123 - Depression Flashcards
Key aspects of history taking in suspected depression
History of depression
Mood elevation
Previous treatments
Nature of social network
Core symptoms of depression
Depressed mood Anhedonia Reduced energy Tiredness after minimal effort Lasted at least 2 weeks
How does depressed mood change in depression
Varies little from day to day
Diurnal variation (worse AM)
Unresponsive to circumstances
Other symptoms of depression
Impaired concentration Reduced self esteem Ideas of guilt and unworthiness Pessimistic about future Ideas/acts of self harm/suicide Disturbed sleep Diminished appetite Irritability
Physical symptoms of depression
Anhedonia Early morning wakening Lifelessness or agitation Weight loss Loss of libido Loss of emotional reactivity
What is mild depression
2 core symptoms + 2 others
What is moderate depression
2 core symptoms + 3-4 others
What is severe depression
2 core symptoms + >4 others. Can include psychotic symptoms
Psychotic symptoms associated with depression
Delusions of sin, guilt, poverty, imminent disaster,
Hypochondira
Auditory hallucinations - defamatory or accusatory
Olfactory hallucinations of faeces or rotting flesh
Severe retardation or stupor
What do 70% of patients with depression present with
Physical symptoms only
Symptoms of anxiety
Foreboding Physical symptoms Dry mouth Palpitations Dizziness Sweating Butterflies SOB Choking May develop into panic attacks Feeling life isn't real
If depression present - also need to consider what?
Anxiety. Closely linked and rarely present separately.
When prescribing anti-depressants need to take into consideration
Overdose toxicity.
May need to increase level of support to patient
Epidemiology of depression
How common
High risk groups
4th leading cause of disability and disease worldwide. In UK - 1/10 men and 1/4 women will need treatment for depression at some point. Mean age of onset 27 but elderly, adolescents and those with chronic diseases at more risk
Hopelessness depression model
Stressor (bad event)
Attributes blame, infers consequences and inferences about self - feels cannot do anything to change it.
Hopelessness
Theory of stress vulnerability
The more vulnerable you are, the less stresses are needed to trigger depression. If remove some stresses or increase resilience then can improve threshold for depression.
Remission from depression classes as
Absence of depressive symptoms for 2 months.
How long does depression generally last?
6-8 months. If relapse - more likely to be more severe in future.
What is Beck’s triad
How you think about:
World
Future
Self
How efficient is CBT at treating depression
Can be more effective than antidepressants over long-term
How does CBT work
Underlying model - events trigger thoughts
Thoughts influence feelings, responses and actions.
CBT acts to teach the patient how to intervene to think things through and change their thoughts
When is ECT used
To treat severe depressive illness where suicide is a high risk. Usually course of 8-10 treatments with response after 2-3
What non-drug therapies can be useful for depression?
CBT - increasing levels - individual guided self help, computerised CBT, structured group therapy. Interpersonal therapy Behavioural therapy Relationship therapy ECT
Commonly prescribed antidepressants.
SSRIs as less side effects and equally effective as others. Antidepressants are non-addictive.
Side effects of antipsychotics
Weight gain, reduced glucose tolerance, affect lipid levels.
When giving lithium to augment antidepressants need to
Monitor renal and thyroid function. Consider ECG monitoring as affects blood viscosity.
Treatment for mild depression
On presentation:
Assess risk
Lifestyle interventions
Watchful waiting - review in 2 weeks. Drugs have poor risk:benefit on presentation
SSRIs - Examples, when to give and side effects
Citalopram, Sertraline, Fluoxetine.
Give for 6 months after resolution of depression for first treatment or 2 years if recurrence.
Mainly GI issues but also hyponatraemia
What is hyponatraemia
Drowsiness, confusion, convulsions
Tricyclic antidepressants.
Examples
Amitryptilline, Butryptilline
Tricyclic antidepressants.
How do they work
Inhibit serotonin and noradrenaline reuptake
Tricyclic antidepressants.
Side Effects
Cardiotoxic (especially in overdose).
Dry mouth, blurred vision, sedation, poor concentration
Tricyclic antidepressants.
Contraindications
Epilepsy and heart disease
Use of monoamine-oxidase inhibitors
e.g. Phenylzine
Inhibit breakdown of MAO neurotransmitters (e.g. serotonin)
Use only in severe depression
How does synaptic transmission work
Action potential - Na+ floods into neutron.
Ca2+ gates open so Ca2+ floods in and binds to vesicle.
Vesicles mature and release neurotransmitters into synapse.
NTs diffuse across synapse and bind post synaptic receptors.
Na+ gates opens - floods in - starts new action potential
Key drug targets for neurotransmitters
Neurotransmitter synthesis/release Post synaptic reception Presynaptic reception Reuptake Degredation
What are ionotrophic receptors
Ion channels. Ligand binding either opens or prevents opening of channel
What are metabotropic receptors
Receptors where ligand binding affects intracellular signalling pathways
Glutamate
Excitatory neurotransmitter. Main excitatory NT of CNS
Hyper stimulation can cause seizures, inhibition can cause sedation.
Glycine
Inhibitory NT. Inhibited by strychnine
GABA
General inhibitory neurotransmitter. Hyperstimulation causes sedation while inhibition causes hyper excitability and seizures
Serotonin
Located in gut and brainstem (Raphae nuclei). Involved in depression, appetite, nausea and sleep.
Where is dopamine found?
Located in midbrain.
Found in substance nigra - involved in movement (destroyed in Parkinsons) and Ventral segmental area - involved in motivation, reward and novelty.
Disorders of dopamine
Schizophrenia
Parkinsons
Tourettes
Noradrenaline
Found in brainstem, acts on sympathetic system.
Involved in attention and arousal.
Targeted by adrenaline, ritalin, TCAs.
Opioids
Located in hypothalamus. Involved in analgesia and reward.
Neuromodulators - affect release and effect of other neurotransmitters.
Acetylcholine
NT located in basal forebrain (involved in memory and cognition) and the brainstem (involved in arousal and sleep). Binds to nicotinic (ionotropic, excitatory) and muscarinic (metabotropic) receptors.
Loss of acetylcholine is involved in
Alzheimers disease
What is dysthmia
Has up to 1 core symptoms of depression and 3 total symptoms of depression
What is the first line treatment for depression after MIs
Setraline.
Treatment for depression and anxiety
Amitriptyline is best choice.
Side effects of TCAs
Can’t see
Can’t pee
Can’t shit
Can’t spit
