Depression Flashcards
1
Q
What is the ICD-10 for depressive disorder?
A
Over a 2 week period (must have at least 2): 1. persistent low mood 2. loss of interest or pleasure 3. fatigue or low energy If any above, then ask about: 4. disturbed sleep 5. poor concentration or indecisiveness 6. low self confidence 7. poor or increased appetite 8. suicidal thoughts or acts 9. agitation or slowing of movement 10. guilt or self blame
2
Q
What is the episode severity of depressive disorder from ICD-10?
A
- 4 symptoms = mild
- 5-6 symptoms = moderate
- 7+ symptoms = severe (+/- psychotic symptoms)
3
Q
What is the DSM-5 of major depressive disorder?
A
5 or more of the following over a 2 week period (must have one of *)
- depressed mood*
- markedly diminished interest or pleasure in all activities*
- poor or increased appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or inappropriate guilt
- diminished ability to think or concentrate
- recurrent thoughts of death or suicide
3
Q
What is the DSM-5 definition of sub-threshold (minor) depression?
A
If the person has at least 2 symptoms but fewer than 5 symptoms of depression.
4
Q
What is the DSM-5 definition of mild major depressive episode (mild MDE)?
A
If the patient has few, if any, symptoms in excess of 5 and mild functional impairment.
5
Q
What is the DSM-5 definition of moderate depressive episode (MDE)?
A
More than minimum number of symptoms and moderate functional impairment.
6
Q
What is the DSM-5 definition of severe depressive episode (MDE)?
A
Most symptoms are present and marked or greater functional impairment.
7
Q
What are the 3 core symptoms of depression?
A
- Low mood
- Anhedonia
- Fatigue
8
Q
What are baby blues?
A
- Recorded in up to 70% of mothers
- Tearfulness, irritability, low mood and restlessness
- Symptoms peak at day 4 post delivery
- Symptoms are transient and should dissipate within 10 days
- Watchful waiting
9
Q
What is postnatal depression?
A
- Ask about risk to self, others and baby
- Features of depression, fears about baby’s health (affects bonding with baby), maternal deficiencies and marital tensions including loss of sexual interest
- Most prevalent 8-12 weeks post partum
- Lifestyle advice, CBT, antidepressant (SSRI), if severe home treatment team or hospital admission (mother and baby unit for psychiatric treatment)
10
Q
What are the investigations for suspected depression?
A
- BP, HR, BMI - baseline for antidepressants
- FBC, U+E, LFT, TFT, HbA1c - diabetes, hypothyroidism
- Vit B12 + folate
- ECG
- MRI - for differentials
11
Q
What are common side effects of SSRIs?
A
- GI upset
- Mild nausea
- Drowsiness
- Dry mouth
- Decreased sex drive, impotence or difficulty having an orgasm
12
Q
What are uncommon side effects of SSRIs?
A
- Palpitations
- Tremor
- Weight gain
- Urinary incontinence/retention
13
Q
What are the symptoms that are risk factors for relapse in MDE patients?
A
- Presence of residual symptoms
- Number of previous episodes
- Severity, duration and degree of treatment resistance of the most recent episode
14
Q
What is the relapse prevention strategy in the management of depression?
A
Continue effective treatment of the acute treatment after remission with the duration determined by risk of relapse:
- Low risk of relapse (e.g. 1st episode patients without risk factors) at least 6-9 months after full remission
- Consider at least 1 year after full remission if any risk factors
- In high risk patients (e.g. >5 lifetime episodes +/or 2 episodes in the last few years) at least 2 yrs should be advised and potentially long term treatment considered.
15
Q
What presentations of depression should the GP refer to psychiatric services?
A
- If there is a significant perceived risk of suicide, or harm to others or of severe self neglect
- If there are psychotic symptoms
- If there is a hx or clinical suspicion of bipolar disorder
- In all cases where a child or adolescent is presenting with major depression
16
Q
What questions need to be asked in the suicide risk assessment?
A
- What precipitated the attempt?
- Why did they choose that time and place?
- Was it planned or impulsive? e.g. leave a note
- Were they intoxicated? e.g. drugs/alcohol
- Did they take precautions against discovery e.g. was their husband out the house?
- Has there been previous attempts at suicide or self harm?
- How do they feel about it now?
- Questions to assess current severity of depression - ongoing suicidal thoughts
- If they go home what supports and stresses will they have?
- Do they have any thoughts to harm/kill anyone else? Do they have kids that are at risk?
- What do they think about the future?
17
Q
Who are at high risk of depression?
A
- Age >45yrs
- Physical illness
- Unemployed
- Divorced, widowed or single
- Psychiatric illness
- FH of depression, substance misuse or suicide
- Previous suicide attempts
- Male
- Substance misuse
18
Q
What is the pharmacological treatment for depression?
A
- 1st line is an SSRI e.g. sertraline, fluoxetine, citalopram
- 2nd line would be switching to a different SSRI or mirtazapine
- Other TCAs and venlafaxine should be considered for more serious forms of depression
19
Q
What is the management of depression?
A
- Intensive management under care of Crisis Resolution/Home Treatment Team (CRHTT)
- CBT - 16-20 sessions over 3-4 months, consider 2 sessions per week for the first 2 weeks in moderate to severe depression
20
Q
What are the risks of stopping antidepressants?
A
- Withdrawal syndrome if antidepressant stopped suddenly/very quickly
- Recurrence of depression when patient stops taking antidepressants
- Important to taper and stop antidepressant over minimum of 4 weeks, if symptoms come back restart treatment
- Choose to stop at appropriate time - not during or approaching time of stress e.g. exams, divorce
21
Q
What to do if a discontinuation reaction occurs when stopping antidepressants?
A
- Explanation and reassurance are often all that is required
- If this is not sufficient and for more severe reactions, the antidepressant should be restarted and tapered, more slowly
- For SSRIs and SNRIs consider switching to fluoxetine which can be stopped when discontinuation symptoms have subsided.
22
Q
What are the symptoms of antidepressant discontinuation (withdrawal) syndrome?
A
- Dizziness
- Headaches
- Nausea
- Lethargy
- Ataxia
- Electric shock sensations (particularly scalp)
- EPSE
- Hypomania/mania
23
Q
Describe the action of mirtazapine
A
- Antidepressant that blocks alpha2-adrenergic receptors which increases release of neurotransmitters.
- It has fewer side effects and interactions than many others.
- 2 main SEs are sedation and increased appetite so useful for insomnia and reduced appetite.
- Can increase cholesterol and triglycerides and weight gain
24
What is postpartum psychosis?
- FH and PMH of postpartum psychosis and bipolar disorder increases risk
- Peak onset 3-7 days
- Symptoms: purposeless activity, change in behaviour or personality, irritability, fleeting anger and insomnia.
- Can develop into florid psychotic symptoms with bizarre delusions, auditory and visual hallucinations
- Need to check if delusions relating to baby
- Anyone with these symptoms need to be seen by psychiatrist in 4 hrs - treatment most likely under the MHA with antipsychotic medication
25
What is maternal OCD?
Onset of intrusive obsessive thoughts in perinatal period, can be distressing with violent or sexualised themes relating to baby - they recognise they are not good thoughts.
26
What is the risks of bipolar affective disorder and schizophrenia in pregnancy?
- Patients are at significant risk of relapse in perinatal period - risk of postpartum depression and psychosis so will require monitoring and potentially prophylactic medication
- Schizophrenia - consideration regarding medication in pregnancy and breastfeeding, increased monitoring
27
What is puerperal psychosis?
- ~6 weeks after birth when mother's reproductive organs return to non pregnant state
- Symptoms tend to develop within first 2 weeks - can take form of cycling between mania and depression or schizophrenia
- May be high suicidal drive
28
What are the perinatal red flags?
- Sudden onset/rapidly worsening mental health
- New thoughts or acts of self harm (especially violent)
- Persistent feelings of estrangement from baby
- Persistent feelings of incompetency as a mother
- Thoughts to harm others
29
How can you assess postnatal mental state?
Edinburgh Postnatal Depression Scale
30
What are the indications for ECT?
- Severe depression - particularly psychotic
| - Depression resistant to other treatments - can become catatonic
31
How is ECT administered?
Given under short IV GA and muscle relaxant by anaesthetist. Given as a course, usually twice weekly for a number of weeks.
32
How is relapse prevented after ECT?
- Prophylactic antidepressants e.g. nortriptyline or venlafaxine
- Maintenance ECT e.g. once monthly
33
What are the adverse effects of ECT?
- Headache
- Nausea
- Cardiac arrhythmias
- Muscle soreness
- Retrograde amnesia for the hour or so before ECT
- Short term memory impairment
- More problematic memory impairment can occur with longer courses
34
When can ECT be administered without consent?
1. Needs emergency treatment because:
- there is a real risk to patient's life
- to stop patient becoming seriously unwell
- to stop patient becoming a risk to self or others
2. Or lacks capacity to consent:
- Requires the agreement of an independent 2nd opinion Appointed Doctor
- However can't be given even if SOAD agrees if patient has a valid advance decision refusing ECT or LPoA refuses on their behalf
