazodone for insomnia) addresses only one symptom and is not a comprehensive treatment for MDD. Option D (thyroid function tests) may be considered, but given the unremarkable blood work mentioned, it's less likely to be the most appropriate next step. Option E (light therapy) is primarily used for Seasonal Affective Disorder, which is not indicated in this case.

References

1. Lam RW, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder. Can J Psychiatry. 2016;61(9):510-523.

2. Statistics Canada. Mental Health Indicators. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310046501 (opens in a new tab)

3. MacQueen GM, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 6. Special Populations: Youth, Women, and the Elderly. Can J Psychiatry. 2016;61(9):588-603.

4. Patten SB, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 1. Disease Burden and Principles of Care. Can J Psychiatry. 2016;61(9):510-523.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.