Depression

Question 1

What are the core features of depression? and how do you define severity?

Answer 1

Use DSMV
Core sx - (if 1> present for most days, for at least 2 weeks)
Lack of energy,Low mood, anhedionia

adjuncts -
FICASAG
Fatigue, insomnia, (poor) concentration, (increased/decreased) appetite, Suicidal thoughts, Agitation (or slowing), Guilt (or self blame

Severities are -subthreshold, mild, moderate, severe
subthreshold -2-5sx but no functional impairment (for over 2 years)
Mild - about 5sx, and mild functional impairment
Moderate - number of sx not relevant (more than mild), and functional impairment mild to severe)
Severe -most sx and functional impairment severe +/- psychotic sx

Question 2

What are the subtypes of depression

Answer 2

Seasonal affective disorde -episodes that recur annualy at the same time with remission in between
Atypical depression - somatic sx -like weight gain, hypersomnia
Anxiety induced insomnia -low sleep causing low mood
Agitated depression -agitated rather than slow
Depressive stupor -so slow it stoms

Question 3

What are the causes/factors in depression

Answer 3

Biosocial -
very commmon 1 in 5 get it, women 5x more then men

NA-mood and appetite
5HT-sleep, appetite, memory, mood
DA-psychomotor, reward

Biological causes/RF
Genetics (eg serotonin receptor gene)
neurochemical (deficiency in monoamins (MA, NT, 5HT)
Endocrine -chronic stress
Illness - direct (cushings) or indirect (cancer)
Medication ( Steroids, COCP, Bblocks, statins<

psychosocial-
childhood events (abuse, critics, etc)
vulnerability (reduce resilience)
Life event (death, divore, jail -LOSS events)
Substance abuse

becks negative cognitive triad - negative views on self -> neg on world -> neg future-> cycle

Question 4

Investigations of depression

Answer 4

FULL HX with physical exam and MSE (and make sure to check for mood elevation)
A-Negecly, dehydration, miserable, disinterested, poor eye contact, tearful
S-slow, quiet, mute
E- restricted affect, nihilism (can be delusions)
P-when severe -hallucination, nihilitic or persecutory desilution, guilt
T-becks neg triad
I -fine -part of risk assessment
C-psychommotor retardation mimics cognitive

Bloods -FBC, TFT, Glucose
Scales -PHQ0, HADs,BDI. CDO

Question 5

What are the differentials to exclude with depression

Answer 5

Physical -hypothyroid, hedinjury, quiet delirium
adjustment disorder -if mild
Bereavement -normal grief -6m
BPAD, Schizo- previous mania or psychotic features
Substance withdrwal
Postnatal
dementia -alzheimers

Question 6

How do you manage mild depression in children and young people?

Answer 6

very rarely use medication in children

Mild -treated in primary care
watchful wait -2 weeks then follow
Self help (mind.org, youngminds.org)
lifestyle -sleep, diet, exercise

2nd line CBT (group)

if after 2-3 motnhs - refer to CAMHS

Question 7

How to manage moderate to severe depression in children and young people

Answer 7

Moderate to severe--treated with CAMHS
5-11y/o
family based IPT (interpersonal (target themes of unresolved loss, social skills, relationship) 
OR family therapy
OR invididual CBT

12-18
individual CBT

needs not met- fam therapy, IPTA, Psychodynamic psychotherapy (try to get kid to see therapy in better light)

depression not responding - camhs and intensive thearpy

Question 8

how do manage subthreshold and mild depression in adults

Answer 8

always check suicude risk - plan making, protective factors, RF

Step 1/subthreshold -
watchful waiting with follow in 2 weeks
Education -sleep hygene, exercise, self help, etc

Step 2/mild-
Low instenisty psychosocial intervention -
Group CBT
Computersied CBT (online material with practitioner review)
Guided self help (based on CBT - written materaial with practitioner review 6-8 session)
Stuctured group phsyical activity program - delivered in groups with support
3x per week for 10-14 weeks

MEDICATIONS only if -hx of moderate to severe depression
subthreshold lasting over 2years
Mild complicating care of other problems -like cancer

Question 9

How do you manage moderate and severe depression in adults

Answer 9

Moderate –
high intensity pyshchosocial invterventions
-individual CBT -16-20 sessions over 3-4months
IPT (identify how interaction with other affect modd etc) - IPT>CBT if due to death

medication and review every 2 weeks for 3months (every week if suicidal)

Severe–
high intensity interventions
medications and ECT if needed
1st line -SSRI - (sertraline, citalopram, fluoxetine)
sertraline step increase from 50 to 200 (increase every 2 weeks, over 6 weeks)
try 2 ssri before 2nd line

2ndline - taper down SSRI, and SNRI (duloxetine, venlafaxine)
Venlafaxine -stepped from 37.5BD to 75BD to 75 morn, 150 eve

3rd line - resistant, so augment treatment with-
Antipsychotic, lithium
other antidepressents

4th line ECT

Question 10

What are the side effects of the main depression medications and thei indication

Answer 10

Mirtazapine - insomnia and appetitte reduction very severe
sertralin -lowest side effect profile
Fluoxetine -children
paroxetine -major depressive episode

SSRI can increase suicidal thoughts initial
5s
suidcide, stomach (NV, Diarrhoea), sex dysf, Sleep (insomia), Seritonin syndrome_

be careful of contraindication like pregnancy, any tryptans,

Question 11

what are the antidepressants used in pregnancy

Answer 11

no one specifically licensed from it but–none have shows significant negative effects

paroxetine - risk in 1st trimester to have congenital heart defects
3d trimerster - PPH

always use lowest dose
mild to moderate -
switch to faciliated self help
always try and encourage stopping
switching to high intensity CBT

severe -continue antidepressant or siwtch to drug with less SE

Question 12

Complications of depression

Answer 12

Psychotic depression -coatrd sx -belief that one is dead

Serotonin sx