Depression

Question 1

Core symptoms of depression (2)

Answer 1

Persistent low mood

Anhedonia

Question 2

DSM classification of depression?

Answer 2

Presence of at least 5/9 symptoms present for at least 2 weeks causing significant distress or impairment in function

Question 3

Other defining symptoms of depression (7)

Answer 3

Fatigue/anergia
Excessive or inappropriate guilt 
Recurrent thoughts of death/suicidality
Loss of concentration
Psychomotor agitation/retardation
Insomnia/hypersomnia
Changes in appetite/weight loss

Question 4

What is the two-question approach recommended by NICE in at-risk groups?

Answer 4

During the past month, have you a) felt low, depressed or hopless b) had little interest or pleasure in doing things?

Question 5

Self-report symptom scales which may be used to assist in diagnosis?

Answer 5

Patient Health Questionnaire
Hospital Anxiety and Depression Scale (needs to be purchased)
Beck’s Depression Inventory

Question 6

Suicide risk factors?

Answer 6

Previous suicidality/self harm
Male gender
Unemployment
Living alone
Being unmarried
Alcohol/drug dependence
Physical health problems

Question 7

Management of persisting subthreshold symptoms or mild-moderate depression (2)

Answer 7

Consider watchful waiting, assessing again normally within two weeks
Low intensity psychosocial interventions such as individual guided self-help, computerized CBT

Question 8

In what circumstances would you consider antidepressants in mild to moderate depression? (3)

Answer 8

People with a history of depression
Persistent refractory subthreshold symptoms
Concomitant chronic physical health problem

Question 9

Management of moderate-severe depression (2)

Answer 9

Antidepressant + high intensity psychological intervention

Question 10

Why are SSRIs recommended as first-line antidepressant? (3)

Answer 10

They are as effective as TCAs , safer in overdose and less likely to be discontinued as a result of side effects

Question 11

Examples of SNRIs (2)

Answer 11

Venlafaxine

Duloxetine

Question 12

Why is sertraline preferred in chronic physical health problems?

Answer 12

Lower risk of drug interactions

Question 13

Why consider gastroprotection with SSRIs?

Answer 13

Increased risk of upper GI bleeding particularly in patients on aspirin/NSAIDs

Question 14

How long does it take for symptoms to improve?

Answer 14

At least 2-4 weeks

Question 15

How long should antidepressants continue to be taken after remission?

Answer 15

6 months (at least)

Question 16

How often should young people/people at risk of suicide be reviewed initially?

Answer 16

Within one week, then every two-four weeks for the first three months

Question 17

Side effects of antidepressants to monitor/be aware of

Answer 17

Suicidal thoughts and suicide attempts
Anxiety, agitation or insomnia 
Hyponatraemia
Sexual dysfunction
Nausea/GI upset- usually transient

Question 18

Which class of drugs is most likely to cause sexual dysfunction?

Answer 18

SSRIs

Question 19

If response is absent/minimal by three to four weeks…?

Answer 19

Increase dose
Switch to different SSRI
Switch to a different class

Question 20

How long should antidepressants be discontinued over?

Answer 20

Four weeks

Question 21

In what situation might an SSRI such as sertraline be particularly useful?

Answer 21

Concurrent anxiety disorders e.g. GAD, panic disorders, OCD

Question 22

SSRIs are contraindicated in..?

Answer 22

Poorly controlled epilepsy

Question 23

SSRIs should be used with caution in…(3)

Answer 23

Patients with conditions/other meds causing hyponatraemia, QTc prolongation, GI bleeding risk

Question 24

In what situation might mirtazapine be useful? (3)

Answer 24

Poor sleep
Poor appetite
Where SSRIs are contraindicated

Question 25

Venlafaxine is also licensed for…?

Answer 25

Relief of menopausal symptoms in women with breast cancer

Question 26

Duloxetine is also licensed for..? (2)

Answer 26

Neuropathic pain

Stress incontinence

Question 27

Guidelines used for switching antidepressants?

Answer 27

Maudsley Prescribing Guidelines

Question 28

When to consider referral to secondary care?

Answer 28

Diagnostic uncertainty (e.g. ? bipolar ? schizophrenia)
Specialist advice required- e.g. polypharmacy, lack of response to several agents in primary care, co-morbidity
Personality or psychosocial factors present which make treatment more challenging

Question 29

In post-natal depression, which is the SSRI of choice for a) breastfeeding women b) non breast-feeding women?

Answer 29

a) Sertraline

b) Fluoxetine

Question 30

When do NICE suggest screening for post-natal depression? (2)

Answer 30

4-6 weeks

2-3 months

Question 31

Discontinuation symptoms for SSRIs? (5)

Answer 31

Dizziness/lightheadedness
Agitation
Poor sleep
Headache
Nausea

Question 32

When might trazodone be indicated?

Answer 32

Where sedation is desirable

Question 33

Anti-depressant with best evidence post-MI?

Answer 33

Sertraline