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Psychiatric Medicine > Affective disorders - Depression > Flashcards

Affective disorders - Depression Flashcards

1
Q

Are mood disorders primary or secondary?

A

Can be both, occur randomly or in resposne to a problem

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2
Q

What changes in mood occur in depression?

A
  • Depression
  • Anxiety
  • Perplexity
  • Anhedonia
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3
Q

What changes occur in thought content in depression?

A
  • Guilt
  • Hopelessness
  • Worthlessness
  • Neuroses - Hypochondriasis, agarophobia
  • Ideas of reference
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4
Q

What changes in beliefs and perceptions can occur in a depressed individual?

A
  • Delusions
  • Hallucination
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5
Q

What changes in bodily function occur in a depressed individual?

A
  • FATIGUE
  • SLEEP DISTURBANCE - most commonly early wakening
  • APPETITE - weight loss
  • LIBIDO
  • CONSTIPATION
  • PAIN
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6
Q

What psychomotor changes can occur in depression?

A
  • Agitation
  • Retardation
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7
Q

What social changes can occur in someone with depression?

A
  • LOSS OF INTERESTS/APATHY
  • IRRITABILITY
  • WITHDRAWAL/LOSS OF CONFIDENCE
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8
Q

When classifying depression, what criteria does it have to meet (besides the actual symptomatology)?

A
  • Last for at least 2 weeks
  • No hypomania or manic episodes
  • Not 2o to drug/alcohol misuse, medications, medical disorder, or bereavement
  • Cause significant functional limitation
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9
Q

What are the core symptoms of depression as defined by ICD-10?

A
  • Low mood - most of the day, everyday, for at least 2 weeks
  • Anhedonia - loss of pleasure/interest
  • Low/decreased energy
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10
Q

What are typical symptoms of depression which are additional to the 3 core symptoms as defined by the ICD-10?

A

Remember GLASS SAC

  • Unreasonable feeling of Guilt
  • Decreased Libido
  • Change in Appetite
  • Sleep disturbance of any sort
  • Low Self esteem
  • Suicide thoughts/behaviour
  • Agitation or retardation
  • Decreased Concentration
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11
Q

What are the criteria for the diagnosis of mild depression?

A

At least 2 core symptoms + 2 additional = 4 symptoms

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12
Q

What are the criteria for the diagnosis of moderate depression?

A

At least 2 core symptoms + 3-4 additional symptoms = 5-6 symptoms

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13
Q

What are the criteria for the diagnosis of severe depression as per ICD-10?

A

All 3 core symptoms + at least 4 additional symptoms = 7 or more symptoms

or

Mild/moderate + psychosis/stupor

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14
Q

The presence of what symptom(s) immediately classes depression as being severe?

A
  • Psychosis
  • Stupor
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15
Q

How would you diagnose psychomotor retardation?

A

Objective measurement

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16
Q

What are aetiological factors which can increase the risk of the development of depression?

A
  • Biological - FH
  • Psychological - Neuroticism, low self-esteem, childhood experience
  • Social - adverse life event, stress, lower social class
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17
Q

If someone presented with symptoms of depression, what would be your differential diagnosis?

A
  • Normal reaction to life event
  • Psychiatric - Bipolar, schizophrenia, anxiety, anorexia
  • Dysthymia/Cyclothymia
  • Substance misuse
  • Stroke, tumour, dementia
  • Infection
  • Medications
  • Endocrine - Hypothyroidism, Addison’s, hyperparathyroidism
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18
Q

If someone presented to you with low mood, what endocrine disorders would you think of?

A
  • Hypothyroid
  • Addison’s
  • Hyperparathyoroidism
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19
Q

If someone presented with low mood, what psychiatric problems would you consider as part of your differential diagnosis?

A
  • Bipolar
  • Schizophrenia
  • Anxiety
  • Anorexia nervosa
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20
Q

If someone presented with low mood, what neurological problems would you consider?

A
  • Stroke
  • Dementia
  • Tumour
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21
Q

What investigations would you do in someone with low mood/apparent depression?

A
  • Assessment - measurement tools

Beyond this, based on excluding treatable causes:

  • Consider Bloods - FBC, ESR, B12/folate, TFTs, LFTs, glucose, Ca2+
  • Consider Toxicology screen
  • Medication reconcilliation/drug history
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22
Q

How would you manage someone with mild depression?

A

Psychological intervention

  • Improved sleep hygeine
  • Anxiety management
  • CBT

No pharmacological intervetion unless symptoms extend beyond 8 weeks

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23
Q

How would you manage moderate depression?

A
  • High intensity psychological intervention
  • Antidepressant - SSRI is first line
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24
Q

How would you manage someone with severe depression?

A

Consider contacting mental health services if high risk of self harm

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25
Q

What medications are used to treat depression?

A

Antidepressants

  • SSRI’s
  • TCA’s
  • Monoamine oxidase inhibitors
  • SNRI’s
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26
Q

What is the mechanism of action of Tricyclic antidepressants?

A

Monoamine (serotonin and noradrenaline) reuptake is blocked by the TCAs which antagonise the amine transporter, resulting in a greater monoamine concentration in the synapse

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27
Q

What are examples of TCAs?

A
  • Amitriptyline
  • Clomipramine
  • Nortriptyline
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28
Q

When are TCA’s indicated for use?

A
  • Depression
  • Anxiety disorder
  • Neuropathy
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29
Q

What are common side effects of TCA’s?

A
  • Anti-cholinergic effects - dry mouth, blurred vision, constuipation, hypotension, urinary retention
  • Arrhythmias/Heart block
  • Hyponatraemia - due to SIADH
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30
Q

What is the mechanism of action of monoamine oxidase inhibitors?

A

Amine neurotransmitters (e.g. 5HT, catecholamines, dopamine) are broken down to inactive metabolites by the enzyme monoamine oxidase (MAO), of which two isoforms exist, in nerve terminals:

  • MAOA - found principally in the gut and liver
  • MAOB - found in the brain

MAO inhibitors prevent breakdown of amine neurotransmitters by irreversibly binding with the enzyme

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31
Q

When are monoamine oxidase inhibitors used?

A
  • Resistant depression
  • Parkinson’s Disease
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32
Q

What are side effects of MAOI’s?

A
  • Orthostatic hypotension
  • Weight gain
  • Dry mouth
  • 3 S’s - Sedation, Sexual dysfunction, Sleep disturbance
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33
Q

What is the mechanism of action of SSRI’s?

A

Serotonin is a monoamine neurotransmitter with a role in regulation of mood. SSRIs selectively inhibit the reuptake of the monoamine serotonin (5-HT) within the synapse. The prolongation of the presence of serotonin in the synapse causes an upregulation of its effects on the postsynaptic neuron.

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34
Q

What are examples of SSRI’s?

A
  • Citalopram
  • Fluoxetine
  • Paroxetine
  • Sertraline
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35
Q

What is a specific adverse reaction that can occur with MAOI’s?

A

Tyramine (cheese) reaction - Tyramine in foodstuffs is not broken down by bound MAOA and enters circulation causing dangerous hypertension due to its sympathomimetic effect

36
Q

When are SSRI’s indicated for use?

A
  • Depressive illness
  • Panic disorder
  • Obsessive compulsive disorder
  • Anxiety disorders
37
Q

What problem can occur when MAOI’s are taken in combination with medications which increase serotonin?

A

Serotonin syndrome

38
Q

What is serotonin syndrome?

A

A group of symptoms that may occur following use of certain serotonergic medications or drugs:

  • Abdo pain/diarrhoea
  • Sweats
  • Tachycardia
  • HTN
  • Myoclonus
  • Irritability
  • Delerium

Can lead to hyperpyrexia, CVS shock and death

39
Q

When starting someone on SSRI’s, what do you have to warn them about?

A

Activation and discontinuation syndromes

40
Q

What symptoms occur in activation syndrome that is caused by SSRI’s?

A
  • Nausea
  • Increased anxiety, panic and agitation
41
Q

How long does activation syndrome last in patients who have been started on SSRI’s?

42
Q

What are the symptoms associated with discontinuation syndrome with SSRI use?

A
  • Agitation
  • Nausea
  • Disequilibrium
  • Dysphoria

More common with drugs with shorter half-life

43
Q

What are the most common side effects associated with SSRI’s?

A
  • GI upset
  • Sexual dysfunction
  • Anxiety
  • Restlessness
  • Nervousness
  • Insomnia
  • Fatigue
  • Sedation
  • Dizziness
44
Q

What can occur when SSRI’s are used in combination with other drugs that increase seratonin levels?

A

Seratonin syndrome

45
Q

What drugs of abuse can in increase the risk of serotonin syndrome developing if used with SSRI’s?

A
  • Amphetamines
  • Cocaine
  • LSD
46
Q

Why does fluoxetine have a lower risk of discontinuation syndrome than other SSRI’s?

A

Longer half-life

47
Q

What is the mechanism of action of serotonin/noradrenaline reuptake inhibitors?

A

Inhibit both serotonin and noradrenergic reuptake like the TCAS but without the antihistamine, antiadrenergic or anticholinergic side effects

48
Q

What are the indications for SNRI use?

A
  • Depression
  • Anxiety
  • Sometimes neuropathic pain
49
Q

What is Mirtazapine?

A

Novel antidepressant

Can be used to augment SSRI action due to different mechanism of action

50
Q

What would be a first line anti-depressant?

A

SSRI - fluoxetine, citalopram, sertaline

51
Q

When using SSRI’s, what do you have to keep and eye on?

A
  • FBC - anaemia
  • U+E’s - hypernatraemia
  • ECG - citalopram causes QT elongation
52
Q

What delusions are often seen in depression?

A
  • Usually negative/guilty
  • Nihilistic
53
Q

What Hallucinations are seen in depressed patients?

A

Auditory - second person - telling them they are worthless

Can also be visual, tactile, olfactory, gustatory

54
Q

When asking about medical history in a patient with depression, what is important to ask about?

A
  • Thyroid disorders - hypo can mimic depression
  • Chronic illness/pain
55
Q

When asking about medications in a patient with suspected depression, what medications are you looking out for?

A

Beta-blockers

56
Q

How would someone with depression appear?

A
  • Poor self-care
  • Reduced range of facial expressions
57
Q

What might you notice when assessing a depressed persons behaviour?

A
  • Psychomotor retardation/agitation
  • Reduced eye contact
58
Q

When assessing speech of someone who is depressed, what might you see?

A
  • Slow
  • Quiet
  • Monotonous
59
Q

When assessing mood and affect in a person with suspected depression, what might you see?

A
  • Subjectively and objectively depressed mood
  • Reduced range and intensity of affects
60
Q

When assesing thought in someone who you suspect to be depressed, what might you notice?

A

Form

  • Thoughts may be slowed

Content

  • Negative, guilty or suicidal thoughts
  • Depressive delusions if psychotic
61
Q

When assessing perceptions in someone who you suspect to be depressed, what might you find?

A

Possible auditory hallucinations if psychotic

62
Q

When assessing cognition in someone with depression, what might you find?

A

Normal cognition

63
Q

When assessing insight in someone with depression, what might you find?

A

Usually present

64
Q

What psychological interventions can be used to treat depression?

A
  • CBT
  • Interpersonal therapy
  • Individual dynamic psychotherapy
65
Q

What physical therapies can be used in depression?

66
Q

When is ECT used?

A
  • Severe intractable depression
  • Prolonged, severe mania
  • Catatonia
67
Q

What is the proposed mechanism of action of ECT?

A

It interrupts the hyperconnectivity between the various areas of the brain that maintain depression

68
Q

What are side effects to ECT?

A
  • Memory loss - Short term retrograde amnesia
  • Confusion
  • Headaches
  • Clumsiness
69
Q

How long would you trial someone on an antidepressant medication?

70
Q

If the dose of an antidepressant medication is found to be effective, how long should you continue it for for first episode of depression?

A

6-12 months

71
Q

If the dose of an antidepressant medication is found to be effective, how long should you continue it for for second episode of depression?

72
Q

If the dose of an antidepressant medication is found to be effective, how long should you continue it for a third episode of depression?

73
Q

What can happen if depression is left untreated?

A

Untreated, depression usually lasts six to twelve months

However it can become chronic

Even if it resolves without treatment, the patient may be left with some symptoms e.g. insomnia

74
Q

What are “complications” of depression?

A
  • Suicide
  • Psychosis
  • Social and Occupational dysfunction
    • Unemployment or problems at work
    • Family and relationship problems
    • Socially isolation
75
Q

What delusions can be experienced in depression?

A
  • Poverty
  • Personal inadequacy
  • Guilt over presumed misdeeds
  • Responsibility for events
  • Deserving of punishment
  • Nihilistic delusions
76
Q

What auditory hallucinations can be experienced in depression?

A
  • Defamatory
  • Accusatory
  • Cries for help
77
Q

What olfactory hallucinations can be experienced in depression?

A

Bad smells

  • Rotting food
  • Faeces
  • Decomposing flesh
78
Q

What visual hallucinations can occur in depression?

A
  • Tormentors
  • The Devil/Demons
  • Dead bodies/Scenes of death or torture
79
Q

What are the somatic symptoms of depression?

A
  • Loss of emotional reactivity
  • Diurnal mood variation
  • Anhedonia
  • Early morning wakening
  • Psychomotor agitation/retardation
  • Loss of appetite/weight
  • Loss of libido
80
Q

What is important to remember in terms of suicide risk with the use of antidepressants?

A

Risk increases in the early stages of treatment

81
Q

When choosing which antidepressant to use, what factors should you take into consideration?

A
  • Patient - age, sex, comrobidities
  • Tolerability
  • Symptomatology
82
Q

In terms of treating someone with depression who was suffering from sleep disturbance, what sort of agent would you potentially use?

A

More sedative agent

83
Q

In terms of treating someone with depression who was suffering from lack of energy/hypersomnia, what sort of agent would you potentially use?

A

Adrenergic/stimulatory agent

84
Q

In terms of treating someone with depression who was suffering from OCD symptoms, what sort of agent would you potentially use?

A

Clomiparmine/SSRI

85
Q

What is seasonal affective disorder?

A

Seasonally dictated recurrent depressive episodes

86
Q

What is dysthymia?

A

The presence of chronic, low-grade depressive symptoms. Possible to have superimposed depressive episodes

Can be regarded as a baseline rather than being euthymic

Psychiatric Medicine (16 decks)

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