Depression Flashcards
What are the core features of depression?
Depressed mood
Loss of interest (anhedonia)
Lack of energy (anergia)
What are additional symptoms of depression?
Loss of confidence/senf-esteem
Unreasonable feelings of self-reproach or excessive guilt
Recurrent thoughts of death or suicide
Decreased ability to think or concentrate, indecisiveness
Change in psychomotor activity - agitation or retardation
Bleak and pessimistic views of the future
Sleep disturbance
Change in appetite and corresponding weight change
What is psychomotor retardation?
Slowing of thoughts and reduction of physical movements, speech and affect
How are appearance and behaviour altered in depression?
Reduced eye contact
Reduced facial expression
Limited gesturing (psychomotor retardation)
Difficult to establish rapport
Describe speech in depression
Slow
Lowered in pitch
Quiet
Monotonous (reduced intonation)
Increased latencies (longer time between end of a question and them starting to speak)
Limited content (answers are often short, brief, and unembellished)
Describe mood in depression
Low, down, miserable, unhappy, sad, flat, empty, black, numb
Describe affect in depression
Reduced range - stays low throughout
Limited reactivity
Describe thoughts in depression
Form - normal
Flow - slow
Content
- Negative, failure, guilt, low self esteem, pessimism
- Delusions - of poverty, nihilism, hypochondriasis
- Suicidal thinking
Describe perception in depression
Most have no perceptual disturbance
Increased self-referential thinking (people are talking about me)
Hallucinations (usually auditory, second person and derogatory, negative and depression)
Describe cognition in depression
Slow
Poor memory (inattention)
‘Pseudo-dementia’
Deficits in working memory, attention and planning
Describe insight in depression
Insight preserved
Aware of their symptoms - recognition intact
Attribution not always correct - symptoms can be blamed on sins, physical illness, personal failings
What are the subtypes of depression?
Somatic syndrome
Atypical depression
Psychotic depression
Chronic depression
What is somatic syndrome?
4 of the following present:
- Marked loss of interest or pleasure in activities that are normally pleasurable
- Lack of emotional reactions to events or activities that normally produce an emotional response
- Waking in the morning 2 hours before the usual time (early morning wakening)
- Depression worse in the morning
- Objective evidence of marked psychomotor retardation or agitation (remarked on or reported by others)
- Marked loss of appetite
- Weight loss (5% or more of body weight in the past month)
- Marked loss of libido
What is atypical depression?
Mood reactivity - mood brightens in response to actual/potential positive events
Weight gain or increase in appetite
Hypersomnia
Leaden paralysis - heavy feeling in arms or legs
Long-standing pattern of interpersonal rejection sensitivity
What is psychotic depression?
Depression with psychotic features
Occasionally paranoid
What is chronic depression?
2 years of depression
Not necessarily treatment refractory
What is the medical differential of depression?
Hypothyroidism Cushing's Syphilis SLE Drugs: steroids, isotretinoin, B blockers
What are the psychiatric differentials of depression?
Bipolar Schizophrenia Generalised anxiety disorder Substance misuse Dementia Dysthymia Bereavement reaction
How would you differentiate depression from bipolar disorder?
Have you ever had periods of the opposite where your mood has been very high?
How would you differentiate depression from schizophrenia?
Have you ever experienced anything (seeing or hearing) that others haven’t or had thoughts that seemed unusual but you weren’t able to shake?
How would you differentiate depression from generalised anxiety disorder?
Do you feel yourself anxious, any physical symptoms of anxiety?
What is dysthymia?
Chronic mild depression for a minimum of 2 years in which episodes are either not long enough or severe enough to meet criteria for depression
What is the criteria for depression?
Symptoms for minimum 2 weeks
Presence of at least 2 of the core symptoms
What is classed as mild depression?
2 core symptoms + 2 additional symptoms
In distress but able to continue with activities of daily living
What is classed as moderate depression?
2 core symptoms + 4 additional symptoms
Associated difficulty in carrying out activities of daily living
What is classed as severe depression?
3 core symptoms + 5 additional symptoms
Associated with hopelessness, worthlessness, suicidal ideation, somatic symptoms and complete inability to carry out activities of daily living
What is the management of depression?
Reassure the patient that in time, mood will get better
Self-supportive measures (self-help, talk to people, exercise, activities you used to enjoy)
CBT
Antidepressants
ECT
How long should antidepressants be continued for? (for a first episode, and subsequent episodes)
First episode - at least 6 months after full recovery w/o reducing dose
Second+ episode - at least 1-2 years after full recovery w/o reducing dose
May be needed lifelong
When is ECT used?
Life-saving or very treatment resistant cases
When a quicker response than anti-depressants can offer is needed
What are the classes of antidepressants?
Selective Serotonin Re-uptake Inhibitors (SSRI)
Tricyclics
Serotonin and Noradrenaline Re-Uptake Inhibitors (SNRI)
Noradrenaline and Serotonin Specific Antidepressant (mirtazapine)
Monoamine oxidase inhibitors
What is the first line class of antidepressant for depression?
SSRIs
What are examples of SSRIs?
Fluoxetine
Sertraline
Paroxetine
Citalopram
What is the mechanism of SSRIs?
Block serotonin re-uptake from the synapse
Reduce inhibitory controls of serotonin release
What other conditions are SSRIs used for?
GAD
Panic disorder
Phobia
OCD
What are the side effects of SSRIs?
GI upset (abdo pain, constipation, nausea) - usually settles in a couple weeks
Increased risk of GI bleeds
Increased anxiety, insomnia, agitation, sexual dysfunction
Increased suicidality in first few weeks in younger patients
Hyponatremia and falls in older patients
Withdrawal
What are the withdrawal symptoms of SSRIs?
Flu-like symptoms Insomnia Nausea Imbalance Sensory disturbance Hyperarousal (FINISH)
What are examples of tricyclics?
Amitriptyline Nortriptyline Imipramine Lofepramine Clomipramine
What is the mechanism of tricyclics?
Block the re-uptake of noradrenaline and serotonin from the synapse by blocking their transporters
When are tricyclics used in depression?
Second line after SSRIs
Effective at reducing anxiety
When should tricyclics be avoided?
For patient working as driver or operating machinery - strong sedative
Recent MI or history of arrhythmia
What are the side effects of tricyclics?
Sedation
Weight gain
Cardiac - long QT (arrhythmia), postural hypotension
Anticholinergic - dry mouth, constipation, blurred vision, urinary retention
sexual dysfunction
What are examples of SNRIs?
Venlafaxine
Duloxetine
What is the mechanism of SNRIs?
Selectively block the re-uptake of noradrenaline and serotonin from the synapse by blocking their transporters
Weak antagonists of dopamine re-uptake
When are SNRIs used?
Second line to SSRI
If others not tolerated
What are the side effects fo SNRIs?
GI upset
Cardiac - HTN, palpitations, dizziness
What is the mechanism of mirtazapine?
Antagonizes presynaptic noradrenaline, serotonin and histamine receptors
When is mirtazapine used?
Second line
For those where weight loss or sleep are issues
Used in isolation or combination with SSRI
What are the side effects of mirtazapine?
Sedation
Weight gain
Can cause nausea or sexual difficulties but less likely to
What are examples of monoamine oxidase inhibitors?
Moclobemide
Phenelzine
What is the mechanism of monoamine oxidase inhibitors?
Block monoamine oxidase which presents the breakdown of serotonin and noradrenaline amongst other neurotransmitters
When are monoamine oxidase inhibitors used?
Good in atypical depression
What are the downsides off monoamine oxidase inhibitors?
Interact with tricyclics and SSRIs so need to be off them for several weeks before starting (risk of hypertensive crisis)
Penelzine requires dietary restriction - avoid cheese, red wine, soy
What are the side effects of monoamine oxidase inhibitors?
Dizziness
Postural hypotension
Anticholinergic effects
How long do antidepressants take to work?
4-6 weeks
What is the general algorithm for order of antidepressants to try?
- SSRI
- Increase dose then try different SSRI
- Switch to SNRI (or tricyclic)
- Mirtazapine
- Augment with antipsychotics, lithium
What antidepressant should be prescribed in the elderly?
Not SSRI due to hyponatremia/falls risk
What antidepressant should be prescribed in teenagers?
SSRI or mirtazapine
What antidepressant should be prescribed if sleep or weight loss is a major issue?
Mirtazapine
