Depression Flashcards
What is a depressive episode
almost daily low mood, low energy, or loss of interest in usual activities for at least 2 weeks
What is atypical depression
Core symptoms + increased appetite, increased sleep fatigue, leaden paralysis
What is dysthymia/chronic depressive symptoms
Symptoms which continually meet the diagnostic criteria of a major depressive episode for at least two years, or have persistent subthreshold symptoms for at least two years, or who have persistent low mood with or without concurrent episodes of major depression for at least two years
What is seasonal affective disorder
episodes of depression which recur annually at the same time each year with remission in between (usually appearing in winter and remitting in spring)
What are the risk factors for depression
Age >65
Female sex
Postnatal status
Personal, social, environmental factors e.g. relationship issues, bereavement, stress, poverty, unemployment et.
FHx depression or suicide (first degree 3x)
Co-existing medical conditions (DM, MI, Cancer, Stroke, obesity)
Personality disorder
Substance abuse
What is the 1 year and lifetime prevalence of major depression
1 year: 5.3%
Lifetime: 13%
What are some theories for aetiology of depression
Monoamine hypothesis: reduced levels of 5-HT (serotonin), epinephrine, dopamine
Dopamine and noradrenaline
HPA axis dysregulation (patients will not have a cortisol surge in the morning)
What are the biological symptoms of depression
Poor sleep - insomnia or early morning wakening (or hypersomnia)
Reduced appetite → weight loss (or gain)
Concentration impairment
Loss of libido
Functional impairment (social, occupational)
Psychomotor retardation (slowed thoughts AND movement)
What are the cognitive symptoms of depression
Hopelessness
Helplessness
Worthlessness
Guilt
What are the psychotic symptoms of depression
Mood congruent delusions e.g. nihilistic
Hallucinations
Catatonia
What is pseudodementia
Those of an older age may present with physical symptoms or a deterioration in cognitive functioning due to depression
What are the core symptoms of depression
Low mood: irritability, anxiety, tearfulness. May show diurnal variation (typically mornings are worse) - may be irritable/flat in adolescents
Anhedonia: inability to feel enjoyment or pleasure
Anergia: feeling ‘tired all the time’, ‘worn out’, or struggling to do everyday activities
What are the differentials for depression
Non-organic: bipolar disorder | acute stress reaction | dementia | Schizoaffective disorder | anxiety
Organic: Substance misuse | hypothyroidism | Cushing’s syndrome |Addison’s | menopause | hyperparathyroidism | hypocalcaemia | anaemia |
Which medications can cause depression
Antihypertensives (beta blockers, methyldopa, CCBs)
Steroids
H2 blockers
Sedatives
Muscle relaxants,
Retinoids
Chemotherapy
Oral contraceptive pill
Gabapentin
Omeprazole
Opioids
What questionnaires can be used for depression
Patient Health Questionnaire (PHQ-9): 9 items, max score 27
Hospital Anxiety and Depression Scale (HADS): 14 items max score 21
Beck-Depression Inventory-II (BDI-II): 21 items, max score 63
What investigations should be done for depression
Bedside: Questionnaires (PHQ-9, HADS, BDI-II), MMSE
bloods: FBC, U&Es, glucose, LFTs, cortisol, vit B12 and folate, calcium, Toxicology
Imaging: MRI/CT head for any atypical examination
What is the acute management for severe depression
Urgent referral to specialist mental health service, consider crisis resolution and home treatment (CRHT)
1. Refer to home treatment
2. Provide 24h crisis line
3. Refer to CMHT
What factors necessitate admission for depression
Self neglect
Risk of suicide/self harm
Risk to others
Poor social support
Psychotic symptoms
Lack of insight
Treatment resistance
What are the steps of psychopharmacology for depression
- Active monitoring + psycho-education
- Medication and/or low-intensity psychological therapies
- Medication and/or high-intensity psychological therapies
- Medications, high-intensity psychological therapies and/or ECT
What is the biological therapy for depression
Considered for moderate-severe depression
First line: SSRI - citalopram, fluoxetine (CAMHS), paroxetine, sertraline
Second line: Venlafaxine, sleeping issues → mirtazapine
Third line: + atypical antipsychotic, antidepressant, lithium
Fourth line: ECT or rTMS
What should the patient be warned about when starting SSRIs
Symptoms of anxiety, agitation, hopelessness, or suicidal ideas may increase when starting treatment
It will start to work within 4 weeks
May be needed for at least 6 months after remission of symptoms to reduce risk of relapse (2 years if recurring)
NOT addictive but can cause withdrawal symptoms if stopped abruptly, doses are missed or not taken as directed
Some may affect alertness and concentration
What is the psychological management for depression
Mild: low-intensity interventions (refer through IAPT)
- Individual guided self-help, apps e.g. calm, headspace
- Group CBT
- Computerised CBT
- Structured group physical activity programme
Moderate/severe: High-intensity inverventions
- Individual CBT for depression
- Psychodynamic therapy
- Interpersonal therapy
- Mindfulness based cognitive therapy (MBCT)
What is the social management for depression
Physical activity e.g. walking, jogging, swimming, dance, gardening
Healthy lifestyle e.g. diet, reduce alcohol
Sleep hygiene
Social support + support for family/carers
Address social stressors e.g. housing, school, work
Community psychiatry nurses: psychoeducation and monitoring
Befriending service
What should follow up be for depression after first presentation
Follow up within 2-4 weeks of initial assessment
If started on anti-depressants:
Concerns about suicide → review within 1 week
Otherwise → 2-4 weeks
then review every 6 months
What is the management of refractory, recurrent or psychotic depression
Check medication adherence
First line: Intensive psychological therapy
± Fluoxetine (or sertraline, citalopram) augmentation with a 2nd generation antipsychotic
Very severe: ECT
What are the complications of depression
Delusion - “Cotard syndrome” = nihilistic delusions where the patient believes they are dead and their insides are rotting
Impact on personal and social functioning e.g. work, school, relationships
Alcohol and substance abuse
Self-harm
Suicide (10x)
Self-neglect
What is the prognosis for depression
For most, the illness is episodic and people will feel well in between acute depressive episodes
- Episodes usually last 3-6 months with treatment (8-9 without treatment)
- Most recover within 12 months
Recurrence risk is high - approximately 50% of people have a second depressive episode
- Risk of recurrence increases significantly with each subsequent episode
Presence of psychotic symptoms has a worse prognosis, but responds better to ECT
Up to 15% of people with depression die by suicide
Describe ECT and its side effects
Psychiatrists and anaesthetists work together, using general anaesthetic and muscle relaxant
Usually twice weekly for 6-12 sessions
A small electrical pulse is passed across the brain via electrodes, triggering a generalised tonic-clonic seizure
SE: tired, achy, nausea, confusion, headaches, retrograde and anterograde memory loss immediate to the ECT
Risks of anaesthetic: MI, arrhythmias, aspiration pneumonia, prolonged apnoea
Describe rTMS
Repetitive transcranial magnetic stimulation (rTMS)
Treatment coil placed on the scalp, produces magnetic pulses that induce nerve cell firing in the dorsolateral prefrontal cortex
Similar efficacy to antidepressants
Few side effects
Describe light therapy
For seasonal depressive disorder
Light box or dawn simulator can compensate for the reduced daylight
