Depression Flashcards
What are the Core Features of Depression?
Low Mood
Anhedonia
Fatigue
How long does it need to last for? (core features of depression)
At least 2 weeks
Depressive Symptoms - Non-core symptoms (biological, psychological, cognitive)
BIOLOGICAL - 4
COGNITIVE - 3
PSYCHOLOGICAL - 4
Depressive Symptoms - Non-core symptoms (biological, psychological, cognitive)
- Sleep
- Appetite
- Libido
- Reduced energy
- All examples of what types of depressive symptoms?
biological
- Difficulty concentrating
- Memory loss
- Attention impairment
- All examples of what types of depressive symptoms?
cognitive
- Worthlessness
- Guilt
- Hopelessness
- Suicidal Ideation
- All examples of what types of depressive symptoms?
psychological
GP Consultation - Depression example
How do we treat?
cbt - 6weeks
What other psychological therapies options might there be in addition to CBT?
- Self-help services
- Mindfulness/online courses/apps
- Counselling
- Interpersonal therapy
- Family therapy
- Psychodynamic Psychotherapy
What else may be helpful for Samir that the GP can support him with?
- Work - time off/support/adjustments
- Finances/benefits
- Sleep Hygiene
- Exercise and regular activity
- Support to recruit the help of family and friends
- Psychoeducation
- Support Groups
Medication example for mild/moderate depression?
sertaline 50mg for 4 weeks
What are the side effects of SSRIs Samir may be experiencing?
- agitation, nausea, dizziness, low sex drive, constipation or diarrhoea, suicidal thoughts can increase, particularly in <25s.
- Sometimes patients don’t disclose sexual side effects – these can persist and contribute to relationship issues – need to ask directly.
Side effects of SSRIS?
agitation, nausea, dizziness, low sex drive, constipation or diarrhoea, suicidal thoughts can increase, particularly in <25s.
NICE Guidelines - Depression
- Fill in table
- Note; medication only comes in from step 2 onwards – Rx for mild depression is psychological/psychosocial!
- Important to reiterate to students here that for mild depression, low intensity psychological intervention is the treatment option, and not straight to pharmacological input. We are treating a ?moderate depressive episode, hence use of both SSRI and CBT.
- We may not see many mild cases of depression that are treated within primary care.
NICE Guidelines - Depression
- Fill in table
- Note; medication only comes in from step 2 onwards – Rx for mild depression is psychological/psychosocial!
- Important to reiterate to students here that for mild depression, low intensity psychological intervention is the treatment option, and not straight to pharmacological input. We are treating a ?moderate depressive episode, hence use of both SSRI and CBT.
- We may not see many mild cases of depression that are treated within primary care.
NICE Guidelines - Depression
- Fill in table
- Note; medication only comes in from step 2 onwards – Rx for mild depression is psychological/psychosocial!
- Important to reiterate to students here that for mild depression, low intensity psychological intervention is the treatment option, and not straight to pharmacological input. We are treating a ?moderate depressive episode, hence use of both SSRI and CBT.
- We may not see many mild cases of depression that are treated within primary care.
NICE Guidelines - Depression
- Fill in table
- Note; medication only comes in from step 2 onwards – Rx for mild depression is psychological/psychosocial!
- Important to reiterate to students here that for mild depression, low intensity psychological intervention is the treatment option, and not straight to pharmacological input. We are treating a ?moderate depressive episode, hence use of both SSRI and CBT.
- We may not see many mild cases of depression that are treated within primary care.
Samir goes back to GP after 6 months… - what is the next steps? (plan)
Try alternative SSRI - citalopram 20mg 1 tablet for 4 weeks
Samir - 3 months later…..
- Samir books urgent appointment with GP as he feels his mood has deteriorated further
- He has lost his job
- Expressing suicidal thoughts although he has no current intent or active plans
- What would the plan be?
- Samir books urgent appointment with GP as he feels his mood has deteriorated further
- He has lost his job
- Expressing suicidal thoughts although he has no current intent or active plans
- Agreed with plan for urgent referral to Community Mental Health Team and safety-netting
What specific parts of a history might Samir be asked if seen in secondary care?
- Presenting complaint and history of presenting complaint
- Past medical history
- Drug history + allergies
- Family history
- Drug and Alcohol History
- Social history - home life, education, work, social support, finances
- Personal and developmental history
- Forensic history
- Pre-morbid personality
- Risk
What is important to include in psych history? 4 things - (different from normal hx)
- Personal and developmental history
- Forensic history
- Pre-morbid personality
- Risk (suicide/self-harm/harm to others etc…)
Samir struggles to cope at home and presents to A+E with suicidal ideation and self-harm (lacerations to wrists) before he can attend his Community Mental Health Team (CMHT) appointment - Which team is Samir likely to see in A+E?
-
Mental Heath Liaison Team
- See people presenting to A+E in acute mental health crisis
- Multidisciplinary Team made up of variety of professionals
- Also provide care for those admitted to a general hospital
Mental Heath Liaison Team
- Who do they see?
- Who is in the team?
- Who else do they provide care for?
- See people presenting to A+E in acute mental health crisis
- Multidisciplinary Team made up of variety of professionals
- Also provide care for those admitted to a general hospital
Mental Health Liaison Team Risk Assessment (Samir)
- The 5 Ps….
- 1. Presenting: Low mood, self-harm wounds, suicidal ideation. Displaying psychotic symptoms - paranoia; believes he is being watched and that his family are going to get hurt or killed as a punishment. Thinks if he kills himself this will stop.
- 2. Predisposing: History of moderate to severe depression.
- 3. Precipitating: Loss of job, relationship breakdown.
- 4. Perpetuating: Little social support, has struggled living alone during lockdown
- 5. Protective: His family and a few friends, wanting to gain employment.
What are the 5P’s?
(1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors
What are the 5P’s?
(1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors
- You are the FY2 working with the Mental Health Liaison Team.
- You have been to see Samir as part of the assessment.
- What would your plan be?
- You are going to go back to discuss with your consultant –what do you think?
- Do you think Samir is safe to be discharged?
- Risk, Historical factors, MSE factors,; reiterate here that it would be a team decision – FY2 would not make decision alone re. discharge.
Samir is admitted informally to Langley Green Hospital…, Seen for Ward Review on admission….
- Highlight to students the MDT interventions that are part of the inpatient care plan – not just medication as an option!
What might the options be for Samir? (Risk for Samir with suicidal ideation and emerging psychotic symptoms, lack of social support system at home/living alone likely to lead to admission)
- Crisis Team – providing care for Samir at home to manage his risk
- Admission to Hospital - How could this happen?
- • Informal Admission
- • Mental Health Act
- • We are aiming for the least restrictive option
Psychotic Symptoms of Depression
- Mood-… vs Non mood-…
- Delusions of …, poverty, illness, … delusions
- Hallucinations
- Higher risk of …-… or …
- Psychotic symptoms may be associated with … outcomes
- Mood-congruent vs Non mood-congruent
- Delusions of guilt, poverty, illness, nihilistic delusions
- Hallucinations
- Higher risk of self-harm or suicide
- Psychotic symptoms may be associated with poorer outcomes
Management of Severe Depression
- … approach – an individualised care plan
- Inpatient vs outpatient care
- Anti…
- Anti…
- … therapies
- E…
- … Interventions
- Holistic approach – an individualised care plan
- Inpatient vs outpatient care
- Antidepressants
- Antipsychotics
- Psychological therapies
- ECT
- Social Interventions
Ward review – 2 weeks on … (Samir)
- Samir was reported to be brighter in mood and engaging with team
- No longer expressing delusions, no psychotic symptoms
- Denied any current suicidal ideation
- 2 weeks on olanzapine
- 1:1 with charge nurse following escorted leave:
- Samir appeared brighter when he returned from leave to the shops. He felt safe when he was out, very relieved, no longer thinks he is being followed or watched. Slept better last night, has been eating more regular meals. We talked about his hope to get back home soon and spend time with his family. Has positive thoughts about the future.
What might we have considered as next treatment step if Samir was not improving?
- Electroconvulsive therapy
- Induced seizure, under general anaesthetic
- Useful in a variety of conditions: severe depression, catatonia, prolonged mania
- Response rate 70% for severe depression
Electroconvulsive Therapy
- What is it?
- Useful in what conditions?
- Response rate is what for severe depression?
- Induced seizure, under general anaesthetic
- Useful in a variety of conditions: severe depression, catatonia, prolonged mania
- Response rate 70% for severe depression
Electroconvulsive Therapy
- What is it?
- Useful in what conditions?
- Response rate is what for severe depression?
- Induced seizure, under general anaesthetic
- Useful in a variety of conditions: severe depression, catatonia, prolonged mania
- Response rate 70% for severe depression
ECT controversy/problems
- Controversy in the past (historically used without …, without…, shown in film/tv).
- Side effects can include
- Immediate: headache, fatigue, confusion, nausea
- Medium: short-term… loss
- Long-term: …-term … loss (changes in … reported, controversial)
- … and consent issues
- Controversy in the past (historically used without anaesthetic, without consent, shown in film/tv).
- Side effects can include
- Immediate: headache, fatigue, confusion, nausea
- Medium: short-term memory loss
- Long-term: long-term memory loss (changes in personality reported, controversial)
- Capacity and consent issues
Moving towards discharge… (depression)
- Discharge planning, MDT working. Ask students who might be involved?
- Pharmacist to discuss meds
- Psychological work
- OT activities on ward, home visit before discharge
- Art therapy
- Psychoeducation with self and family around relapse prevention plan
Discharged with CRHTT
- What is the role of the CRHTT? (Crisis Resolution and Home Treatment Team)
- Patients under their care in the … term
- Aimed at reducing … and … of hospital admissions
- Help ease the … on inpatient units – keep people at home safely
- Mixed MDT of different … … professionals
- Can visit people at home, in crisis centres, or in hospital who are due to be discharged
- 24/7 and act as … to acute mental health services
- What is the role of the CRHTT? (Crisis Resolution and Home Treatment Team)
- Patients under their care in the short term
- Aimed at reducing number and length of hospital admissions
- Help ease the pressure on inpatient units – keep people at home safely
- Mixed MDT of different mental health professionals
- Can visit people at home, in crisis centres, or in hospital who are due to be discharged
- 24/7 and act as gatekeeper to acute mental health services
Discharged with CRHTT
- What is the role of the CRHTT? (Crisis Resolution and Home Treatment Team)
- What is the role of the CRHTT? (Crisis Resolution and Home Treatment Team)
- Patients under their care in the short term
- Aimed at reducing number and length of hospital admissions
- Help ease the pressure on inpatient units – keep people at home safely
- Mixed MDT of different mental health professionals
- Can visit people at home, in crisis centres, or in hospital who are due to be discharged
- 24/7 and act as gatekeeper to acute mental health services
Discharged back to community - Samir
- Samir improved significantly
- Discharged from home treatment team back to GP in 2 weeks
- He has a new job
- Seeing friends and showing interest in activities
- Spending time with family
- Untreated depression is a major cause of … or …
- It is often under-… and under…
- Untreated depression is a major cause of morbidity or mortality
- It is often under-recognised and undertreated
…-…% of people with major depressive disorder can achieve a significant reduction in symptoms, although around half may not respond to the initial treatment trial.
- 70-80% of people with major depressive disorder can achieve a significant reduction in symptoms, although around half may not respond to the initial treatment trial.
70-80% of people with major depressive disorder can achieve a significant reduction in symptoms, although around … may not respond to the initial treatment trial.
Depression - Treatment should be maintained for minimum of … months after remission for one episode, … years for recurrent episodes
Depression - Treatment should be maintained for minimum of 6 months after remission for one episode, 2 years for recurrent episodes
Treatment for depression should be maintained for how long after remission? (one episode vs recurrent episodes)
minimum of 6 months after remission for one episode, 2 years for recurrent episodes
Treatment for depression should be maintained for how long after remission? (one episode vs recurrent episodes)
minimum of 6 months after remission for one episode, 2 years for recurrent episodes
