Depression

Question 1

Define and classify depression

Answer 1

Clinically low in mood with cluster of physical, psychological associated symptoms which distort thinking and reduced motivation. Depression may be mild, moderate, severe or severe with psychotic symptoms, depending on the number of sx and how pervasive the disease is. Biological sx tend to emerge as the disease becomes more severe (psychotic sx occur in very severe cases.)

Question 2

1-year prevalence and lifetime prevalence of major depression

Answer 2

• The 1-year prevalence of major depression in the general population is 5.3%
• Lifetime prevalence of major depression is 13%.

Question 3

Mean age of onset of depression

Answer 3

Mean age of onset of depression is 30 years.

Question 4

Risk factors for depression

Answer 4

• Women have a higher prevalence, incidence and morbidity associated with depressive disorders compared to men (1 in 4 women compared to 1 in 10 men develop depression requiring tx)
• Past hx of depression
• Hx of mental health disorders (dementia, personality disorder) or chronic pain disorders
• Social factors
• More common in people from African-Caribbean Asian, refugee communities (not in native communities)

Question 5

ICD10 criteria for depression diagnosis

Answer 5

ICD10 requires that the depressive episode must last for at least 2 weeks and represent a change from normal. It must not be secondary to other causes such as drugs, alcohol misuse, medication etc. Must have 2 of the 3 core symptoms (ICD11 categorises anergia under biological sx)

Core Symptoms:

• Low mood, Anergia, Anhedonia

Question 6

Other (not core) symptoms of depression

Answer 6

• Irritability, anxiety, tearfulness, diurnal variation – classically mornings feel worse,
• Biological symptoms- poor sleep including ‘initial insomnia’ or ‘early morning wakening’, poor appetite and weight loss, poor concentration, poor motivation, loss of libido, aches and pains, constipation
• Cognitive symptoms- reduced self-esteem/self-confidence, slowing of thoughts, psychomotor retardation, Ideas or acts of self-harm or suicide. In older people loss of memory can be assumed to be dementia but will actually resolve with treatment of depression- ‘pseudodementia’
• Psychotic symptoms- Hallucinations or delusions which are usually ‘mood congruent’e.g second person ‘derogatory’ auditory hallucinations (visual is less common.) Delusions are often nihilistic, persecutory, or guilt related.

Question 7

What is recurrent depressive disorder

Answer 7

when someone experiences at least two depressive episodes, separated by several months of wellness.

Question 8

What is atypical depression

Answer 8

Depression with features such as increased appetite, increased sleep, fatigue, leaden paralysis

Question 9

What is dysthmia

Answer 9

Chronic low grade depression >2 years, less severe than depression but low spontaneous remission rate

Question 10

What is seasonal affective disorder

Answer 10

low mood related to season, likely related to melatonin synthesis responds to light therapy (can also give SSRIs)

Question 11

Depression differentials

Answer 11

• Medications: antihypertensives (beta blockers, methyldopa, calcium channel blockers), steroids, Histamine H2 blockers, sedatives, muscle relaxants, retinoids, chemotherapy agents, sex hormones e.g. oestrogen etc, psychiatric medications.
• Substance misuse: alcohol, benzodiazepines, opiates, marijuana, cocaine, amphetamines etc.
• Psychiatric illness: BPAD, dysthymia, anxiety disorder, schizoaffective, schizophrenia (negative), personality disorder, adjustment disorder, normal bereavement
• Neurological: dementia, Parkinson’s disease, tumours, stroke etc
• Endocrine: hyper/hypothyroidism, Addison’s disease, Cushing’s disease, menopause, hyperparathyroidism
• Metabolic: hypoglycaemia, hypercalcaemia, porphyria
• Others: anaemia, infections, (syphilis, Lyme disease, HIV encephalopathy), sleep apnoea (might explain tiredness, anergia)

Question 12

Necessary investigations (outline)

Answer 12

• Collateral history to establish baseline
• Exclude physical causes
• Scrrening tools

Question 13

Required investigations for excluding physical causes of depression

Answer 13

• Blood tests: may include blood glucose, U&Es, LFTs, TFTs, calcium levels, FBC and inflammatory markers.
• Other tests may include magnesium levels, HIV or syphilis serology, or drug screening.
• Cognitive assessment where dementia/pseudodementia are differentials
• Imaging (MRI or CT brain scanning) may be indicated where presentation or examination is atypical or where there are features suspicious of an intracranial lesion e.g. unexplained headache or personality change.

Question 14

Screening tools used to identify and classify depression

Answer 14

• Patient Health questionnaire-9 (PHQ-9): uses 9 questions to diagnose and assess the severity of depression. It takes about three minutes to complete. Scores are categorised as minimal (1-4), mild (5-9), moderate (10-14), moderately severe (15-19) and severe depression (20-27).
• Hospital anxiety and depression scale (HADS): It is designed to assess both anxiety and depression. It takes about 5 minutes to complete. The anxiety and depression scales each have seven questions and scores are categorised as normal (0-7), mild (8-10), moderate (11-14) and severe (15-21).

Question 15

How can mild depression be managed in the community?

Answer 15

• Resolves spontaneously if mild à watchful waiting approach or refer for supportive counselling or problem-solving therapy
• Advice on: Sleep hygiene, Exercise, Self-help, Access to CBT or counselling
• Address social stressors: time off work, respite for carers, support groups

Question 16

Factors necessitating hospital admission

Answer 16

• Self-neglect, risk of suicide/ self-harm, risk to others, poor social support, psychotic symptoms, lack of insight, treatment-resistant.

Question 17

Steps in depression stepped care model

Answer 17

• Always choose the least intrusive and most effective intervention
• Step 1: all known and suspected presentations of depression > Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions
• Step 2: persistent subthreshold depressive symptoms, mild-to-moderate depression > Low-intensity psychological interventions, psychological interventions, medication, referral for further assessment and interventions
• Step 3: Persistent subthreshold depressive symptoms or mild-to-moderate depression with inadequate response to initial interventions, moderate-to-severe depression > Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions
• Step 4: Severe and complex depression, risk to life, severe self-neglect > Medication, high-intensity psychological interventions, ECT, crisis service, combined treatments, multi-professional and inpatient care • Explain that symptoms may get worse soon after starting treatment (refer to help services such as crisis lines, Samaritans, A&E)

Question 18

When are antidepressants usually indicated?

Answer 18

For moderate to severe depression, ideally alongside psychological interventions.

An antipsychotic is added in psychotic depression. SSRIs are the first choice antidepressants since they have more mild SEs and are less dangerous in overdose (should still be counselled on risk of suicide).

Question 19

When can an effect be expected after commencing antidepressant treatment. For ho long should it continue?

Answer 19

Within 1-2 weeks of commencing antidepressant therapy. Treatment should continue for 6-9 months after recovery to prevent relapse and for up to 2 years after in recurrent depression.

Question 20

Management of mild to moderate depression

Answer 20

• Should be managed in the community setting as above: sleep hygiene advice etc.
• Need to arrange a further assessment within 2 weeks
• Offer low-intensity psychological intervention:
  
  • Individual-guided self-help based on the principles of CBT
  • Computerised CBT: typically takes place over 9-12 weeks using CBT model
  • Structured group physical activity programm
  • Group CBT if low-intensity psychological intervention is declined
• ONLY offer medication if: past history of moderate or severe depression, sx have been present for >2 years (likely dysthymia), or symptoms persist after other interventions fail.
• Warn against St John’s wort- can cause serotonin syndrome and has unknown interactions

Question 21

Management of moderate to severe depression

Answer 21

• Provide a combination of:
  
  • Antidepressant medication
  • High intensity psychological intervention > CBT or interpersonal therapy (IPT)
  • After starting antidepressant medication: review after 2 weeks (if low suicide risk), then every 2-4 weeks thereafter for 3 months.
• Patients < 30 years old or who are at increased risk of suicide should be followed up after 1 week.
• Response to treatment should be reviewed after 3-4 weeks
• Antidepressants should be stopped over a period of 4 weeks
• Be especially cautious when switching the following antidepressants:
  
  • From fluoxetine to other antidepressants (as fluoxetine has a long halflife)
  • From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
  • To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
  • From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)

Question 22

What is CBT and how does it work?

Answer 22

This helps people think about their thoughts, feelings and behaviours. It is delivered individually or in groups, usually for a period of 8-24 weeks. It focusses on the present rather than past events. First involves behaviour activation using techniques such as activity schedules. Then identify negative automatic thoughts (NATs) including ‘cognitive distortions’ using a thought record. Finally identify rules and assumptions and core beliefs and then build up an alternative set of more realistic beliefs (e.g ‘Im not perfect, but Im ok.’) This process involves discussion and behavioural experiments. The whole process involves homework and active engagement.

Question 23

What is interpersonal therapy?

Answer 23

Focuses on unresolved loss, role transitions, relationship conflicts and social skills defects.

Question 24

What is psychodynamic psychotherapy and how does it work

Answer 24

Involves the development of a relationship between the psychologist and the patient. Psychologists attempt to draw out distorted transferences and draw them to the patient’s conscious awareness. This process usually takes place over a year or more, but can be distilled to 16-20 weeks.

Question 25

Management of complex and severe depression

Answer 25

• Use crisis resolution and home treatment teams to manage crises 186 > Develop a crisis plan that identifies potential triggers and strategies to manage triggers (share with the GP and any other people involved in the patient’s care)
• Consider inpatient treatment if significant risk of suicide, self-harm or neglect
• Consider ECT for acute treatment of severe depression that is life-threatening and when a rapid response is required, or when other treatments have failed

Question 26

What is ECT and what are its indications?

Answer 26

ECT: A passage of a small electric current through the brain with a view to inducing a generalised fit which is therapeutic. 8/10 respond well to ECT, is well supported by evidence and is equal to or better than antidepressant (but is probably best if used alongside) Indications for ECT include:

• Severe depressive illness: only if there is a life-threatening situation i.e poor oral intake, acutely suicidal, or if the depressive illness is treatment-resistant
• Uncontrolled mania
• Catatonia: a motor symptom of schizophrenia- increased resting muscle tone which is not present in active or passive movement

Question 27

Side effects of ECT

Answer 27

• Risks of anaesthetic: MI, arrhythmias, aspiration pneumonia, prolonged apnoea, malignant hyperthermia, broken teeth, death (1 in 50,000 treatments)
• Risks from ECT: - Common complaints (80%): confusion, muscle pain, headache, nausea –
• Effect on Cognition (10%); usually retrograde and anterograde memory so events immediately before and after ECT and most patients will fully recover at 6 months.
• Very rare to have long-term complications

Question 28

Management of recurrent episodes of depression

Answer 28

• Must check medication adherence in a non-accusatory manner, then optimise dose and side effect profile
• Switch antidepressant, initially to an alternative SSRI
• Switch to an alternative antidepressant class e.g Mirtazapine, venlafaxine, TCA
• This is now ‘refractory depression’- try combinations such as addition of an SSRI or augment with lithium or another antipsychotic

Question 29

What is the prognosis for patients after a depressive episode (recurrence likelihood, how long it lasts, risk of suicide)

Answer 29

• Approximately 50% of patients have a second depressive episode and risk of recurrence increases significantly with each subsequent recurrence
• An average episode lasts 8-9 months untreated and 2-3 months with treatment
• Up to 15% of patients with depression die by suicide