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4th year passmedicine by topic > Depression > Flashcards

Depression Flashcards

1
Q

The following two questions can be used to screen for depression

A

‘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?’

A ‘yes’ answer to either of the above should prompt a more in depth assessment.

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2
Q

There are many tools to assess the degree of depression including

A

Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).

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3
Q

Hospital Anxiety and Depression (HAD) scale

A

consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly

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4
Q

Patient Health Questionnaire (PHQ-9)

A

asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe

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5
Q

NICE use the DSM-IV criteria to grade depression:

A

1-9

  1. Depressed mood most of the day, nearly every day
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
  3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
  4. Insomnia or hypersomnia nearly every day
  5. Psychomotor agitation or retardation nearly every day
  6. Fatigue or loss of energy nearly every day
  7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  8. Diminished ability to think or concentrate, or indecisiveness nearly every day
  9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
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6
Q

Define Subthreshold depressive symptoms

A

Fewer than 5 symptoms

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7
Q

Define Mild depression

A

Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment

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8
Q

Define Moderate depression

A

Symptoms or functional impairment are between ‘mild’ and ‘severe’

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9
Q

Define Severe depression

A

Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms

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10
Q

Persistent subthreshold depressive symptoms or mild to moderate depression

General measures

A

sleep hygiene

active monitoring for people who do want an intervention

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11
Q

Persistent subthreshold depressive symptoms or mild to moderate depression - drug treatment is first line

A

false

do not use antidepressants routinely but consider them for specific people

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12
Q

Persistent subthreshold depressive symptoms or mild to moderate depression - drug treatment indicated in

A

a past history of moderate or severe depression or

initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or

subthreshold depressive symptoms or mild depression that persist(s) after other interventions

if a patient has a chronic physical health problem and mild depression complicates the care of the physical health problem

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13
Q

low-intensity psychosocial interventions may be useful in persistent subthreshold depressive symptoms or mild to moderate depression - these include

A

Individual guided self-help based on CBT principles - (Includes behavioural activation and problem-solving techniques)

Computerised CBT
group-based CBT

A structured group physical activity programme

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14
Q

Individual guided self-help based on CBT principles should include?

A

include written materials (or alternative media)
be supported by a trained practitioner who reviews progress
consist of up to 6-8 sessions (face-to-face and by telephone) over 9-12 weeks, including follow-up

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15
Q

Computerised CBT should include?

A

explain the CBT model, encourage tasks between sessions, and use thought-
challenging and active monitoring of behaviour, thought patterns and outcomes
be supported by a trained practitioner who reviews progress and outcome typically take place over 9-12 weeks, including follow-up

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16
Q

A structured group physical activity programme should include?

A

Interventions should:

typically consist of 3 sessions per week (lasting 45 minutes to 1 hour) over 10-14 weeks

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17
Q

Group based CBT should include?

A

be based on a model such as ‘Coping with depression’
be delivered by two trained and competent practitioners
consist of 10-12 meetings of 8-10 participants
typically take place over 12-16 weeks, including follow-up

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18
Q

For patients with chronic physical health problems NICE also recommend considering a group-based peer support programme:
focus on

A

focus on sharing experiences and feelings associated with having a chronic physical health problem
consist typically of 1 session per week over 8-12 weeks

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19
Q

for Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression

The following ‘high-intensity psychological interventions’ may be useful

A

Individual CBT
Interpersonal therapy (IPT)
Behavioural activation
Behavioural couples therapy

counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression; offer 6-10 sessions over 8-12 weeks
short-term psychodynamic psychotherapy for people with mild to moderate depression; offer 16-20 sessions over 4-6 months

For patients with chronic physical health problems the following should be offered:
group-based CBT
individual CBT

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20
Q

Describe delivery of Interpersonal therapy (IPT)

A

typically 16-20 sessions over 3-4 months

for severe depression, consider 2 sessions per week for the first 2-3 weeks

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21
Q

Describe delivery of Behavioural activation

A

typically 16-20 sessions over 3-4 months
consider 3-4 follow-up sessions over the next 3-6 months
for moderate or severe depression, consider 2 sessions per week for the first 3-4 weeks

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22
Q

Describe delivery of Behavioural couples therapy

A

typically 15-20 sessions over 5-6 months

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23
Q

Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression

For these patients NICE recommends an antidepressant - normally a ?

A

selective serotonin reuptake inhibitor, SSRI

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24
Q

currently the preferred SSRIs

A

fluoxetine

citalopram

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25
Q

sertraline is useful

A

post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants

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26
Q

SSRIs should be used with caution in

A

children and adolescents

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27
Q

SSRI most common side effect

A

gastrointestinal symptoms

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28
Q

SSRI there is an increased risk of

A

gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID

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29
Q

SSRI patients should be counselled

A

patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI

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30
Q

SSRI higher propensity for drug interactions

A

fluoxetine and paroxetine

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31
Q

Citalopram should noe be used in

A

those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval

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32
Q

Citalopram max dosage?

A

maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

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33
Q

Citalopram QT prolongation is/is not dose dependent

A

is dose dependent

34
Q

SSRI drug interactions

A 
NSAIDs
warfarin / heparin
aspirin
triptans
monoamine oxidase inhibitors (MAOIs)
35
Q

NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs

A

true

but if given co-prescribe a proton pump inhibitor

36
Q

warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering

A

mirtazapine

37
Q

SSRIs & what increase risk of serotonin syndrome

A

triptans - increased risk of serotonin syndrome

monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

38
Q

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after

A

2 weeks

For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.

39
Q

If a patient makes a good response to antidepressant therapy they should continue on treatment for at least

A

6 months after remission as this reduces the risk of relapse.

40
Q

When stopping a SSRI do what?

A

dose should be gradually reduced over a 4 week period

(this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

41
Q

SSRI Discontinuation symptoms

A 
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
42
Q

SSRIs and pregnancy first trimester

A

gives a small increased risk of congenital heart defects

43
Q

SSRIs and pregnancy third trimester

A

can result in persistent pulmonary hypertension of the newborn

44
Q

Paroxetine has an increased risk of

A

Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

45
Q

Serotonin and noradrenaline reuptake inhibitor (SNRI’s) are

A

class of relatively new antidepressants. Inhibiting the reuptake increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects.

46
Q

SNRI examples

A

venlafaxine and duloxetine.

47
Q

SNRI used for?

A

major depressive disorders, generalised anxiety disorder, social anxiety disorder and panic disorder and menopausal symptoms.

48
Q

Mirtazapine is an antidepressant that works by

A

blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.

49
Q

Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in

A

older people who may be affected more or be taking other medications

50
Q

side effects of mirtazapine

A

sedation and an increased appetite

51
Q

Side effects of mirtazapine can be beneficial in older people

A

True
sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.

52
Q

mirtazapine generally take when

A

generally taken in the evening as it can be sedative.

53
Q

Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose

A

true

54
Q

TCA used widely in the treatment of

A

neuropathic pain, where smaller doses are typically required.

55
Q

TCA common side effects

A 
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
56
Q

TCAs that are more sedative

A

Amitriptyline
Clomipramine
Dosulepin
Trazodone

57
Q

TCAs that are less sedative

A

Imipramine
Lofepramine
Nortriptyline

58
Q

Choice of tricyclic

A

low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)

lofepramine has a lower incidence of toxicity in overdose

amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

59
Q

Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI

A

the first SSRI should be withdrawn* before the alternative SSRI is started

60
Q

Switching from fluoxetine to another SSRI

A

withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI

61
Q

Switching from a SSRI to a tricyclic antidepressant (TCA)

A

cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)

  • an exceptions is fluoxetine which should be withdrawn prior to TCAs being started
62
Q

Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine

A

cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly

63
Q

Switching from fluoxetine to venlafaxine

A

withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly

64
Q

Electroconvulsive therapy is a useful treatment option for patients with

A

severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.

65
Q

ECT cintraindications

A

The only absolute contraindications is raised intracranial pressure.

66
Q

ECT short term S/E

A 
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
67
Q

ECT long term S/E

A

some patients report impaired memory

68
Q

The risk stratification of psychiatric patients into ‘high’, ‘medium’ or ‘low risk’ can usefully guide decision making

A

false
review in the BMJ (BMJ 2017;359:j4627) concluded that ‘there is no evidence that these assessments can usefully guide decision making’ and noted that 50% of suicides occur in patients deemed ‘low risk’.

69
Q

Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide

A 
male sex (hazard ratio (HR) approximately 2.0)
history of deliberate self-harm (HR 1.7)
alcohol or drug misuse (HR 1.6)
history of mental illness
history of chronic disease
advancing age
unemployment or social isolation/living alone
being unmarried, divorced or widowed
70
Q

schizophrenia: NICE estimates that ?% of people with schizophrenia will complete suicide

A

10%

71
Q

If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date:

A 
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
72
Q

factors which reduce the risk of a patient committing suicide. These include

A

family support
having children at home
religious belief

73
Q

SAD should not be treated the same way as depression

A

false

74
Q

seasonal affective disorder, you should not give the patient sleeping tablets as this can make the symptoms worse

A

true

75
Q

seasonal affective disorder evidence for light therapy is limited

A

true

76
Q

SAD mx

A

mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed

77
Q

Factors suggesting diagnosis of depression over dementia

A

short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)

78
Q

Non-selective monoamine oxidase inhibitors examples

A

tranylcypromine, phenelzine

79
Q

Non-selective monoamine oxidase inhibitors examples used in

A

used in the treatment of atypical depression (e.g. hyperphagia) and other psychiatric disorder

80
Q

Non-selective monoamine oxidase inhibitors not used frequently due to side-effects

A

true

81
Q

Adverse effects of non-selective monoamine oxidase inhibitors

A

hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
anticholinergic effects

82
Q

serotonin and noradrenaline are metabolised by what in the presynaptic cell

A

monoamine oxidase

4th year passmedicine by topic (96 decks)

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