2. Depression Flashcards
What is the first line choice of antidepressants in older adults?
Selective serotonin reuptake inhibitors (SSRIs) - fewer side-effects and are less toxic in overdose than tricyclic antidepressants. Sertraline is safer than fluoxetine as there are generally fewer drug interactions, and less effect on QT interval.
What is the treatment for young people with mild depression?
Two week period of watchful waiting
Psychological therapies - supportive therapy, group CBT, guided self-help
Antidepressants should not be used for initial treatment of mild depression in CAMHS
What are the two ‘depression identification questions’?
1) During the last month, have you often been bothered by feeling down, depressed, or hopeless?
2) During the last month, have you often been bothered by having little interest or pleasure in doing things?
Patient must have depressed mood OR anhedonia for >2 weeks for diagnosis
If they answer YES to one of the questions and this has been present most days, most of the time for at least 2 WEEKS, ask the associated symptoms of depression
What are the associated symptoms of depression?
(as well as depressed mood and/or anhedonia)
- Sleeping more or less than usual
- Increased or decreased appetite/weight
- Fatigue/low energy
- Agitation or slowing of movements and thoughts (psychomotor retardation)
- Poor concentration/indecisiveness
- Feeling worthless/excessive guilt
- Recurrent thoughts of death/suicide/suicide attempt or plan
What is the initial management of ‘less severe’ depression in primary care?
For all diagnoses:
* Self help materials, support groups e.g RCPsych website, MIND
* Wellbeing activities e.g exercise, diet, sleep, alcohol reduction
‘Less severe’ depression not wanting treatment:
* active monitoring
* social support
* safety netting
* Review in 2-4 weeks.
‘Less severe’ depression wanting treatment:
* Guided self help first line
* CBT (see wheel of all options)
* Medication NOT first line, but if patient preference - SSRI
* Review 2-4 weeks after starting Rx
What is ‘less severe’ depression?
Subthreshold and mild depression, defined as depression ** scoring less than 16 **on the PHQ-9 scale.
What is ‘more severe depression’?
moderate and severe depression, defined as depression scoring 16 or more on the PHQ-9 scale.
Chronic depression = continuous symptoms for >2 years
What are the 4 traditional depression categories?
- Subthreshold depressive symptoms - <5 symptoms.
- Mild depression - few, if any, symptoms in excess of the 5 required to make the diagnosis, minor functional impairment.
- Moderate depression - symptoms or functional impairment are between ‘mild’ and ‘severe’.
- Severe depression - most symptoms present. Symptoms markedly interfere with normal function.
What is the initial management of ‘more severe depression’ in primary care?
For all diagnoses:
* Self help materials, support groups e.g RCPsych website, MIND
* Wellbeing activities e.g exercise, diet, sleep, alcohol reduction
For more severe depression:
Offer any treatment option first line:
* individual CBT
* Antidepressant: SSRI or SNRI first line
(Individual CBT+Antidepressant is most effective)
* Individual behavioural activation
* Counselling
* Guided self-help
* Group exercise.
* Review in 2-4 weeks after starting treatment.
Must not drive and must notify DVLA if significant memory/concentration problems, agitation, behaviour change, or suicidal thoughts.
Urgent referral to mental health services if:
* significant risk of self-harm or suicide, harm to others, or self-neglect.
* psychotic symptoms.
Which antidepressants should be avoided when there is risk of overdose?
Tricyclic antidepressants (except lofepramine).
Venlafaxine (SNRI)
Due to risk of death.
Which antidepressants are first line for most people?
SSRI - good safety and tolerability
What should be done if there is no improvement in symptoms at follow-up after 4 weeks of anti-depressants at a theraputic dose/4-6 weeks psychological therapy or combined Rx?
- can any risk factors for depression be modified
- check concordance
- ?alternative Dx/comorbid condition
- ?chronic depression
- psych intervention alone - switch to alternative therapy, or add in SSRI/use SSRI alone.
- medication alone - augment with group exercise or other psychotherapy, or switch to psych intervention alone, or increase drug dose, or switch drug to same or different class (SSRI or SNRI).
- combo of medication and psych intervention - try the above or seek specialist advice/refer for consideration of additional antidepressant/specialist augmentation.
What are risk factors for depression?
- female
- older age
- Prev Hx depression/other mental illness
- Social/personal/environmental
- post-partum
- FHx
- substance misuse
- chronic physical illness
How often should someone be reviewed when they are taking antidepressant medication longterm to prevent relapse?
- every 6 months - symptoms, concordance, ADRs, relapse, suicidal ideation, plans for ongoing treatment.
- Consider PHQ-9 to monitor response
How should antidepressants be switched in general?
- switch to one they found helpful before
- Avoid one they failed to respond to or had side effects
- Advise that symptoms of mood changes, anxiety, agitation, hopelessness, or suicidal thoughts or ideas may increase when changing treatment.
- Advise on risk of SS if cross-tapering
- Explain cross-tapering - reducing current dose, whilst starting new drug at low dose
- Can do direct switch with one SSRI to another SSRI or an SNRI EXCEPT fluoxetine - long half life and ‘washout’ needed.
