Depression Flashcards
Single Episode Depressive Disorder:
Define
What are the 3 clusters of a depressive episode
State the ICD-11 essential features for diagnosis of a depressive episode
How would you determine the severity?
How would you manage a depressive episode?
What if the patient is already on antidepressants and there is inadequate response?
Decreased mood/pleasure accompanied by other cognitive or neurovegetative symptoms that significantly affect the individual’s ability to function. Patient is also not diagnosed with previous manic, mixed, or hypomanic episode
ICD 11 states that a depressive episode requires at least 5 of the following characteristic symptoms occurring most of the day, nearly everyday for at least 2 weeks. At least one from the affective cluster must be present.
1. Affective Cluster: Depressed mood reported by the patient (feeling down/sad) or as observed (tearful, defeated). In children and adolescents this may manifest as irritability OR Anhedonia - Markedly diminished interest or pleasure in activities that used to be enjoyable including sexual desire
In summary: Depressed mood and Anhedonia
2. Cognitive-behavioural:
- Reduced Concentration
- Beliefs of low self-worth or excessive guilt (may be delusional) and cannot be due to being depressed
- Hopelessness about the future
- Recurrent thoughts of death, recurrent suicidal ideation, or evidence of attempted suicide
3. Neurovegetative cluster:
- Significantly disrupted sleep (Early morning awakening, difficulty falling asleep, waking up in the middle of the night) insomnia or hypersomnia
- Significant changes in appetite or weight change(diminished or increased)
- Psychomotor agitation or retardation
- Reduced energy/fatigue
Finally, I would have to ensure that there is no evidence of marked anxiety, no evidence of a manic episode, and that it is not due to bereavement.
Severity: Based on how many symptoms, how marked the symptoms are, the degree of effect in patient’s normal functioning, and the presence or absence of psychotic symptoms such as delusions and hallucinations
Managing this patient should take into account an MDT using the biopsychosocial approach. I may also ask for collateral history. To begin, I would have to ensure that there is no comorbid alcohol/substance missuse (Benzoduazepines) (urine dipstick). CT brain can be used to rule out a brain tumour. I would also take routine bloods such as FBC, UandE, LFTs and TFTs as well as glucose levels (for diabetes)
Biological: I would prescribe an SSRI (Sertraline, fluoxetine, citalopram). If this was their first episode, I would prescribe it for 6-9 months and 2 years if recurrent.
Psychological: CBT (best), psychoeducation, supportive therapy, family/couples therapy, mindfullness
Social: Alcohol/substance counselling, social work, Occupational therapy, abuse counselling etc…
I would first ensure compliance with their current medication and then if compliant, I would either increase the dose or switch to another antidepressant of a different class such as venlafaxine (SNRI). If that still doesnt work then I can either prescribe another antidepressant such as Mirtazapine (NaSSA), OR Prescribe a mood stabiliser (Lithium), OR Prescribe an anti-psychotic. If all else fails —> ECT
What are the biggest risk factors to for translating suicidal ideation into suicidal behaviour
Note that this is very important also in knowing what to take in a history with a patient with a hx of self-harm or suicidal ideation
What is the name of the agency that you would refer a patient to?
History of self harm
A suicide plan
Previous exposure to suicide modelling from peers and family
Impulsivity tendencies
Access to a means of suicide (medication or firearm)
Being alone/unsupervised/isolated
Consuming alcohol or other drugs that reduce behavioural inhibition
SCAN - Suicide crisis assessment Nurse Service
What are some triggers of mania/hypomania from a depressive episode other than spontaneously?
What may predict a depressive disorder diagnosis could change to bipolar?
Stress, sleep deprivation, ECT, antidepressants (induced hypomania), Steroids, and amphetamines
Younger age of onset, poor response to antidepressants, anti-depressant induced hypomania, psychosis, postpartum depression
What are normally forgotten things that should be included in every history
Rule out anxiety - Have you felt On-edge recently, or paranoid?
Check for bipolar - Any periods that you were happy in? If yes, does it occur simultaneously/rapidly alternating?
Check for brain injury - Have you had any injuries to your head in your recent memory?
T or F: A depressive disorder should not be diagnosed in individuals who have ever experienced a manic, mixed, or hypomanic episode
True, These individuals should be diagnosed with Bipolar type 1 if they’ve experienced a manic episode, and type 2 if it is hypomanic
When beginning to present your management what are 4 things that you will need to state before beginning the biopsychosocial model:
- Consider most appropriate location for tx (inpatients, home-based, or outpatient). If admitting, decide on level of observation
- MDT approach
- Consider involving family member if appropriate
- Keep GP informed and updated
Patients prescribed Antidepressants should have them checked out every…
6 months
Why would you prescribe fluoxetine over other SSRIs? What is something important to note though?
Best for avoiding weight gain but a lot of drug interactions due to CYP inhibition
Why would you use Escitalopram over Citalopram
MAinly because of the reduced risk of QT prolongation. Another reason is the additional indications for its effect on anxiety disorders as well
What are the down-sides of prescribing Sertraline over other SSRIs?
Increased SE of diarrhoea + Sexual SEs
SSRIs have a notable bleeding risk. What medications are to be avoided in this case?
Anticoagulants, Aspirin, and NSAIDs
A patient with epilepsy enters the clinic. You diagnose them with depression and want to commence them on antidepressants. You are still deciding which to give however in any case, what is something to consider?
You have decided to go for SSRIs. Why? (Give 3/4 reasons)
SSRIs and TCAs reduce seizure threshold
Less sedating, Less anticholinergic effects, Less cardiotoxicity, and safer in OD
Mirtazapine:
What type of Drug is it?
What are its indications
What are its side effects
What other antidepressant can be prescribed with it for boosted effects?
NaSSA - Noradrenergic and specific serotonergic antidepressant
Depression only
Sedation + weight gain
Venlafaxine XL
All antidepressants share 1 major side effect. What is it and how is it caused
Hyponatraemia caused by SIADH (syndrome of inappropriate secretion of antidiuretic hormone
Serotonin Syndrome:
What is it?
What are the main signs and symptoms?
What is it caused by? Give a few
4-step treatment
Define: Life-threatening condition caused by elevated serotonin levels
Signs: Neuro (Agitation , confusion, coma), Neuromuscular (ataxia - no coordination, hyperreflexia - esp lower limbs, Myoclonus/myoclonic seizures, rigidity, tremors), Autonomic (GI upset - Nausea diarrhoea, Hyperthermia, Hypertension, Tachycardia, Tachypnea)
Causes: Serotenergic agent (increased dose of Any Anti-depressant, Lithium -or other mood stabilisers, or analgesics such as Tramadol, fentanyl, or oxycodone) OR Recreational drugs (MDMA, ecstasy, LSD, cocaine, amphetamines)
Treatment:
1. Discontinue any serotenergic agents
2. Administer Benzodiazepine for neuromuscular symptoms
3. Administer Beta blocker for autonomic symptoms
4. Administer Serotonin receptor agonist —> Cyproheptadine
