Depression Flashcards
Define affective disorders
Spectrum from severe mania to severe depression
* Euthymia = normal mood
- Unipolar affective disorder – recurrent episodes of depression
- Bipolar affective disorder – recurrent episodes of mania and depression
Define the main symptoms of depression
DSM-V definition (NICE use DSM-V in preference of ICD-10 in depression)
ICD-10 core features
* low mood
* anhedonia
* anergia
Cognitive Symptoms
* Feelings of worthlessness, helpless (useless)
* Guilty- dwell on past misdeeds
* Lack of confidence
* Reduced concentration
* Marked tiredness after even minimum concentration
Biological (Somatic) Symptoms
* Initial insomnia
* Early morning waking - 2-3hrs earlier than usual
* Diminished appetite (may be increased in some pts
* Reduced libido (not in ICD10) - imp to distinguish from impotence
* Weight loss
* Diurnal variation- feel worse in the morning
* Physical symptoms: constipation, aches and pains, dysmenorrhoea
Atypical Symptoms
* Hypersomnia
* Increased appetite
Psychotic Symptoms
1. Auditory hallucinations- derogatory voices, cries for help or screaming
2. May get olfactory - usually bad smells like rotting flesh etc
3. Rarely visual hallucinations of evil spirits and scenes of destruction may be seen
4. Delusions- nihilistic or persecutory, overbearing guilt for misdeeds, deserving of punishment
Other Symptoms/ Signs
* Agitation or slowing of movements
* Catatonic symptoms - can’t move or react (very severely depressed)
Suicidal thoughts or acts
* Stupor - being unresponsive, akinetic, and mute but fully conscious
In Children
* Complaining of somatic symptoms- headaches, tummy-aches (more likely to be this)
* Irritability, apathy, boredom
* Reduced self-esteem/ concentration
* Deterioration in school performance
* Social withdrawal
In elderly/ older adults
- Severe psychomotor agitation or retardation
- Cognitive impairment- ‘pseudodementia’
Confusion
- Cognitive impairment - marked loss concentration/ memory
- Decline in normal functioning
- Psychomotor retardation
- Poor concentration
- Generalised anxiety
- Excessive concerns of about physical health
- Global memory loss
Rank the severity of depression
Severity based on… number/severity of symptoms and degree of functional impairment
**Mild Depression: **diagnosed if the person has atleast 4 symp (inc 2 core ones) and only result in minor functional impairment
**Moderate Depression: **diagnosed if has atleast 5 symp (inc 2 core)
**Severe Depression: **diagnosed if the person has atleast 7 symp (inc all 3 core)
Epidemiology
Epidemiology
VERY COMMON
- Leading cause of disability and premature death in 18-44 year olds
Mean age of onset = 30
After puberty, females > males
Subtypes of depression
Subtypes:
- Seasonal affective disorder – episodes of depression, recur annually at the same time with remission in between
- Atypical depression – somatic symptoms (weight gain, hypersomnia)
- Anxiety-induced insomnia – increased sleep + eating = increased mood
- Agitated depression – psychomotor agitation instead of retardation
- Depressive stupor – psychomotor retardation so bad that they grind to halt
Aetiology
Result from complex interaction of biological, psychological and social factors
Factors that may contribute:
* Chronic comorbidities / Medicines
* Female gender
* Older age
* Recent childbirth
* Psychosocial issues (e.g. divorce, unemployment, poverty, homelessness)
* Personal history of depression
* Genetic and family factors- e.g. family history of depressive illness (combo of genes)
* More common in people from African-Caribbean, Asian, refugee, and asylum seeker communities
* Adverse childhood experiences (e.g. poor parent-child relationship, physical or sexual abuse)
* Personality factors (e.g. neuroticism)
* Past head injury, including hypopituitarism following trauma
Beck’s -ve cognitive triad: negative views about self - negative world views - negative future views - cycle
SIDE NOTE: biological factors are more likely to respond to meds than psychosocial factors
Monoamine hypothesis of depression (less monoamines such as NA, 5HT and DA or could be fewer receptors or less sensitivity of receptors?)
- Noradrenaline: mood and energy
- Serotonin: sleep, appetite, memory and mood
- Dopamine: psychomotor activity
Medications that may cause depression
Medications that may cause Depression
- Steroids
- COCP
- Beta-blockers (propranolol)
- Statins
- Ranitidine
- Retinoids (isotretinoin)
- HIV medications
Investigations
Investigations:
- Full history, collateral history, physical exam, and MSE – ensure you check for mood elevation
- Bloods: FBC (anaemia), TFT (hypothyroid), glucose/HbA1c (diabetes), vitamin D and calcium, cortisol (addisons and cushings), hormones (menopause), vit D, inflamm (infections like lyme disease can mimic) and HIV/Syphilis toxicology
- Rating Scale: PHQ9, HADS, BDI-II (adults) or CDI (children) – EPDS (pregnancy)
- MSE – snapshot of the CURRENT state of the patient
Post natal depression - check if started after giving birth
CT - head injury
Drugs and alcohol
Benzo, opiates, marijuana, cocaine, amphetamines
Differentials
Adjustment disorder – mild affective symptoms following life events -> do not reach the severity of depression
Bereavement – normal grief for <6m (look for: “numbness”, “pining”, “depression” and “recovery”)
Other psych illnesses - bipolar, anxiety disorder, schizoaffective, schizophrenia, personality disorders
Dementia – depression S/Ss may mimic dementia, but dementia can start with affective changes
Global memory loss in SEVERE DEPRESSION (i.e. pseudodementia) – also has a quicker onset
Short-term memory loss in Alzheimer’s disease
Management of children
Mild Depression
-treated in primary care
1st line: watchful waiting (for 2 weeks, and follow-up)
- Self-help (mind.org, youngminds.org)
- Lifestyle advice (i.e. sleep hygiene, diet, exercise)
2nd line: CBT (digital, group)
Needs not met (2-3m) -> referral to CAMHS
Moderate to severe depression – treated with CAMHS:
5-11yo – psychological intervention:
- Family-based IPT (Interpersonal Therapy); OR
- Family therapy; OR
- Individual CBT
12-18yo – psychological intervention:
- Individual CBT ± SSRI (fluoxetine)
- Needs not met -> family therapy, IPT-A (“Adolescents”), psychodynamic psychotherapy
Depression unresponsive to treatment – treated with CAMHS
- Intensive psychological therapy
Management of adults - psychological
- RISK ASSESSMENT!
* CHECK SUICIDE RISK: suicidal acts or intent? -> have they made plans? -> protective factors? -> risk factors?
* Risk factors = young male, occupation (doctor, vet), live alone, mental illness, unmarried
* Assess for any comorbid conditions with depression
* Make an urgent psych referral if pt has active suicidal ideas or plans/ imm harm/ severe agitation or is self-neglecting
Step 1 Indications: initial suspected depression; subthreshold symptoms:
- Watchful waiting with follow-up in 2 weeks
- Education – sleep hygiene, exercise, self-help, information, support (MIND UK, depression UK)
Step 2 Indications: persistent subthreshold symptoms; mild depression:
Low-intensity psychosocial interventions:
1. Group CBT
2. Computerised CBT:
- Online materials supported by trained practitioner to review progress
- Over 9-12 weeks including follow-up
3.Guided self-help (based on the principles of CBT):
- Written materials supported by trained practitioner to review progress
- 6-8 sessions (face-to-face or telephone)
- over 9-12 weeks including follow-up
4.Structured group physical activity programme:
- Delivered in groups with support from a trained practitioner
- 3 sessions per week (45-60 mins) over 10-14 weeks
Medications ONLY if…
- History of moderate-to-severe depression
- Subthreshold depressive symptoms lasting >2 years
- Mild depression complicating care of chronic physical health problems (i.e. cancer)
Step 3 – Indications: persistent subthreshold symptoms [refractory to step 2]; moderate depression:
1.High-intensity psychosocial interventions:
- Individual CBT [16-20 sessions over 3-4 months]:
- Talking therapy based on idea that thoughts, mood and behaviour are intertwined
- Interpersonal Therapy / IPT [16-20 sessions over 3-4 months] – IPT > CBT if due to death:
- Identifies how interactions with others are affecting the patient’s mood
- Identifies ways of improving these interactions
3.Medications (and regular review every 2 weeks for 3 months; every week if suicidal)
Step 4 – Indications: severe depression; risk to life; neglect: if suicidal -> urgent referral to crisis team
- High-intensity psychosocial interventions Section via 2, 3 or 4 if necessary
- Medications -> ECT if necessary
Management of adults - biological
Medications * [See “Antidepressants” for key information to inform patients and contraindications]:
1st line = SSRI (sertraline, citalopram, fluoxetine, paroxetine):
- Sertraline: stepped increase from 50mg to 200mg (50mg increase every 2 weeks; over 6 weeks) § 2 trials of SSRIs before moving to 2nd line (see switching guidance in SSRI medications section)
**2nd line **= taper down SSRI, switch to SNRI (venlafaxine, duloxetine):
- Venlafaxine: stepped increase from 37.5mg BD à 75mg BD à 75mg morning / 150mg evening
- SNRI pharmacology does not switch from SSRI effect to SNRI effect until reach maximum dose
3rd line = treatment resistance -> augment treatment with…
- Antipsychotic (i.e. quetiapine 150-300mg) See SSRI notes overleaf
- Lithium (blood level of 0.4-0.8)
- Other antidepressant (e.g. mirtazapine or mianserin)
4th line = ECT Check compliance at every review
Antidepressants on side effect and indication profiles:
o Mirtazapine -> symptoms of insomnia and appetite reduction are evident and debilitating
o Sertraline -> smallest side effect profile (i.e. for those with co-morbid conditions like IHD)
o Fluoxetine -> children
o Paroxetine -> major depressive episode
o Be aware of specific contraindications
· “Catch-up” phenomena – recovery from depression with treatment, which is subsequently stopped, and that person falls back into depression leads to a worse depression state than before
Antidepressants for pregnancy
No antidepressant is specifically licenced for use in pregnancy however, no antidepressant has been found to cause significant negative effects to the foetus or mother during pregnancy
- However, the lowest-effective dose should be used if possible
Paroxetine may have mild risks:
- 1st trimester -> congenital heart defects
- 3rd trimester -> persistent pulmonary hypertension
Mild or moderate depression -> encourage to taper down and switch to… (if possible)
- Mild -> facilitated self-help
- Moderate -> CBT (or switch to a drug with lower risk of adverse effects)
Severe depression -> continue antidepressant or switch to a drug with lower risk of adverse effects
Complications
Psychotic depression – a severe depression with delusions and hallucinations
- “Cotard syndrome” – a set of nihilistic delusions where the patient believes they are dead, and their body parts are rotting (or something to that effect)
- Delusion = ‘he wants to kill me with an axe’ à ask ‘why is that?’…
- Psychotic depression = ‘the world is better off without me’
- Schizophrenia = ‘I have no idea, but I got the message’
Serotonin syndrome (from large serotonin increase in the body)
- Causes: SSRI or SNRI (or both)
**Complications associated with the use of antidepressants: **
- Risk of self-injurious behaviour- children, adolescents and young adults may experience a transient increase in risk for self-injury
- Sexual adverse effects of SSRIs/ SNRIs, undesired weight gain, HypoNa, agitation or excessive activation, risk of suicide
- Serotonin syndrome (look at Medication for more details)
- Problems with stopping: antidepressant discontinuation syndrome, mania
- If stop antidepressants abruptly- discontinuation syndrome: restlessness, problems sleeping, unsteadiness, sweating, abdominal symptoms, altered sensations
