Depression Flashcards
Associated symptoms of depression
Disturbed sleep Decreased/increased appetite/weight Fatigue Poor concentration Feelings of worthlessness Suicidal thoughts
When is seasonal affective disorder diagnosed
If the person has episodes of depression which recur annually at the same time each year with remission in between
Which factors may affect the development, course and severity of depression
Hx of mental illness Past history of mood elevation Living conditions and social isolation Family history Domestic violence/sexual abuse Employment and immigration status
Co-morbid conditions associated with depression
Alcohol or substance abuse Anxiety Eating disorders Psychotic symptoms Dementia
Which questions are important to ask when assessing the risk of suicide
Any thoughts about death or suicide?
Do you feel life is not worth living?
Have you made a previous suicide attempt?
Is there a family history of suicide?
What questions should be asked if an individual has said yes to any of the initial suicide assessment questions
Have you considered a method?
Do you have access to the materials?
Have you made any preparations?
Risk factors which increase the risk of suicide
Previous suicide attempts Active mental illness Family history of mental disorder Male gender Being unemployed Physical health problems Drug/alcohol abuse
Recommended questionnaires for detecting depression and assessing severity
PHQ-9
HADS
BDI-II
Interpretation of PHQ-9
Max score of 27
Scores of 5, 10, 15 and 20 represent cut off points for mild, moderate, moderately severe and severe depression, respectively
General management of depression in primary care
Manage suicide risk
Manage safeguarding concerns
Manage any co-morbid condition associated with depression
Useful contact for managing suicide risk in primary care
Crisis Resolution and Home Treatment(CRHT) team for urgent assessment
When should antidepressants be considered for mild-to-moderate depression
Avoid routine use
Consider in:
History of moderate or severe depression
Subthreshold depressive symptoms that have persists for a long period
Mild depression that is complicating the care of a chronic physical health problem
Management of mild-to-moderate depression in primary care
Low-intensity psychosocial intervention
CBT
What should be evaluated before starting an antidepressant
Suicide risk and toxicity in overdose
Risk of anxiety worsening
Explain that antidepressants take time to work and should be continued for at least 6 months following remission of symptoms to reduce risk of relapse
Who does the mental health act allow compulsory admission for
People who:
Have a mental disorder of a nature or degree that warrants assessment or treatment in hospital, and
Need to be admitted in the interests of their own health or safety, or for the protection of other people
How long does section 2 allow compulsory admission for
Up to 28 days for assessment
How long does section 3 allow compulsory admission for
Up to 6 months for treatment
Who does section 2 and 3 of the mental health act require approval from
Approved mental health professional, or the person’s nearest relative
Written recommendations from two doctors; one of whom is section 12 approved(psychiatrist) and one who has previous acquaintance with the individual(usually GP)
When is section 4 of the mental health act used and how long does it allow for compulsory admission for?
Used in exceptional cases to permit compulsory admission for up to 72 hours if there is urgent necessity, and undesirable delay
Who does section 4 require approval from
Requires application from an AMHP(or person’s nearest relative) and just one medical recommendation
Who can use section 136 of the mental health act
Used by the police to take people from a public place to a place of safety so they can be assessed
Can young people who have capacity to consent be admitted on the basis of their parents’ consent
Young people aged 16 or 17 who have capacity to consent, but refuse to do so, cannot be admitted or kept in hospital for treatment on the basis of parents’ consent
They will need to be formally detained under MHA
Examples of low-intensity psychosocial interventions
Individual guided self-help, based on the principles of CBT
Computerised CBT
Structured group-based physical activity programme
Examples of high-intensity psychological interventions
Individual CBT
Interpersonal therapy
Behavioural activation
Couples therapy
First line antidepressant for the first episode of depression
SSRI such as citalopram, fluoxetine, paroxetine or sertraline
Which SSRI may be preferred if a person has a chronic physical health problem alongside depression
Sertraline due to lower risk of drug interactions
Which SSRI should be avoided in patients already taking medications that can prolong QT interval
Citalopram or escitalopram
Organisations that can help with depression
MIND
Depression Alliance
General advice for an individual receiving SSRIs for treatment
To be vigilant for worsening depressive symptoms and suicidal ideas especially when starting and changing meds
Usually takes 2-4 weeks to improve
Not addictive
May experience discontinuation symptoms if they stop taking antidepressants abruptly
When should you review someone with depression if they are not considered to be at an increased risk of suicide
Arrange an initial review within 2 weeks
Review regularly thereafter - for example, every 2-4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered
When should you review someone with depression if they are at an increased risk of suicide, or people aged under 30 years
Arrange an initial review within 1 week
Review frequently thereafter until the risk is no longer considered clinically important
Next step of treatment if low-intensity psychosocial intervention has not worked for depression
High-intensity psychological intervention or an antidepressant
Next step is combination therapy
Advice regarding use of St john’s wort in depression
Advise to avoid
Adverse effects of antidepressants that should be monitored for
Suicidal thoughts and suicide attempts
Anxiety, agitation, or insomnia
Hyponatraemia
Sexual dysfunction
Symptoms of hyponatraemia
Dizziness Drowsiness Confusion Nausea Muscle cramps Seizures
Management of hyponatraemia in individuals taking antidepressants
Stop the antidepressant
Manage according to severity and duration of symptoms, and state of hydration
After serum sodium levels have normalised, choose another appropriate antidepressant
Risk factors for hyponatraemia in individuals taking antidepressants
Older age Female gender Major surgery History of hyponatraemia Co-therapy with diuretics, NSAIDs etc Reduced renal function Low body weight Medical comorbidity
Management of sexual dysfunction in depression
Watchful waiting
Reducing dose of antidepressant
Drug holidays(missing doses prior to planned sexual activity)
Adjunctive treatment with sildenafil
Features of serotonin syndrome
Confusion Delirium Shivering Sweating Changes in blood pressure Myoclonus
How should antidepressants be stopped
Reduce the dose or frequency gradually over a 4-week period
Discontinuation symptoms of antidepressants
Restlessness Problems sleeping Unsteadiness Sweating Abdominal symptoms Altered sensations(Paraesthesia) Irritability Anxiety
What should be co-prescribed if a patient is taking an NSAID along with an SSRI
PPI
SSRIs in pregnancy
Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
What type of antidepressant is rasagiline
MAOI
Which SSRI has a longer half-life and therefore has a lower risk of inducing withdrawal symptoms
Fluoxetine
Definition of treatment-resistant depression
Persistent depressive symptoms not responsive to two antidepressants for a minimum of 4-6 weeks at therapeutic dose
Management of treatment-resistant depression
- Mirtazapine(NaSSA) and venlafaxine(SNRI), or other combinations
- Augment with an antipsychotic
- Lithium
- ECT
First line treatment of diabetic neuropathy
Duloxetine
Side effects of SNRIs
Risk of cardiac dysfunction with SNRIs such as venlafaxine + greater risk of toxicity in overdose than SSRIs + seizures
Section 5(2) of MHA
Detention of a patient already in hospital for up to 72 hours (A&E does not count)
Can be put on by the ward doctor or an Approved Clinician
Section 5(4) of MHA
Any authorised psychiatric nurse may use force to detain a voluntary ‘mental’ patient who is taking their own discharge against medical advice, if such a discharge would be likely to involve serious harm to the patient (eg, suicide) or to others.
During the 6 hours, the nurse must find the necessary personnel to sign a Section 5(2) application or allow the patient’s discharge.
Section 2 of MHA
The period of assessment (and treatment) lasts for up to 28 days and is not renewable.
Patients’ appeals must be sent within 14 days to the mental health tribunal (composed of a doctor, lay person and lawyer).
An AMHP or the NR makes the application on the recommendation of two doctors, one of whom is ‘approved’ under Section 12(2) of the Act (in practice a consultant psychiatrist or a specialist registrar of sufficient experience). The second medical recommendation is given by a doctor who knows the patient personally in a professional capacity.
Section 3 of MHA
Detention for treatment for 6 months. The exact mental disorder must be stated.
Detention is renewable for a further six months (annually thereafter).
Two doctors must sign the appropriate forms and know why treatment in the community is contra-indicated. They must have seen the patient within 24 hours and there may not be more than five clear days between the time the first doctor saw the patient and the time when the second doctor saw them. They must state that treatment is likely to benefit the patient, or prevent deterioration; or, that it is necessary for the health or safety of the patient or the protection of others. The AMHP has 14 days after the second doctor has signed their recommendation in which to make an application to hospital.
Section 136 of MHA
For up to 72 hours
Allows police to arrest a person ‘in a place to which the public has access’ and who is believed to be suffering from a mental disorder.
The patient must be conveyed to a ‘place of safety’ (usually a designated A&E department) for assessment by a doctor (usually a psychiatrist) and an approved social worker.
The patient must be discharged after assessment or detained under Section 2 or 3. The patient may also accept the offer of a voluntary admission into hospital.
SSRI discontinuation symptoms
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
How should SSRIs be reduced
Over 4 week period
