Depression Flashcards
what is depression?
Depression and mania are mood disorders (affective disorders)
Depressed mood and/or loss pleasure in activities are central to depression
what is the definition of mood and affect?
In psychiatric terms:
Affect: an objective description of a person’s emotional behaviour
Mood: an individual’s prevailing subjective emotional state
Thus, mood disorders include illnesses with abnormally high or low mood, i.e. mania and depression.
Mood disorders broadly include:
Depression including its variants, bipolar disorder, dysthymia (subthreshold depression), cyclothymia…
how can you Classify Mood/Affective Disorders
what is used for diagnosis ?
Typically based upon assessments of:
Severity
Presence or absence of physical (somatic/biological) features
Presence or absence of psychotic features
Course (duration and recurrence)
Presence or absence of intervening manic phases
Criteria used to diagnose:
UK: ICD-11/DSM-5
what is the aetiology of depression?
Brain regional changes:
Regions important for mood and other functions linked to depression
Genes and environment:
Family history is common in depression
Genetic and/or environmental components
Temperament/personality
Medical conditions and medications (as well as substance misuse)
Biochemical:
Reserpine (anti-hypertensive) a non-specific central amine depleter was reported to cause depression - controversial and has been disputed. Other drugs can cause depression (e.g. isotretinoin, interferon alpha)
Tricyclic anti-depressants prevent amine reuptake
Monoamine oxidase inhibitors act as effective antidepressants
Above evidence supports an ‘amine deficiency theory’ of depression, specifically 5-HT (serotonin) but not the only theory
AND there are no reliable metabolic or biochemical markers for depression
Monoamine Neurotransmission
function ?
depletion in the levels of serotonin, norepinephrine, and/or dopamine in the central nervous system.
Noradrenaline (norepinephrine, NA, NE):
Energy, concentration, memory, fight or flight
Serotonin
(5-hydroxytryptamine, 5-HT):
Mood, impulse control, cognition, appetite
Dopamine:
Reward, pleasure, motivation, alertness, appetite
what is the diagnosis of depression?
Two main diagnostic criteria scales are used in diagnosis: DSM-V and ICD-11. [NICE guidance is based on these two sets of criteria – see later]
Patient must exhibit at least one key (core) symptoms: low mood and/or loss interest/pleasure and symptoms should have been present for most of the time, most days for at least 2 weeks accompanied by other specific symptoms
Not consistent with previous behaviour/personality and not secondary to other treatment
Depression questionnaires such as the Beck Depression Inventory II (BDI-II), Patient Health Questionnaire 9 (PHQ-9) or Hospital Anxiety and Depression scale (HADS) can be to aid the diagnosis, assess symptom severity, functioning (and also to assess treatment effects) – valid in primary care. Hamilton Depression Rating Scale (HAMD) is also used. For example, PHQ-9 is based on DSM-5 and scores each criterion out of 3 – to maximum of 27
Need assess severity of symptoms
But it’s all subjective
From current NICE guidance, HCPs need to: be alert to possible depression (particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment) and consider asking people who may have depression two questions, specifically:
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
If patients answer yes to either of these, a HCP qualified to perform a mental health assessment for the patient should do so (or refer if necessary), preferably using a validated measure to do so
Current ICD-11 or Current DSM-5
Depression questionnaires can also be used in conjunction (e.g. HADS, BDI-II and PHQ-9)
what is the difference between ICD-11 and DSV-5
DSM-5
Depressed mood most of the day, nearly every day
Marked diminished interest or pleasure in all or almost all activities most of the day, nearly every day
Fatigue / loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide
Diminished ability to think or concentrate or indecisiveness, nearly every day
Psychomotor agitation or retardation
Insomnia or hypersomnia nearly every day
Significant weight loss or gain or increase/decrease in appetite nearly every day
ICD-11
Depressed mood
Diminished interest or pleasure in activities
Reduced energy or fatigue
Hopelessness about the future
Beliefs of low self-worth or excessive or inappropriate guilt
Recurrent thoughts of death or suicidal ideation or evidence of attempted suicide
Reduced ability to concentrate and sustain attention or marked indecisiveness
Psychomotor agitation or retardation
Significantly disrupted sleep or excessive sleep
Significant changes in appetite or weight
DSM-V requires at least 5 out of 9 symptoms during same 2-week period with at least one core symptom
ICD-11 at least one core symptom most of the day nearly every day for at least 2 weeks plus other symptoms such as those listed
how to assess the severity?
Less severe encompasses sub-threshold and mild, score <16 on PHQ-9
More severe encompasses moderate and severe, score >16 on PHQ-9
Sub-threshold - 2+, <5, including 1 core
Severity- DSM-IV Major Depression- ICD-10 Depressive Episode
Mild - Minimal above minimum of 5 - 4
Moderate- Between mild and severe - 5-6
Severe- Several in excess of 5- 7+
What is the stepped care model?
STEP
Focus of Intervention
Nature of Intervention
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
step 3
- Persistent subthreshold depressive symptoms or mild-to-moderate depression with inadequate response to initial interventions; moderate and severe depression
- Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions
step 2
- Persistent subthreshold depressive symptoms; mild-to-moderate depression
- Low-intensity psychosocial interventions, psychological interventions, medication and referral for further assessment and interventions
step 1
-All known and suspected presentations of depression
-Assessment, support, psychoeducation, active monitoring and referral for further assessment and interventions
what is the matched care model
STEP
Focus of Intervention
Nature of Intervention
4
- Chronic depression, psychotic depression, depression with personality disorder
- Medication, high-intensity psychological interventions, ECT, crisis service, combined treatments, multi-professional and inpatient care
3
- More severe depression or less severe with limited response to initial interventions
- Medication, high or low-intensity psychological interventions, combined treatments
2
- Less severe depression
- High or low-intensity psychological and psychosocial interventions, medication
1
- All known and suspected presentations of depression
- Assessment, support, psychoeducation, active monitoring and referral
what is the Treatment Options Less SevereDepression: 2022
Options for Less Severe Depression, in order of recommendation:
1.Individual guided self-help
2.Group Cognitive Behavioural Therapy (CBT)
3.Group Behavioural activation (BA)
4. Individual CBT
5. Individual BA
6. Group exercise
7. Group mindfulness and meditation
8. Interpersonal psychotherapy (IPT)
9. SSRIs
10. Counselling
11. Short-term psychodynamic psychotherapy (STPP)
what is the Treatment Options More SevereDepression: 2022
Options for More Severe Depression, in order of recommendation:
- Combined Individual CBT + antidepressant*
- Individual CBT
3, Individual BA - Antidepressant medication*
- Individual problem-solving
- Counselling
- Short-term psychodynamic psychotherapy (STPP)
- Interpersonal psychotherapy (IPT)
- Guided self-help
- Exercise
*Antidepressant medication: can be SSRI, SNRI or other AD indicated, based on clinical & treatment history
Treating Depression: Antidepressants
Monoamine oxidase inhibitors (MAOIs)
Many dangerous side-effects, rarely
Used (sub-group called RIMAs safer)
Inhibitors of monoamine uptake
e.g. Selective Serotonin
Reuptake Inhibitors (SSRIs)
[as well as SNRIs, NRIs – see later]
and tricyclics (TCAs)
Modulators of serotonin (5HT) receptors and other NT receptors
e.g. NaSSa, SMS and others (next slide)
St John’s Wort
Unknown MoA, may be problematic due to effects upon hepatic enzyme activity, OTC but unlicensed and many interactions
Antidepressants: Inhibitors of monoamine uptake
Tricyclics (TCAs):
drug class
examples
side effects
Tricyclics (TCAs): were used before SSRIs
e.g. imipramine, clomipramine, lofepramine,
Relatively non-selective inhibitors of noradrenaline and serotonin (5-HT)
reuptake
Slow onset (2-4 weeks)
Side effects: dry mouth, blurred vision, constipation, urinary retention (mAChRs); sedation, drowsiness (histamine H1), weight gain. Greater CV risk
Problem for compliance
Toxicity in overdose
Interactions with other drugs
Antidepressants: Inhibitors of monoamine uptake
SSRIs
drug class
examples
side effects
SSRIs: Now usual first Line
e.g. sertraline, fluoxetine, paroxetine, citalopram, escitalopram
Similar efficacy to TCAs
Slow onset (2-4 weeks)
Fewer side effects, no anticholinergic, lack of toxicity in overdose, less sedating than TCAs
Side effects: Nausea, sexual dysfunction, insomnia, anxiety
Also used for some anxiety disorders
Washout when switching to be considered – discontinuation symptoms
Suicidal ideation (rare)
Interactions with other drugs
