Depression Flashcards
Most common classes
- Major depressive disorder (clinical depression)
Symptoms: Loss of pleasure in activities/lack of reactivity to pleasurable stimuli 2+weeks, at least 3 of:
continuous low mood/sadness, feeling hopeless and helpless, low self esteem, tearful, guilt ridden, irritable, intolerant of others, no motivation/interest in things, difficult to make decisions, no enjoyment, suicidal thoughts and self harm. - Atypical Depression: some/all of clinical depression + 1/all: increased appetite/weight gain, increased sleep, heaviness of the arms, sensitivity in the legs.
- Seasonal affective disorder:
Relationship between time of year and depression. show at least 2 eps of depressive disturbance in the last 2 years. seasonal eps outnumber non seasonal eps.
seasonal disorder- more likely to report atypical symptoms like hypersomnia (day time sleepiness) and increased appetite.
Causes, Pathophysiology and Diagnosis
Depressed mood and/or loss of pleasure in most activities.
Severity = number and severity of symptoms + amount of functional impairment.
ICD-11 = needs 4 out of 10 symptoms, for diagnosis
DSM-IV = needs 5 out of 9 symptoms, for diagnosis
Symptoms prevalent for at least 2 weeks and each symptom should be present enough for every day.
DSM-IV = 1 KEY symptom,
ICD-11 = 2 KEY symptom
Key symptoms = For both: low mood, loss of interest and pleasure,
ICD only : Loss of energy
Most depression have triggering life event. Some don’t
Primary care:
For primary care PHQ-9, GAD7 to do diagnosis.
Treatment
NICE stepped care model:
Step 1 - Depression confirmed: assessment, support, psychoeducation, active monitoring and referral for further investigation
Step 2 - Persistent subthreshold depressive symptoms; Mild/moderate depression:
Low intensity psychosocial/psychological interventions, MEDICATION and referral
Step 3 - inadequate response to step 2 OR moderate - severe depression:
MEDICATION, High intensity psychological interventions, combined treatments, collab care and referral
Step 4 - Severe and complex depression; Risk to life/ Severe self neglect:
MEDICATION, High intensity psychological interventions, Electroconvulsive therapy, crisis service, Combined treatments, Multi-professional and inpatient care
- any referral would = more assessment/interventions
NEW EPISODES
Subthreshold/mild depression:
1st line psychological and psychosocial therapies.
- Guided self help –> group CBT –> group behavioural activation –> individual CBT –> individual behavioural activation –> group exercise –> group mindfulness and meditation –>interpersonal psychotherapy –> SSRi –> counselling –> short term psychodynamic psychotherapy (Nice for more details)
More Severe depression:
individual CBT + anti depressant –> individual CBT –>individual behavioural activation –> Anti depressant –> individual problem solving –> counselling –> short term psychodynamic psychotherapy –> interpersonal psychotherapy –> guided self help –> group exercise
Prevent relapse:
- NICE visual summary 3
Continuing treatment after full or partial remission can stop relapse.
If High risk -
Depending on what achieved relapse, that should be continued (psychological therapy, drug therapy, combo) OR IF on antidepressant alone can continue or + Psychological therapy (CBT/MCBT). If on combo can take away psychological or drug or continue. If on psychological continue with same relapse adapted therapy.
RISK of relapse should be asses at the end of psychological therapy and every 6 months if on meds.
Further line treatment:
- NICE visual summary 4
No response after 4-6 week of treatment asses adherence/other health factors
STILL NO response to:
- psychological monotherapy SWITCH TO ALT, Add SSRi OR try SSRi alone.
- NO response to drug monotherapy, consider + group intervention; switch to psychological therapy; increase drug dose; switch to different drug same/different class; or change to COMBO of therapy.
- SAME AS ABOVE FOR people on combo initially.
2 antidepressant FAIL ALT Vortioxetine
- When switching drug class or adding drugs refer/get advise from specialist
- ECT, transcranial magnetic stimulation, and implanted vagus nerve stimulation can be utilised
Chronic depression:
- NICE visual summary 5
BNF
- IF patient has symptoms that significantly impair functioning, Treatment options:
- Monotherapy - CBT or Drugs (SSRi, SNRi, or TCA)
- CBT + SSRi or TCA
TCA greater risk of overdose - Lofepramine better safety profile
- Don’t respond to SSRi/SNRi ALT - specialist setting/ advise. ALT = TCAs, moclobemide, irreversible MOAis, or amisulpride
psychotic and with personality disorder check pic
Medication choice
Medication choice depends:
Patient safety and tolerability, physician familiarity, history of previous treatment,
All antidepressants are potentially effective.
Takes 2-6 weeks for response. However, most PTs don’t feel the effects until 6-8 weeks after starting.
Alter treatment if no good response within 6-8 weeks.
once good response continue for 4-9 months in person with 1st ep depression. 2 or + eps then longer course.
Drug choices (SSRI FAIL)
Increase dose/Switch to different SSRi/ Mirtazapine if initial SSRI fail.
2nd line:
Lofepramine, Moclobemide, Reboxetine,
Venlafaxine, Reserved for more severe cases
MOAi under specialist
3rd line:
+ another antidepressant or Lithium/Antipsychotic
Lifestyle and long term monitoring
Dietary restrictions are necessary only when prescribing MAOIs. Foods high in tyramine, which can produce a hypertensive crisis with MAOIs, so AVOID.
Tyramine triggers nerve cells to release NA = increases BP = Throbbing headaches
- Examples: soy sauce, aged chicken/beef liver, raisins, sour cream, beer, wine, yogurt, mature cheese, bean pods, soy beans, Bovril, OXO, marmite (or similar meat/yeast extracts)
Exercise and activity can help recover from depression.
Meds should be re-evaluated every 8-12 weeks
Non-response to treatment should raise chance of ALT diagnosis (e.g., bipolar or dementia).
Evaluate Patient’s functional status and wellbeing every visit.
- Suicidal ideation - evaluated each visit and between visits if needed.
PRSC notes
1st line - SSRi
TCA similar efficacy to SSRi but more AEs.
- TCA toxicity is problematic
- TCA more sedating, More antimuscarinic/Cardiotoxic AEs.
MAOi
Dangerous with some foods/drugs (tyramine)
- Reserved for specialist
Review PTs within 2 weeks at start of treatment - suicide risk PTs 1 week with repeated reviews within 4 weeks.
BNF- Pt should know drug may takes minimum 4 weeks to work
- Recurrent depression maintenance treat for at least 2 yrs.
- Take at least 6 months after remission
12 months for generalised anxiety disorder - more risk of relapse
AVOID ALL Antidepressants in manic phase in bipolar - gives them more energy boost.
Antidepressant and Hyponatraemia (EXAM Q)
Hyponatraemia associated with ALL antidepressants.
- more in SSRi
Signs of Hyponatraemia:
(SALT LOSS)
S- Stupor/coma
A- Anorexia
L- Lethargy
T- Tendon reflexes decreased
L- Limp muscles (weakness)
O- Orthostatic hypotension
S- Seizures/Headaches
S- Stomach cramps
Suicide & Antidepressant
They linked with suicidal thoughts and behaviour
younger esp more risk
Monitor PTs for this esp at the start of treatment
Serotonin syndrome
When there’s too much serotonin in the body.
uncommon ADR with SSRi/SNRIs.
- Happens normally with SSRi/SNRi with drug that increases serotonin.
symptoms happen at initiation, dose increase, overdose, adding new drug or replacement of 1 drug without proper washout period.
- washout esp. in irreversible MAOis or drug with long half life.
- Symptoms can be mild-life threatening
Sever toxicity normally occur with MAOi and another drug.
SYMPTOMS of Serotonin syndrome
Neuromuscular hyperactivity - tremor, hyperreflexia, rigidity
Autonomic dysfunction - Hyperthermia, shivering, diarrhoea, BP change tachycardia
Alerted mental state: Agitation, confusion, mania
STOP MEDS if these occur.
