Amy - Depression Flashcards
What does the case video with Amy discuss in terms of her symptoms, and what she is doing currently?
Situation = better, injunction against ex, ex no longer in the picture
Feels rubbish - ongoing
Support from mum and dog, her and her mum get along okay
Texts friends, don’t talk about troubles with friends
Doesn’t get out much - can’t be bothered, too much effort, doesn’t think she’ll enjoy herself
Working at the salon
Couple days off in the last month
Poor sleep - wakes up early even when she’s tired
Over-eat during her lows - junk food
Self harm thoughts - but no actions taken
Cetanoprem everyday - anti-depressant (best one for her)
Couple of courses and 1 a year ago in psychotherapy
What is clinical depression?
Persistent low mood
Illness of the mind
What are the psychological, physical and social symptoms of depression?
Psychological: Lasting feelings of unhappiness and hopelessness Low self-esteem Feeling guilt-ridden Feeling irritable / intolerant of others Finding it difficult to make decisions Feeling anxious / worried Having suicidal thoughts / self-harm
Physical: Constant tiredness, poor sleep, loss of appetite / sex drive, various aches / pains
Social: Losing interest in hobbies, avoiding friends / social contact, difficulties in your home or work life
Co-morbid with anxiety, stress etc.
What are the 3 severities of depression?
Mild depression – has some impact on your daily life
Moderate depression – has a significant impact on your daily life
Severe depression – makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms
How can grief and depression be distinguished?
Grief - natural process to loss, they can let go of their sadness and loss to look forward to the future
Depression - constantly feel sad, difficulty finding enjoyment / happiness about the future
What are some other types of depression?
Post-natal depression - new mothers or fathers after having a baby
Bipolar disorder - spells of depression followed by excessively high mood (mania)
SAD (seasonal affective disorder) - winter depression
What causes depression?
Sometimes there is a trigger
Family history of depression = risk factor
Personality traits e.g. low self-esteem, self-critical etc. Loneliness
Giving birth
Alcohol and drugs
Illness - life threatening or longstanding diseases, hypothyroidism
Sometimes there is no obvious reason or trigger
When is the time to seek help .g. speaking to the GP?
If experiencing symptoms of depression most of the day, every day, for 2 weeks
Find your mood is affecting daily life e.g. work, relationships
Having suicidal or self-harming thoughts
GP can ask about your general health and things affecting you mentally to diagnose you with depression and let you know how severe it is
How can depression be treated?
Lifestyle changes = self-help groups, exercising, cutting down alcohol, smoking, eating more healthily
Talking therapies = CBT
Medications = anti-depressants
What are the treatments recommended for mild depression?
Exercise, self-help groups / books / online forums, mental health apps
What are the treatments recommended for mild to moderate depression?
Talking therapy / CBT / counselling
What are the treatments recommended for moderate to severe depression?
Anti-depressants
Combination therapy - antidepressants plus talking therapy
Referral so a team of psychologists, psychiatrists, specialist nurses and occupational therapists can help
What are the different types of talking therapy and briefly explain each one?
CBT - concentrates on challenging and eventually changing thought patterns, behaviours
Online CBT - CBT delivered through a computer rather than ftf with a therapist
Interpersonal therapy (IPT) - focuses on relationships with others ad problems within those relationships
Psychodynamic psychotherapy - psychoanalytic therapist encourages you to say whatever is on your mind
Counselling - helps you think of the problems in your life and how to deal with them
How should anti-depressants be taken?
Need to try different types until one works
See GP or specialist nurse every week for at least 4 weeks to see how they’reworking
Need to take up to 4-6 months after symptoms have eased
Some take up to 5 years or more
Not addictive, may get withdrawal symptoms
What are SSRIs and how do they work?
Selective serotonin reuptake inhibitors = antidepressants e.g. paroxetine (Seroxat), fluoxetine (Prozac) and citalopram (Cipramil)
Increase serotonin levels
Work as well as older anti-depressants but with fewer side effects e.g. headaches, dry mouth
What are TCAs and how do they work?
Tricyclic antidepressants - e.g. imipramine (Imipramil) and amitriptyline
Raising serotonin and noradrenaline levels in the brain
Side effects include dry mouth, blurred vision, constipation, problems passing urine, sweating, feeling lightheaded and excessive drowsiness but ease within 10 days
What are SNRIs and how do they work?
Serotonin-noradrenaline reuptake inhibitors - antidepressants
e.g. Venlafaxine and duloxetine
SNRI can be more effective than an SSRI, but not routinely prescribed because they can lead to a rise in blood pressure
What are the withdrawal symptoms of antidepressants?
Usually mild, resolves in 1-2 weeks
An upset stomach, flu-like symptoms, anxiety, dizziness, vivid dreams at night, sensations in the body that feel like electric shocks
What is Mindfulness?
Paying closer attention to the moment
What is St. John’s Wort?
Herbal treatment, not recommended by doctors
What is Brain Stimulation?
What are the 3 main brain stimulations used to treat depression?
Electromagnetic currents used to stimulate certain areas of the brain to try and improve symptoms of depression
Transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT)
What is tDCS?
Transcranial direct current stimulation delivers low constant current through 2 electrodes placed on the head
What is rTMS?
Repetitive transcranial magnetic stimulation - place electromagnetic coil against head and it sends repetitive magnetic energy impulses
What is ECT?
Electroconvulsive therapy - more invasive type of brain stimulation, carefully calculated electric current is passed to the brain through electrodes placed on the head
What is lithium and why does it help with depression?
2 forms, usually take one: either lithium carbonate and lithium citrate, tagets CNS and balances mood
What do you do if you’re living with depression?
Take your medications as prescribed Healthy diet and exercise regularly Mindfulness Talk out your problems Smoking, drugs and alcohol cessation Try get back to work ASAP
What are some warning signs for self-harm / suicide?
Making final arrangements, such as giving away possessions, making a will or saying goodbye to friends
Talking about death or suicide
Self-harm, such as cutting their arms or legs, or burning themselves with cigarettes
A sudden lifting of mood, perhaps decision to attempt suicide makes them feel better
What are the symptoms of severe depression?
Sad and hopeless for most of the day, every day Fatigue (exhaustion) Loss of pleasure in things Disturbed sleep Changes in appetite Feeling worthless and guilty Being unable to concentrate or being indecisive Thoughts of death or suicide
What is psychotic depression and what causes it?
What are some symptoms of psychosis?
Severe depression alongside episodes of psychosis - usually triggered by a traumatic event
Delusions - thoughts or beliefs unlikely to be true
Hallucinations - hearing or seeing things that are not actually there
What are the treatment options for psychotic depression?
Medicine – a combination of antipsychotics and antidepressants
Psychological therapies – the 1-to-1 CBT has proved effective in helping some people with psychosis
Social support – support with social needs, such as education, employment or accommodation
ECT
What is the biopsychosocial model?
Suggests biological, psychological and social factors are interlinked to promoting health or causing disease
Mind and body are interdependent
How can the biopsychosocial model b applied to depression?
Bio = disturbed endocrine (hormone), immune, and neurotransmitter system functioning, genetic vulnerability Psych = negative patterns of thinking, deficits in coping skills, judgment problems, and impaired emotional intelligence Social = traumatic situations, early separation, lack of social support, or harassment (bullying)
What are the symptoms of depression shown in Amy?
Slow speaking Disturbed sleep Avoiding friends contact / social withdrawal Anhedonia - lack of enjoyment in hobbies Overeating Work difficulties - couple days off Nervous fiddle Apathy Low mood
What other symptoms of depression may we wish to ask about for Amy?
Ask about physical symptoms e.g. bowel movements, libido, menstrual cycle
Suicidal thoughts?
Relationships?
Weight loss or gain?
What is major depressive disorder? (MDD) How is it categorised?
How can MDD be diagnosed (using NICE guidelines)? What symptoms are required?
Clinical depression
Mild, Moderate, Severe
At least 1 core symptom - persistent sadness or low mood, or anhedonia daily for 2 weeks
And then an additional 5 associated symptoms: poor concentration, indecisveness, fatigue, disturbed sleep, feelins of worthlessness, suicidal thoughts or acts, appetite changes
What does the NICE framework use?
The DSM
What are 3 other risk factors that manifest as thoughts and/or actions?
How relevant is it in depression? Which are more common in what demographic?
- Self-harm
- Suicide
- Harm to others
1 and 3 more important in psychotic disorders, 2 important equally in depression and psychotic disorders
1 = females aged 17-19 2 = males aged 40-59
What factors in the patient’s environment could be affecting the likelihood of the 3 risk factors, and vice versa?
Occupation Alcoholism Smoking Drug abuse Family Relationships Abuse Where in the world? Demographics (sex, culture, etc.)
What are some facts about self harm?
- History self-harm is associated with…?
- Self-harm is a way of…?
- Other forms of self-harm include…?
- Self-harm can involve…?
- Suicide is…?
- History of self-harm is associated with an increased risk of suicide
- Self-harm is usually a way of coping or expressing difficult feelings
- May take other forms such as punching a wall, banging one’s head against a wall, or even getting into fights
- Can involve cutting, hair-pulling, scratching etc.
- Suicide is a fatal act of self-harm initiated with the intention of ending one’s own life
Place the factors below into Bio, Biopsych, Psych, Biosocial, Psychosocial or Social categories:
Genetic vulnerability Physical health Sleep Diet/lifestyle Self-esteem Attitudes / beliefs Trauma Family circumstance Financial Security
Bio = Genetic vulnerability
Physical health
Biopsych = Sleep
Psych = Self-esteem
Biosocial = Diet and lifestyle
Psychsocial = Trauma, attitudes / beliefs
Social = Family circumstance, financial Security
What are ACEs?
Adverse childhood experiences
ACEs = potentially traumatic events during childhood that affects development and perceiving of the world
Which of the adult behaviours below are highly linked to ACE influence according to the study we looked at?
Binge drinking Heavy drinking Smoking status High risk HIV behaviour Obesity Diabetes MI CHD Stroke Depression Disability caused by poor health Use of special equipment because of disability
Binge drinking Heavy drinking Smoking status High risk HIV behaviour Depression Disability caused by poor health Use of special equipment because of disability
What is BRFSS?
Questionnaire that asks about traumatic events in childhood, comprised of 11 questions
What is the difference between heavy drinking and binge drinking?
Binge drinking: large alcohol consumption within a set time. More than 8 units in a single session for males, more than 6 units in a single session for females
Heavy drinking: pattern of binge drinking that occurs frequently
What is the difference between statistical and clinical significance?
May not show statistical significance, but there may be improvement etc. at the end of the trial (clinical significance)
Or perhaps there is statistical significance, but the value added clinically is very minimal and is not economically feasible
Which drugs would have anti-depressant effects?
Which of these would not?
SSRIs Post-synaptic serotonin receptor agonist Tryptophan hydroxylase inhibitor Monoamine oxidase inhibitor Serotonin auto-receptor antagonist
Anti-depressant effects:
SSRIs - prevents reuptake of serotonin, leaves serotonin in synapse longer
Serotonin auto-receptor antagonist - receptor decreases serotonin release
Monoamine oxidase inhibitor - serotonin builds up in the pre-synaptic terminal, conc. gradient affected so serotonin leaves at a slower rate
No anti-depressant effects:
Tryptophan hydroxylase inhibitor - inhibits serotonin production in presynaptic neuron
Post-synaptic serotonin receptor agonist - acts as serotonin and activates same receptors
What is the monoamine hypothesis?
Developed for TB - noticed it has anti-depressant properties
Blocks monoamine oxidase
Began theory that serotonin is involved in depression
What should patients be told before starting anti-depressants?
Suicidal thoughts
Serotonin syndrome (high levels of serotonin left in the synapse leading to tremors, parkinson’s like symptoms)
Nausea
Drowsiness
Lowered libido / sexual dysfunction
Drugs may not work, usually takes several weeks to kick in
Sudden stop = side effects; wean drugs slowly
Serotonin = hippocampal regrowth = takes time
Careful with interactions of other medications
Symptoms may worsen initially - anxiety and agitation in the first few week
Need to continue until 6mo after symptoms ease
What is social prescribing?
Recognises health is holistic (social, economic, environmental factors) - addresses patient’s needs in a holistic manner
Refer patients to local, non-clinical services
Prescribing activity schemes e.g. support groups (e.g. family issues, finance issues), exercise groups, cooking classes, art sessions etc.
Christina’s story - Depression?
What depressive symptoms did she experience?
What did the doctor prescribe her?
What did she do on her own that helped?
What helped her?
Fear, panic, lack of concentration, feeling isolated even when around people, feeling disintegrated, rashes, headaches, exhaustion, emotionally dead, sleeping problems
Benzodiazepines (found them v. helpful), sleeping tablets
Self-help group, other forms of expression e.g. with art
Talking with people who are accepting and understanding
How do monoamine oxidase inhibitors (MAOIs) work as anti-depressants?
Inhibits the enzyme monoamine oxidase = increases the amount serotonin released into the synapse
How do tricyclics (TCAs) work as anti-depressants?
All have a 3 ring structures
Block norepinephrine and serotonin reuptake channels so they stay in the synapse for longer
How do SSRIs work as antidepressants?
Similar to TCA, except only block serotonin reuptake channels on very specific receptors
How can you decide which anti-depressant to give, if they are all more or less equally effective?
Decide based on side effects
MAOIs and TCAs = 1st generation anti-depressants = more side effects
SSRIs = 2nd generation = fewer side effects
What are the side effects for MAOIs?
Monoamine NTs = epinephrine, norepinephrine, serotonin, dopamine
Drugs increase NT availability all over the body
Drug interactions - MAOIs also inhibit enzyme in liver that helps metabolise medications
MAOIs can also prevent some food breakdowns - restrictive diet
What are the side effects of TCAs?
Only act on some monoamine NTs - norepinephrine and serotonin
Can affect histamines = sluggishness
Higher levels = toxicity = cardiac arrest (suicide attempt)
Prescribed for bipolar disorders (rather than SSRIs which can trigger manic episodes)
What are the side effects of
First choice - effective but fewer side effects
Most selective on what they act on - only serotonin but still act everywhere in the body
Sleeping problems, weight gain, sexual dysfunction
Serotonin syndrome
What are some new types of anti-depressants / anti-depressant combos?
SSRIs and SNRIs (like more selective TCAs)
NDRIs (norepinephrine and dopamine reuptake inhibitors)
NDRAs (norepinephrine and dopamine releasing agents)
CBT reading:
Same as A level psychology notes
What is social prescribing?
Enables primary care professionals to refer people to a range of local, non-clinical services
Designed to support people with a wide range of social, emotional or practical needs, and many schemes are focused on improving mental health and physical well-being
Effectiveness of social prescribing?
Issues with evidence supporting social prescribing?
Can lead to a range of positive health and well-being outcomes - improvement in quality of life and emotional wellbeing
However, many studies are small scale, outcomes difficult to measure (qual instead of quan), do not have a control group and focus on progress rather than outcomes
Determining the cost, resource implications and cost effectiveness of social prescribing is difficult
