CSI 3 - Low mood Flashcards
1
Q
What is the mildest symptom of depression?
A
Feeling persistently low in spirit
2
Q
What can severe depression make you feel?
A
Suicidal - life is no longer worth living
3
Q
Is it important to see the GP if you feel depressed?
A
Yes - the sooner you see a doctor, the sooner you can be on the way to recovery
4
Q
What are examples of triggers that can cause depression?
A
Life-changing events e.g. bereavement, losing your job or giving birth
5
Q
Who is more likely to experience depression?
A
Those with a family history of depression
6
Q
If you have mild depression, what might the doctor recommend?
A
- watchful waiting - may suggest waiting to see whether it improves on its own, while monitoring your progress
- lifestyle measures e.g. exercise and guided self-help
7
Q
For mild depression that is not improving/moderate depression, what two therapies are given?
A
- cognitive behavioural therapy - CBT (talking therapy)
- antidepressants
8
Q
For moderate to severe depression, a combination of what is often recommended?
A
Talking therapy and antidepressants
9
Q
How can severe depression be managed?
A
Referral to specialist mental health team for intensive specialist talking treatments and prescribed medicine
10
Q
What lifestyle changes can help with depression? (4)
A
- exercise
- cutting down on alcohol
- giving up smoking
- eating healthily
11
Q
What can self-help books and joining support groups help with?
A
Help you gain a better understanding about what causes you to feel depressed, sharing experiences with others in a similar situation can be very supportive
12
Q
What is the biopsychosocial model?
A
- model that suggests that biological, psychological and social factors are all interlinked and important with regard to promoting health or causing disease
- wellness or illness is not a matter of only physical state but also influences by psychological and social status
13
Q
Can genes influence transmission of depression from generation to generation?
A
Yes
14
Q
What biological factors are significantly disturbed in depression?
A
Endocrine, immune and neurotransmitter functioning + bidirectional link between depression and physical health disorders
15
Q
What psychological factors influence depression? (4)
A
- characteristic negative patterns of thinking
- deficits in coping skills
- judgement problems
- impaired emotional intelligence
16
Q
How can psychological factors be influenced by biology and social factors?
A
- people’s innate temperament / biologically-based personality characteristics can influence people to be more or less likely to act in ways characteristic of depression
- by social factors e.g. what coping behaviours are modelled by parents/teachers etc
17
Q
What are examples of social factors that can lead to depression? (4)
A
- traumatic situations
- early separation
- lack of social support
- harassment (bullying)
18
Q
What can serve as triggers for turning genes on and off by causing changes in brain function?
A
Stressful social events
19
Q
What were Amy’s symptoms of depression? (9)
A
- indecisiveness
- disturbed sleep
- fatigue
- increased appetite
- anergia and apathy
- anhedonia
- self-harm thoughts
- self-neglect
- pessimistic
20
Q
What other symptoms may need to be asked about? (5)
A
- persistent sadness or low mood
- loss of interests or pleasure
- agitation or slowing of movements
- feelings of worthlessness or inappropriate guilt
- suicidal thoughts or acts
21
Q
What are the key symptoms of major depressive disorder according to the DSM-V? (2)
A
- persistent sadness or low mood
- marked loss of interests or pleasure
22
Q
What are the associated symptoms of major depressive disorder according to the DSM-V? (7)
A
- disturbed sleep
- decreased or increased appetite and/or weight
- fatigue or loss of energy
- agitation or slowing of movements
- poor concentration or decisiveness
- feelings of worthlessness or excessive or inappropriate guilt
- suicidal thoughts or acts
23
Q
What are the criteria for diagnosis of major depressive disorder according to DSM-V?
A
1+ key symptoms (most days, most of the time) and 5+ total symptoms for minimum two weeks
24
Q
What three categories are patients risk assessed for in MDD?
A
- risk to self (self-harm, suicide)
- risk to others
- risk from others
- (slides - self-harm, suicide, harm to others)
25
Acts of self-harm are most common in who?
Females 17-19
26
Acts of suicide are most common in who?
Males 40-59
27
What are the biological factors of depression?
- physical health (migraines)
- genetic vulnerability (mum has depression)
- diet/lifestyle (junk food)
- metabolic disorders
- immune/stress response
- neurochemistry
- emotions
- cognitive factors/IQ
- sleep
- drug effects
28
What are the psychological factors of depression?
- self-esteem
- attitudes/beliefs
- traumatic life events
- emotions
- cognitive factors/IQ
- sleep
- coping skills
- personality/temperament
- interpersonal relationships
29
What are the social factors of depression?
- financial security
- family circumstances
- traumatic life events
- diet/lifestyle
- drug effects
- culture
- work/school
- social support
- interpersonal relationships
30
What should interventions for depression be targeted to?
All three aspects - biological, psychological, social
31
What are adverse childhood experiences (ACEs)?
ACEs are potentially traumatic events that can have negative, lasting effects on health and wellbeing
## Footnote
e.g. parents with depression/alcoholics/drug users/criminal record, parental divorce/separation, adults in home physically abusing each other, physical abuse before 18, verbal abuse before 18, sexual violation by adult/5y older
32
What is the BRFSS adverse childhood experience module?
Questionnaire that asks about traumatic events in childhood
33
What behaviours have a significant association with ACE scores (in order of how likely they are to occur)? (7)
- disability caused by poor health
- depression
- high risk HIV behaviour
- smoking status-current
- use of special equipment because of disability
- binge drinking - drinking anywhere above the legal limit to drive
- heavy drinking - events of this occurring at least 5x a month
34
What kind of association do MIs have with ACEs?
- MI has U-shaped change of association with ACEs
- more and less they occur, the more likely MIs are to occur
- median ACE = low risk of MI
35
What is statistical significance?
When p<0.05
36
What is clinical significance?
- occurs when there is a practical importance of a treatment effect - it makes a difference to the patient
- subjective - clinician's decision
- depends on cause and preference
37
When can you say an intervention is important?
When there is both statistical and clinical significance
38
What is bias?
When systematic error is introduced into sampling or testing by selecting or encouraging one outcome or answer over others
39
What phase of research can bias occur in?
Bias can occur at any phase of research, including study design or data collection, as well as the process of data analysis and publication
40
What are examples of bias?
- confirmation bias
- selection bias
- recall bias
41
What is confirmation bias?
Tendency to interpret new evidence as confirmation of one's existing beliefs or theories
42
What is selection bias?
- selection of individuals, groups or data for analysis in such a way that proper randomisation is not achieved, thereby failing to ensure the sample obtained is representative of the population intended to be analysed
- usually seen in observational studies e.g. cohort, case-control and cross-sectional
43
What is recall bias?
Differences in accuracy or completeness of recollections retrieved by study participants regarding events or experiences from past
44
What is the mechanism of action of SSRIs?
- prevents re-uptake of serotonin so increases its effect in the synapse
- anti-depressant
45
What is the mechanism of action of post-synaptic serotonin receptor agonist?
- mimics effect of serotonin
- anti-depressant
46
What is the mechanism of action of tryptophan hydroxylase inhibitor?
- tryptophan hydroxylase is an enzyme involved in the conversion of tryptophan --> 5-HTP --> serotonin
- therefore an inhibitor would prevent serotonin synthesis
- not an anti-depressant
47
What is the mechanism of action of monoamine oxidase inhibitor?
- monoamine oxidase breaks down serotonin therefore inhibitor prevents serotonin breakdown
- anti-depressant
48
What is the mechanism of action of serotonin auto-receptor inhibitor?
- auto-receptor involved in the negative feedback of serotonin (where serotonin produced binds to reduce production of more)
- inhibitor means it prevents negative feedback of serotonin
- anti-depressant
49
What is the monoamine hypothesis?
- underlying pathophysiology basis of depression is a depletion in the levels of monoamines (serotonin, norepinephrine and/or dopamine) in the CNS
- discovered as drug that treated TB (Isoniazid) also treated depression and was found to impact serotonin and other monoamines
50
What should patients be told when starting antidepressants? (5)
- drugs take several weeks to work
- symptoms may worsen initially
- need to continue for around 6 months after remission of symptoms
- need to wean off drugs gradually - if stopped suddenly it may lead to side effects
- antidepressant interact with many commonly prescribed drugs so it is important to tell doctors you are taking them
51
What would the doctor do if the patient has started the drug for a week and no changes have occurred?
Wait - drugs take several weeks to work
52
What should the doctor do if the patient has started the drug for a few days and the symptoms have worsened?
Wait - symptoms may worsen initially
53
How long after remission of symptoms should you continue the drugs?
6 months
54
Why is it important to tell doctors what other drugs you are taking?
Antidepressants interact with many commonly prescribed drugs so it is important to tell doctors that you are taking them
55
Why do you need to wean off drugs gradually?
If stopped suddenly, can cause side effects
56
Mean Drug-Placebo Difference Scores as a Function of Initial Severity - what does this study show?
- less severe depression may not benefit from antidepressants
- increased severity of depression is associated with better response to antidepressant (vs placebo)
- antidepressants good for severe depression but not for mild/moderate (placebo had similar effect)
57
What is social prescribing?
- means of enabling healthcare professionals to refer people to a range of local, non-clinical services
- recognises that health is determined by a range of social, economic and environmental factors, and seeks to address needs in a holistic way
58
What is the aim of social prescribing?
Aims to support individuals to take greater control of their own health
59
What can social prescribing involve?
A variety of activities which are typically provided by voluntary and community sector organisations
60
What social prescribing should be given to Amy?
- dietary changes
- bereavement counselling (nan passed away)
- self-help books
- gratitude journaling
- legal advice - injunction with ex
61
What is the function of monoamine oxidase and therefore how do MAOIs have an anti-depressant effect?
- MAO breaks down monoamine neurotransmitters not stored in vesicles - serotonin, dopamine, epinephrine, norepinephrine etc
- inhibitors therefore increase the amount of NT in the synapse
62
What two neurotransmitters do tricyclic antidepressants (TCAs) act on?
Serotonin and norepinephrine
63
How do TCAs act as an antidepressant?
They block re-uptake channels of serotonin and norepinephrine, increasing their amounts in the synapse
64
How do SSRIs act as an antidepressant and give an example of one?
- inhibit re-uptake of serotonin to increase its concentration in the synapse
- e.g. Fluoxetine (Prozac)
65
Out of MAOIs, TCAs and SSRIs, which two have more side effects than the third and what are these side effects?
- MAOIs - affect all monoamine NTs in the whole body
- TCAs - can also affect histamines leading to fatigue and sluggishness, also toxic at high doses so dosage should be monitored
66
Why is it that when taking MAOIs you should be careful about what other drugs you take?
MAOIs disrupt metabolism in the liver so other drugs may interact different than how is expected
67
Give examples of the food types you should avoid when taking MAOIs?
Fruits, alcohol, dairy
68
TCAs and lithium are both given in what mental disorder?
Bipolar disorder - SSRIs can sometimes cause manic episodes so not prescribed
69
Which antidepressants are first choice and what are the side effects of these?
- SSRIs
- effect only serotonin but side effects include weight gain, sexual dysfunction and sleeping disturbances --> can affect QoL
70
What is serotonin syndrome?
Too much serotonin caused by TCAs, SSRIs, MAOIs
71
What are three new types of anti-depressants?
- SSRIs and selective norepinephrine reuptake inhibitors (SSRIs + SNRIs - like more restrictive TCAs)
- selective norepinephrine and dopamine reuptake inhibitors (NDRIs)
- selective norepinephrine and dopamine releasing agents (NDRAs)
72
The monoamine hypothesis proposes that patients with depression have depleted concentrations of which NTs?
- serotonin
- norepinephrine
- dopamine
73
What was the original condition that reserpine treated and what does it do in addition?
- hypertensive vascular disease in 1950s
- also inhibited vesicular monoamine transporter --> depletion of brain monoamines like serotonin and catecholamines --> depressant effects
74
What does the revised monoamine hypothesis suggest?
Monoamine depletion may play more of a modulatory role such that it influences other neurobiological systems (e.g. intracellular signalling or other NT and neuropeptide systems) or must be present in the context of stressors
75
What were some of the side effects of Isoniazid (MAOI) which treated TB? (4)
- euphoria
- psychostimulation
- increased appetite
- improved sleep
76
What is monoamine oxidase A primarily responsible for?
Enzyme activity for the deamination of serotonin, melatonin, noradrenaline and adrenaline
77
Is it monoamine oxidase A or B which deaminates dopamine, tyramine and tryptamine?
Both A and B isoenzymes
78
Why were there safety concerns and removal of Isoniazid from US market?
Non-selective irreversible MAOI leading to hypertensive crisis
79
What is an example of a reversible and selective MAOI, and what are its side effects?
Moclobemide - generally well tolerated with most common side effects being nausea and insomnia
80
What class of antidepressant is Imipramine and what does it treat?
Tricyclic antidepressant (TCA) - treatment for major depressive disorder
81
What are five actions of TCAs?
- inhibit presynaptic norepinephrine reuptake transporters
- inhibit presynaptic serotonin reuptake transporters
- blocking postsynaptic adrenergic alpha1 (vasoconstriction and positive ionotropic effects) and alpha2 (analgesia, sedation, vasodilation and bradychardia) receptors
- blocking postsynaptic muscarinic receptors (responsible for decreasing heart rate and inotropy)
- blocking postsynaptic histamine H1 receptors (for nociception, vasodilation and bronchoconstriction)
82
What are some side effects of TCAs?
- blocking of adrenergic receptors --> dizziness and cardiac arrest
- blocking of muscarinic receptors --> memory impairments
- blocking of histaminergic receptors --> drowsiness
83
Other than Fluoxetine, what other SSRIs are there?
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Paroxetine (Paxil)
- Escitalopram (Lexapro)
84
Do SSRIs stimulate the release of serotonin stimulate the release of serotonin/NA presynaptically?
No - also have weak/no direct pharmacological action at postsynaptic serotonin
85
What are three most common side effects of SSRIs?
- nausea
- insomnia
- sexual dysfunction
86
What class of drug is Venlafaxine?
Serotonin-norepinephrine reuptake inhibitor
87
Do SNRIs have pharmacological action at adrenergic, histamine, muscarinic, dopamine or postsynaptic serotonin receptors?
No
88
What side effect may be seen with SNRIs?
Prevalence of sexual dysfunction of SNRIs are comparable with other antidepressant drug treatments
89
What are the general adverse effects of most antidepressants?
- take several weeks to work - hippocampal growth takes a while since in most depressed patients it has shrunk
- need to be weaned gradually
90
What is CBT?
- talking therapy - common treatment for a range of mental health problems
- CBT teaches coping skills for dealing with difficult problems
- focuses on how your thoughts, beliefs and attitudes affect your feelings and actions
91
What two types of therapy does CBT combine?
- cognitive therapy - examining the things you think
- behavioural therapy - examining the things you do
92
What conditions can CBT treat?
- anger problems
- anxiety and panic attacks
- bipolar disorder
- depression
- drug or alcohol problems
- eating problems
- hoarding
- OCD
- perinatal mental health problems
- phobias
- PTSD
- psychosis
- schizoaffective disorder
- schizophrenia
- self-harm
- sleep problems
- stress
93
What alteration of CBT is given to treat PTSD?
Trauma-focused CBT (TF-CBT)
94
Can you be given CBT for physical health problems?
Yes - e.g. if you experience a mental health problem alongside a physical health problem
95
What is stepped care?
- needing to try CBT before you can get to other treatments
- if CBT does not work, they may offer other types of talking therapy/counselling
96
What is social prescribing?
- means of enabling health professionals to refer people to a range of local, non-clinical services
- also aims to support individuals to take greater control of their health
97
Who can generally refer patients to social prescribing?
Professionals working in primary care settings e.g. GPs, practice nurses
98
What are some examples of social prescribing?
- volunteering
- arts activities
- group learning
- gardening
- befriending
- cookery
- healthy eating advice
- range of sports
99
What type of people could benefit from social prescribing?
- mild or long-term mental health problems
- people with complex needs
- people who are socially isolated
- people with multiple long-term conditions who frequently attend either primary or secondary care
100
Organisations of which two sectors typically provide social prescribing activities?
Volunteering and community sector organisations
101
What is the name of the person who works with people to access local sources of support?
Link worker AKA community connector, navigator and health advisor
102
What is the aim of community-centred approaches?
To mobilise the power of communities to generate good health
103
Is social prescribing cost effective?
Yes - study showed that for >8/10 people referred, there were reductions in NHS use (A&E, outpatient appointments, inpatient admissions) - scheme can pay for itself over 18-24 months due to reduced NHS use
104
Does social prescribing work?
Evidence to suggest so e.g. evaluation projected highlighted improvements in anxiety levels and in feelings about general health and QoL
105
Which plan was the first to open the door to social prescribing with its focus on prevention?
NHS Five Year Forward View - 2014
106
Which plan then noted the role of voluntary and community sector organisations?
General Practice Forward View (2016)
107
What did the NHS long-term plan (2019) incorporate?
- social prescribing into its comprehensive model of personalised care
- composed of 6 programmes including personalised care planning and personal health budgets
- model aims to enable people (particularly those with more complex needs) to take greater control of their health and care
108
What is a primary care network made of?
Groupings of GP surgeries serving populations of around 30-50k patients
109
Summary on the side effects of different classes of antidepressants?
- MAOIS - affect many NTs so systemic effects
- TCAs - fatigue and sluggishness since they act on histamine receptors; dizziness, cardiac arrest (adrenergic) and memory impairments (muscarinic)
- SSRIs - weight gain, sexual dysfunctions, sleeping disturbances
- SNRIs - sexual dysfunction
- Isoniazid - euphoria, psychostimulation, increased appetite and improved sleep
- moclobemide - nausea and insomnia
