Depression Flashcards
What is depression?
It is a defined as a condition in which individuals experience persistent low mood, anergia and anhedonia
What is anergia?
It is defined as low energy
What is anhedonia?
It is defined as a loss of interest/enjoyment in everyday activities
What are the two neurochemical imbalances associated with depression?
Decreased serotonin
Decreased noradrenaline
What are the four classifications of depression?
Mild Depression
Moderate Depression
Severe Depression
Recurrent Depression
What is mild depression?
It is defined as the presentation of two core features plus two cognitive features
What is moderate depression?
It is defined as the presentation of two core features plus at least three cognitive features
What is severe depression?
It is defined as the presentation of three core features plus at least four cognitive features
There is usually the presence of psychotic features.
What is recurrent depression?
It is defined as the presentation of more than two depressive episodes
What are the twelve risk factors associated with depression?
Female Gender
Young Age, 18 – 40 Years Old
Family History
Childhood Trauma
Traumatic Life Events
Personality Traits
Chronic Disease
Co-Morbid Substance Use
Drug Administration
Lack of Social Support
Separated/Divorced Marital Status
Poor Economic Status
What six chronic diseases are associated with depression?
Parkinson’s Disease
Multiple Sclerosis
Hypothyroidism
Psoriasis
Addison’s disease
Wilson’s disease
What four drugs are associated with depression?
Beta-blockers
Steroids
Levodopa
Isotretinoin
What are the three protective factors of depression?
Employment
Good Social Support
Married
What are the three core symptoms of depression?
Persistent Low Mood
Anhedonia
Anergia
What are the eight cognitive clincial features of depression?
Weight Changes
Disturbed Sleep
Psychomotor Retardation/Agitation
Reduced Libido
Feelings of Worthlessness/Guilt
Decreased Concentration
Psychotic Features
Suicidal/Self-Harm Thoughts
What are the two psychotic features of depression?
Delusions of Guilt & Personal Inadequacy
Hallucinations
What are the seven somatic/biological features of depression?
Anhedonia
Loss of Emotional Reactivity
Diurnal Mood Changes
Early Morning Wakening
Psychomotor Agitation/Retardation
Appetite Loss
Weight Loss
Describe the diurnal mood changes in depression
The mood tends to be worse in the morning
Describe the early morning waking in depression
Individuals wake 2 - 3 hours earlier than usual
What though disorder is associated with severe depression?
Cotard syndrome
What is cotard syndrome?
It is defined as a condition in which individuals believe that they are dead or non-existent
What are the four investigations used to diagnose depression?
Patient Health Questionnaire (PHQ-9)
Hospital Anxiety & Depression (HAD) Scale
Blood Tests
CT Scans
What is the most common depression screening tool?
PHQ-9
What is PHQ-9?
It involves asking questions whether they have experienced nine clinical features over the last two weeks – which are scored 0 – 3 in terms of severity
What PHQ-9 score defines mild depression?
5 - 9
What PHQ-9 score defines moderate depression?
10 - 14
What PHQ-9 score defines moderately severe depression?
15 - 19
What PHQ-9 score defines severe depression?
20 - 27
What is the HAD scale?
It involves asking 7 questions screening for depression and 7 questions screening for anxiety – which are scored 0 – 3 in terms of severity
This provides a score for both depression and anxiety
What HAD scale score is considered normal?
0 - 7
What HAD scale score is considered borderline for anxiety and depression diagnosis?
8 - 10
What HAD scale score defines a diagnosis of depression/anxiety?
> 11
How are blood tests used to diagnose depression?
They are used to exclude organic causes to the patient’s presentation
What five blood tests are used to investigate depression?
Full Blood Count
Urea & Electrolytes
Liver Function Tests
Thyroid Function Test
Vitamin B12 Deficiency
How are CT scans used to investigate depression?
They are used to exclude organic causes
When are CT scans used to investigate depression?
In cases where patient’s present with atypical features – such as low mood associated with a sudden loss of memory or change in personality
What are the three diagnostic criteria of depression?
The clinical features must be present for at least 2 weeks
The clinical features are not attributable to other organic or substance causes – normal bereavement, etc.
The clinical features result in functional impairment and cause significant distress
What five psychological therapies are used to treat depression?
Psychoeducation
Cognitive Behaviour Therapy (CBT)
Behavioural Activation
Interpersonal Psychotherapy (IPT)
Psychodynamic Psychotherapy
What is psychoeducation?
It involves providing patients with information about depression and ways in which they can control and minimise it
What is CBT?
It is a talking therapy used to manage the way in which patients think, feel and behave
What is behavioural activation?
It is a talking therapy that encourages patients to use behaviour in influencing their emotional state
What is IPT?
It is a talking therapy used to identify and address problems in the patients’ relationship with family, partners and friends
What is psychodynamic psychotherapy?
It is talking therapy which focuses on the psychological roots of emotional suffering
What five pharmacological management options are used for depression?
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Noradrenaline Reuptake Inhibitors (SNRIs)
Tricyclic Antidepressants (TCAs)
Monamine Oxidase Inhibitors (MAOIs)
Antipsychotics
When are SSRIs used to manage depression?
They are the first line pharmacological management option
Name five SSRIs used to manage depression
Sertraline
Fluoxetine
Citalopram
Escitalopram
Paroxetine
What SSRI is prescribed to patients with depression, alongside other chronic health problems? Why?
Sertraline
There is a reduced risk of drug interactions
How long does it usually take for SSRIs to become effective?
4 - 6 weeks
When are SNRIs used to manage depression?
They are the second line pharmacological management option
Name two SNRIs used to manage depression
Duloxetine
Venlafaxine
In which patient group is SNRIs the first line anti-depressant drug class?
Children
Adolescents
When are TCAs used to manage depression?
They are the third line pharmacological management option – which should be administered under psychiatric advice
Name four TCAs used to manage depression
Amitriptyline
Desipramine
Imipramine
Nortriptyline
When are MAOIs used to manage depression?
They are the fourth line pharmacological management option – which should be administered under psychiatric advice
Name three MAOIs used to manage depression
Selegiline
Isocarboxazid
Phenelzine
When are antipsychotics used to manage depression?
They are recommended in severe depressive episodes with psychotic features
Name four antipsychotics used to manage depression
Olanzapine
Risperidone
Quetiapine
Aripiprazole
How do we switch individuals from an SSRI (citalopram, escitalopram, sertraline, paroxetine) to another SSRI?
The first SSRI should be withdrawn, through a gradual dose reduction then stopped, before the alternative SRRI is started
How do we switch individuals from an fluoxetine to another SSRI? Why is fluoxetine different to other SSRIs?
It should be withdrawn, through a gradual dose reduction then stopped, leave a gap of 4 - 7 days before starting a low dose of the alternative SSRI
It has a longer half life
How do we switch individuals from SSRIs (citalopram, escitalopram, sertraline, paroxetine) to TCAs?
There should be cross-tapering, which is when the current dose drug is reduced slowly whilst the dose of the new drug is slowly increased
How do we switch individuals from fluoxetine to a TCA? Why is fluoxetine different to the other SSRIs?
It should be withdrawn, through a gradual dose reduction then stopped, before starting a TCA
It has a longer half life
How do we switch individuals from SSRIs (citalopram, escitalopram, sertraline, paroxetine) to venlafaxine?
There should be cross-tapering cautiously, which is when the current dose drug is reduced slowly whilst the dose of the new drug is slowly increased
Venlafaxine should be started at 37.5mg daily and increased very slowly
How do we switch individuals from fluoxetine to venlafaxine? Why is fluoxetine different to the other SSRIs?
It should be withdrawn, through a gradual dose reduction then stopped, before starting venlafaxine
It has a longer half life
When are physical management options used to treat depression?
When depression is unresponsive to other treatment options
What are the four physical management options used in depression?
Electroconvulsive Therapy (ECT)
Deep Brain Stimulation (DBS)
Vagus Nerve Stimulation (VNS)
Psychosurgery
In which four circumstances is ECT considered to manage depression?
The patient has a strong preference to ECT
Rapid treatment is required due to the patient not eating or drinking
When multiple other treatment have been trialled unsuccessfully
There is severe depression, with catatonia features
What is ECT?
A procedure in which small electric currents are passed through the brain, intentionally triggering a brief seizure
This leads to neurochemical changes, which can reverse the clinical features of depression
How do we modify antidepressant medication prior to ECT?
We reduce the daily dose, however it should not be stopped
Towards the end of the ECT course, an increase dose of antidepressant may be added
What are the five short term side effects of ECT?
Headache
Nausea
Short Term Memory Impairment
Retrograde Amnesia
Cardiac Arrythmia
What is a long term side effect of ECT?
Impaired Memory
What is an absolute contraindication of ECT?
Raised ICP
What is DBS?
It involves implanting electrodes within certain areas of the brain
These electrodes produce electrical impulses that regulate abnormal impulses or can affect certain cells and chemicals within the brain
What is VNS?
It involves the use of a device to stimulate the left vagus nerve with electrical impulses
When stimulated, the left vagus nerve will send electrical signals to the brainstem, which are then transmitted to certain areas in the brain
What is psychosurgery?
It is the selective surgical removal or destruction of nerve pathways in order to influence psychiatric disorders
What are the eleven management options recommended in mild depression - in order of preference?
Self-Guided Cognitive Behavioural Therapy
Group Cognitive Behavioural Therapy
Group Behavioural Activation
Individual Cognitive Behavioural Therapy
Individual Behavioural Activation
Structured Group Physical Activity Programme
Group Mindfulness & Mediation
Interpersonal Psychotherapy
Selective Serotonin Reuptake Inhibitors
Psychological Counselling
Short-Term Psychodynamic Psychotherapy
It is recommended that antidepressant medication should not be routinely offered as first line management of mild depression. In which four circumstances are there exceptions to this rule?
Moderate/Severe Depression History
Mild Depression For At Least 2 Years
Mild Depression That Is Resistant To Psychological Interventions
Patient Preference
What are the ten management options recommended in moderate/severe depression - in order of preference?
Individual Cognitive Behavioural Therapy & Antidepressant
Individual CBT
Individual Behavioural Activation
Antidepressant Medication
Individual Problem Solving
Psychological Counselling
Short Term Psychodynamic Therapy
Interpersonal Psychotherapy
Self-Guided Cognitive Behaviour Therapy
Structured Group Physical Activity Programme
Following initial presentation of depression, when should a follow up appointment be arranged?
2 weeks
Then monthly for 3 months
In which patient group should weekly follow up appointments be arranged following intial presentation of depression?
Those who are at high suicide risk
What are the six risk factors of suicidal attempt?
Male
Age< 30
Previous Suicidal Attempt
Alcohol/Drug Use
No Spouse Or Other Social Support
Stated Future Intent
What is the strongest risk factor of suicide?
Previous Suicidal Attempt
How long does it usually take patients with depression to recover?
4 - 6 months
