Depression Flashcards
Depression due to Another medical condition examples
Stroke
Parkinson’s
Endocrine: thyroid and adrenal
Autoimmune: lupus
Viral: hiv hepatitis
Cancer: pancreatic
Metabolic:b12
4 ways of diagnosing depression
And preferred method
-exclusive: neroveg symptoms not included
-substitutive: neuroveg replaced by psychological symptoms (like guilt)
-etiologic: each symptom evaluated separately
-inclusive: all included, picks up the most patients
Preferred is inclusive
Why under detection of depression
Medical conditions confuse diagnosis
Present with somatic symptoms
Less likely to use word depressed
Ad vs depression
Apathy, agitation vs anhedonia and anxiety
Sundowning va insomnia
Weight loss and no loss of appetite vs weight loss and loss of appetite
Minimizing cognitive def vs subjective complaints
Guessing during testing vs “I don’t know”
Aphasia/apraxia vs language and motor skills intact
Positive predictors of response
Female gender
Less severe symptoms
No substance use
Good social supports
Religion/faith
Self-efficacy
Factors associated with longer times to response when treating depression
-poor adherence
-duration of depressive ep
-severity of depressive ep
-comorbid anxiety
-Comorbid substance
-Comorbid physical Illness
-failure to respond to a previous antidepressant
As per ccsmh guidelines for depression, what is universal vs selective vs indicated prevention
-general public, regardless of risk status
-targets those at higher risk
-identified as having prodrome symptoms/ markers however don’t meet criteria
As per ccsmh guidelines what are the interventions that reduce social isolation
Primarily group based and in long term care settings
Reminiscence therapy
Physical exercise programs
Videoconferences with family
Horticultural therapy
Gender based social groups
As per ccsmh depression, when do you consider ECt?
In MDD, single or recurrent ep, severe with no psychosis
-previously had good response to ECT
-failed to respond to 1 or more adequate med trials plus psychotherapy
- rapidly deteriorating health due to depression
As per ccsmh dep guidelines what are clinicians supposed to screen for when managing partial response or tx resistant depression
-MEDICATION ADHERENCE
-use of substances
-use of medications that cause depression
-review medical conditions (rule out hyponatremia)
-review working diagnosis
As per ccsmh guidelines for depression what are the core elements for treating late Life depression in primary care
-patient education
-incorporating inter professional staff as depression care managers
-utilizing a stepped care approach
- as needed psychiatric consultation
As per textbook, what are the systemic limitations for suicide in geri
-do not directly assess mental healthcare, downplay symptoms
-long waits to see free therapists
-demands on fam docs great, low number of providers
-primary care system is not designed for assessment and treatment of mental health issues
Resilience factors for suicide (as per textbook)
As per guidelines
-religious or spiritual practice
-perception of meaning and purpose
-sense of hope or optimism
-active social networks
-positive help seeking behaviours
-engagement in activities of personal interest
-better health care practices
-connect with family and friends
-active interests
Religious practices
-openness, extravrrsion, conscientiousness
As per textbook, what are the therapies that have the most evidence for suicidal older adults
-PST and antidepressants
-IPT and antidepressants
Seizure threshold determinants
-age (older>younger)
-male>female
-BF placement > BT >RUL
-concurranrs meds
Anesthetic dose
Anesthetic agents
As per textbook, what therapeutic level to aim for with lithium, and what theoretical risks exist
-0.3-0.8
-excessive cognitive disturbance
-prolonged apnea
-spontaneous seizures
-postictal delirium
-increase permeability of BBB so potential for toxicity
Ect related common side effects
-bradycardia, transient asystole
-transient HTN
-jaw pain
-headache
-N/V
-postictal confusion
-falls
What to do if poor quality seizure
-ensure pre oxygenation
-consider switch electrode position
- “ switch pulse width
-“ anesthesia meds (propofol increases seizure threshold)
-increase intensity
-consider flumazenil if on benzos
-consider ketamine
Ect rare and serious side effects
-death (same risk as anaesthesia)
-CVD at high risk
-over 80 high risk
Aspiration
Malignant hyperthermia
Posticstal delirium/agitation
Strategies to lower sz threshold
-pre ox
Give meds to lower like buproprion
Choice of anesthetic
Lower propofol
Ensure adequate hydration
Caffeine and theophylline lengthen the LENGTH of the seizure, NOT NECESSARILY CHANGE SEIX THRESHOLD
Theoretical risk around AchI during ECT
- may prolong succ effect (as used same enzyme)
-may enhance bradycardia (so increase risk of asystole and prolonged seizures)
As per canmat, factors that give cognitive def in ECT
- bitemoroal placement
-BRief pulse
-suprathreshold stimulation
-3x week treatment
-use of lithium
-use of high doses of anesthetic
Medical and psychiatric outcomes due to bereavement
-increased mortality from all causes
-increased MI
-sleep disruption
-impaired immune function
-increased cancer rates
-Incrwased substance use
-anxiety, PTSD
Most treatment evidence for bereavement related depression
Other meds that have been used
-RCT nortryptiline and IPT
-buproprion and escitalopram
Complex grief vs PTSD
(Remember complex grief not a DSM diagnosis)
Trigger is a loss vs threat
Yearning vs fear
Intrusive thoughts are person related vs event related
Avoidance is loss based vs fear
Reminders pervasive vs linked to event
Grief vs MDE
Emptiness vs persistantly depressed mood
Dyshpiria decreases with time, “pangs “ of grief vs persistent depressed mood
Thoughts of deceased vs worthlessness and self loathing
Self esteem preserved vs not
Symptoms that favour depression in context of bereavement
-persistent depressed mood
-depressed mood not associated with thoughts or preoccupations
-pervasive unhappiness and misery
-feelings of worthlessness and self loathing
-inability to anticipate happiness or pleasure
Things that DELAY response or give lower response rates in depression pharmacontx
-non compliance
-not optimized dose
-failure to respond to previous antidepressant
-Comorbid anxiety
Comorbid substance
Comorbid physical illness
Community level interventions with evidence that help with suicide
- Referring to telephone outreach and support
-community depression lectures for those that have depression
-shared care
-means restriction (fences on bridges)
Clinical interventions that reduce suicidality
Few trials but
Combo pharmaco and therapy
Then not specific to elderly
-li
-clz
-ect
4 common delusions in elderly in depression
Somatic
Nihilistic
Persecutors
(Guilt, paranoid?)
4 most common delusions (as per my exam)
-nihilism
-somatic
-persecutory
-guilt
5 behaviours that signal suicide warning signs
Vs communication
-gives away possessions
-has affairs in order
-ceases taking medication or food
-stops seeing medical provider
-inexplicably seems better
Vs communication
Talks about the end
Talks a lot about death
Refers to themselves as a burden
