Depression Flashcards
Anthodonia
loss of interest in things you used to enjoy
Anergia
Loss of energy
How long should medication trials last at maximum tolerable dose?
at least 6 weeks
What is the maximum length of prescription for benzodiazapines or hypnotic prescription?
Max 2 weeks
What is combination treatment?
2+ treatments, adds extra effect and doesn’t alter action of other drugs
What is augmentation?
Adding drug that improves efficacy of antidepressant
Before prescribing off label or unlicensed meds need to:
- The medicine is better suited to the patient/client’s needs than an appropriately licensed alternative
- There is a sufficient evidence base and/or experience of using the medicine to demonstrate its safety and efficacy
- The reasons why medicines are not licensed for their proposed use should be explained to the patient/client, or parent/carer
- A clear and accurate record of medicines and the rational for use should be documented on Paris (unless the medication is included in TEWV off-label permissions) as part of the Medication Treatment Plan
- Off-label and unlicensed medications monitoring and prescribing arrangements are likely to remain in secondary care unless transfer has been agreed
Any drug marked with an (N) is recommended by NICE guidelines
Any drug marked with an asterisk (*) should only be initiated by a Consultant Psychiatrist or Level 3 Non-Medical Prescriber with competency to initiate the medication.
Depressed symptoms in need of activation
Loss of interest
Oversleeping
Overeating
Poor concentration
Indecisive
General slowing
Depressive symptoms in need of sedation
Lack of sleep
Lack of appetite
Agitation/restlessness
Suicidal thoughts
Loss of libido
Medication for depression in need of activation
SSRI or low dose venlafaxine
Initial medication for depression in need of sedation
Mirtazapine
Side effect of mirtazapine
Weight gain
Initial dose sertraline
100mg OM - titrate up to this
Venlafaxine initial dose
37.5mg BD
Mirtazapine initial dose
30mg ON (15mg is more sedating)
What to do if partial reponse to inital treatment for depression?
Consider increase to maximum dose for further 6 week trial if tolerated
Steps 2 + 3 for depression that doesn’t respond to initial medication
2 trials of single drug therapy on top of initial
different drug groups
4-6 weeks at treatment dose
Step 2 for depression with activation needs
Venlafaxine and hypnotic (2 weeks for sleep) OR trazodone 50-150mg
Mediations ofr anxiety and depression
Sertraline
Why is fluoxatine better for people who are bad at taking medication?
Stays in system longer
What drug often add if max dose of sertraline?
Mirtazipine
Why do yuo get weight gain on SSRIs?
Increased appetite
What is a stronger SSRI?
Venlafaxine
Side effects of SSRIs
GI disturbance in first couple weeks then settles down
Feel more tired at first (sertraline, venlafaxine)
Side effect of venlafaxine
Sweats
When review in 2 weeks on antidepressants
Under 30
When review someone high risk on antidepressants
1 week
average wehn need to review on antidepressants
4 weeks
When start on Vortioxetine in depression
if 2 prev failed or non tolerated trials
When refer to secondary care
No recovery after maximum dose for 4-6 weeks of step 2 + 3 medications
Step 4 for refractory depression secondary care initiation
-Alternative monotherapies - moclobemide
-Combination of different antidepressants
-Augmentation of partially effective antidepressants
Combination of different antidepressants for step 4
SSRI or SNRI + Mirtazapine
Mirtazapine or SSRI + Reboxetine (2-8mg daily)
6 weeks
Augmentation of partially effective antidepressants
Quetiapine immediate release (150-300mg/day)
Lithium
Aripiprazole
Step 5 in secondary care
If no recovery from step 4
-Augmentation
-Alternative monotherapies
Augmentation partially effective antidepressants step 5
SSRI + buspirone (60mg/day)
Amisulpride
Alternative monotherapies step 5
Agomelatine
Bupropion
Agomelatine when use
step 3 of monotherapy
If 3 previous failed or non tolerated trials
Step 6 refractory depression
After all medication options have failed
Consider ECT
Consider referral to tertiary service or specialist within TEWW
NICE guidelines for depression
www.nice.org.uk/guidance/cg90
DEPRESSION in adults with a chronic physical health problem guidance
www.nice.org.uk/guidance/cg91
What type of drug is venlafaxine?
SNRI
What type of drug is venlafaxine?
SNRI
When is step 4 treatment used in depression?
Medication, high intensity psychological interventions, ECT, crisis service, combined treatments, multiprofessional anad inpatient care
Steps 2 and 3 interventions depression
High intensity or low intensity psychological and psychosocial interventions, medications
Depression treatments listed in order of recommendation for basic management
Guided slef help
Group CBT
Group behavioural action
Individual cognitive therapy
Individual behavioural action
Group exercise
Group mindfulness and meditation
Interpersonal psychotherapy
SSRI antidepressants
Counseling
Short term psychodynamic psychotherapy
Depression treamtent in order of recommendation for more severe depressive episode
Individual cognitive behavioural therapy and antidepressant
Individual CBT
Individual behavioural activation
Antidepressant medication
Individual problem solving
Counselling
Short term psychodynamic psycotherapy
Interpersonal psychotherapy
Guided self help
Group exercise
When is risk of relapse increased in depression?
History of recurrent episodes and/or incomplete response previously
History of severe depression
Coexisting physical or mental health problems
Unhelpful coping styles eg avoidance, rumination
Personal, social or environmental factors that contributing to depression
What to do when low risk of relapse depression
Continuing treatment can reduce risk of relapse
There are risks of longer term side effects with medication
Stopping antidepressants can be difficult
What to do if discontniuing medication
Explain how to withdraw safly
Advise to seek help promptly if symptoms recur
What to do if on antidepressatns alone and high risk of relapse
Consider continuing with same
Consider switching group CBT or MBCT
Consider continuing with antidepressant adn adding CBT
How often review antidepressant medication?
every 6 months
Types of neurostimulation
ECT
Transcranial magnetic stimulation (TMS)
others:
-vagus nerve stimulation
-transcranial direct current stimulation (tDCS)
-Deep brain stimulation
How do transcranial magnetic stimulation and aim
Place electrodes on head
Place against head and pass small current between them
Aim - stimulate neurons in brain
Indications for ECT
Severe depression
Mania
Catatonia
Psychosis
Caution whne using ECT with
MI, cardiac surgery, AAA, valvular disease
Risks ECT short term
Anaesthetic risks
headaches, mylagia, nausea, retrograde/anterograde
Long term risks ECT
?memory loss
1/3 autobiographical/retrograde memory loss
Research studies shows memory loss is temporary - research measures anterograde memory
Most clinics do cognitive assessment before and after treatment
Post loading video
: https://youtu.be/9L2-B-aluCE
DSM vs ICD - one basic depressive syndrome
DSM-5 - major depressive episode
ICD - single episode depressive disorder
DSM vs ICD - one basic depressive syndrome
DSM-5 - major depressive episode
ICD - single episode depressive disorder
More than one episode of depression ICD vs DSM
DSM - Major depressive disorder
ICD-11- Recurrent depressive disorder
Specifiers you cna get with depression according to DSM 5
With anxious distress
With melacholic features
With atypical features
With psychotic features
Peripartum onset
Seasonal pattern
ICD-11 specifiers with depression
With prominent anxiety
With panic attacks
With melacholia
With or without psychous
Ass w peripartum period
Seasonal pattern
Types of depression according to DSM 5
Persistent depressive disorder
Premenstrual dysphoric disorder
Types of depression according to ICD
Dysthmic disorder
Premenstrual dysphoric disorder
Mixed depression and anxiety disorder
How does melancholia present?
Prominent anhedonia
Early morning wakening
Diurnal variation
Psychomotor retardation
Weight loss
Guilt
How do psychotic symptoms present with depression?
Mood congruent
How do psychotic symptoms present with depression?
Mood congruent
Symptoms of atypical depression
Increased appetitie
Hypersomnia
Leaden paralysis
What severity levels of depression does ICD 11 describe?
Mild
Moderate
Severe
What is severity of depression based on in ICD-11?
Severity of symptoms
Fucntiona impairment
Course of depression
Relapsing remitting
50% relapse after 1 episode, 80% after 2
Assess if patients are in - non-response, partial remission, in remission
What tool is used to assess depression?
PHQ-9
Patient health questionnaire
Based on DSM criteria but NOT a diagnostic tool
Scoring and severity on PHQ-9
0-5 = normalk
5-9 = minimal symptoms
10-14 = dysthmia or mild MDE
15-19 = moderate MDE
>20 = severe MDE
What are persistent depressive disorder (DSM)/ICD dysthmic depression?
Sub syndromal symptoms for at least 2 years, most commonly life long
What is double depression?
Dysthmia + MDD
What is premenstrual dysphoric disorder?
Depression and irritability before menstruation, more severe than premenstrual syndrome
What is premenstrual dysphoric disorder?
Depression and irritability before menstruation, more severe than premenstrual syndrome
Where is mixed depression and anxiety diagnosed?
Primary care
Only ICD - sub syndromal
What is considered recurrent depressive disorder?
History or at least two episodes sperated by at least several months without significant mood disturbance
