Depression Flashcards by Aoife Madden

What are the core symptoms of depression?

Low mood
Anhedonia
Lack of energy

How well did you know this?

Not at all

Perfectly

What are the biological symptoms of depression?

Weight change
Disturbed sleep: early morning waking, insomnia or hypersomnia
Psychomotor retardation
Restlessness
Reduced libido
Worthlessness or guilt feelings
Reduced concentration
Nihilistic thoughts

How well did you know this?

Not at all

Perfectly

What are the psychotic symptoms of depression?

Mood-congruent
- Delusions: often revolving around guilt or personal inadequacy
- Hallucinations: auditory, olfactory or visual

Mood-incongruent
- Delusions/ hallucinations that aren’t consistent with depressive symptoms/ thoughts

How well did you know this?

Not at all

Perfectly

What is the classification tool for depression?

ICD-10 classification
- Mild depression: 2 core symptoms, >=2 cognitive symptoms
- Moderate depression: 2 core symptoms, >=3/4 cognitive symptoms
- Severe depression: 3 core symptoms, >=5 cognitive symptoms

How well did you know this?

Not at all

Perfectly

How are risk factors for depression classified?

Predisposing
Precipitating (trigger)
Perpetuating (maintaining)

How well did you know this?

Not at all

Perfectly

What are the predisposing biological risk factors?

Family hx depression and anxiety
Age (teenage - early 40s)
Female sex

How well did you know this?

Not at all

Perfectly

What are the predisposing psychological risk factors?

Personality traits
Childhood trauma

How well did you know this?

Not at all

Perfectly

What are the predisposing/ percipitating social risk factors?

Lack of social support
Poor socioeconomic status
Marital status (separated/ divorced)

How well did you know this?

Not at all

Perfectly

What are the percipitating/ perpetuating biological risk factors?

Substance misuse
Physical health problems (chronic pain etc)

How well did you know this?

Not at all

Perfectly

What are the percipitating psychological risk factors?

Traumatic life events
Low self-esteem

How well did you know this?

Not at all

Perfectly

What are the perpetuating psychological risk factors?

Failure to cope with loss
Ongoing loss

How well did you know this?

Not at all

Perfectly

What are the protective factors for depression?

Current employment
Good social support
Marital status: being married

How well did you know this?

Not at all

Perfectly

What is dysthymia?

Chronic low grade depression for >=2 years

How well did you know this?

Not at all

Perfectly

What is minor depressive disorder?

1-2 symptoms of depression or <2 weeks

How well did you know this?

Not at all

Perfectly

What is the PHQ-9?

Patient Health Questionnaire - 9

Usually used in primary care to evaluate the severity of depression and response to treatment, rather than for depression screening itself

How well did you know this?

Not at all

Perfectly

What is the NICE stepped-care model for managing depression?

Step 1: any case of suspected depression
- Assessment
- Consider active monitoring and psychoeducation

Step 2: subthreshold depression resistant to interventions step 1, mild and moderate depression
- Low-intensity psychological and psychosocial therapies
- Pharmacological management
(either alone or in combination)

Step 3: subthreshold, mild or moderate depression resistant to step 2 and severe depression
- Pharmacological
- High-intensity psychological therapies
(either alone or in combination)

Step 4: severe depression at high risk of self harm
- Pharmacological
- High-intensity psychological therpy
- Electroconvulsive therapy
(either alone or in combination)
- Involvement of specialist services

How well did you know this?

Not at all

Perfectly

What are the principals of CBT?

Behavoiural activation
Cognitive work (challenging core beliefs)
Compassion-based therapy

How well did you know this?

Not at all

Perfectly

What are the commonly used classes of anti-depressants?

SSRIs
TCAs (lower doses for neuropathic pain, higher doses for depression)
Monoamine Oxidase Inhibitors (MAOIs)

How well did you know this?

Not at all

Perfectly

What are the common side effects of SSRIs?

Headache
GI (nausea, diarrhoea/ constipation)
Sleep disturbance/ vivid dream
Sexual dysfunction

How well did you know this?

Not at all

Perfectly

What drug interaction with SSRIs can be dangerous?

SSRIs + NSAIDs as this can result in GI bleeding

If giving NSAIDs and SSRI, must give PPI

How well did you know this?

Not at all

Perfectly

Why should patients on SSRIs be monitored in the first 1-2 weeks?

There is a small chance of increased suicidality <1/10000, but more common in younger people

How well did you know this?

Not at all

Perfectly

How often should patients on SSRIs be reviewed?

Initially every 2 weeks (if <30 every 1 week) then regularly after that

How well did you know this?

Not at all

Perfectly

What are examples of SSRIs?

Fluoxetine
Sertraline
Citalopram

What are the side effects of TCAs?

Anticholinergic/muscarinic (dry mouth, blurred vision, constipation, urinary retention)
Cardiotoxic (QT prolongation, ST elevation, AV block)
Anti-histaminergic (sedation, postural hypotension, weight gain)

Why does fluoxetine have to be stopped completely before starting a different anti-depressive?

Because the 1/2 life is weeks long after prolonged use and therefore can't be cross titrated with other medications

What is serotonin syndrome?

Excessive seratonin in the brain

What are the three core symptoms of seratonin syndrome?

1. Altered mental state: agitation, confusion, coma 2. Neuromuscular changes: hallmark features are myoclonus, hypertonia, hyperreflexia, tremor 3. Autonomic dysfunction: tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis

Why are TCAs not commonly prescribed in depression?

- Associated with many side effects - Lethal in overdose and therefore avoided in high risk patients

What are examples of TCAs?

Amitriptyline, clomipramine, lofepramine

What diet is required for patients taking MAOIs?

Low tyramine diet (cheese is high in tyramine) as this can lead to acute hypertension

What are examples of MAOIs?

Phenelzine, moclobemide

What is Mirtazapine?

A tetracyclic antidepressant

What are the side effects of mirtazapine?

- Drowsiness - Increased appetite - Weight gain So is useful for patients who are struggling with insomnia and appetite

What is venlafaxine/ duloxetine?

An SNRI (similar side effects to SSRIs)

What is important to monitor when patients are given venlafaxine?

Patients require blood pressure monitoring (possibly due to increased sympathetic activation)

What are the steps for managing depression that does not respond to treatment?

1. Check medication adherence, side effects and optimize dose 2. Switch antidepressants: initially to alternative SSRI 3. Alternative antidepressant class 4. At this stage depression can be classed as refractory

What are the options for managing refractory depression?

- Combinations: add mirtazapine to an SSRI - Augmentation with lithium/ antipsychotic - ECT

What are the symptoms of discontinuation syndrome?

- Flu-like symptoms - Electric shock symptoms - Headache - Dizziness - GI effects - Anxiety - Trouble sleeping

How does discontinuation syndrome differ from withdrawal?

Anti-depressants aren't addictive, therefore the symptoms aren't withdrawal symptoms

Which SSRI has the highest risk of discontinuation syndrome?

Paroxetine because the 1/2 life is ~24 hours, therefore the symptoms come on rapidly after stopping the drug

What are the risk factors for serotonin syndrome?

- Antidepressant use - Combination of antidepressants - Overdose of antidepressants - Lithium use - ECT - Opiates, antiemetics, illicit drugs

What are the complications of serotonin syndrome?

- DIC - Rhabdomyolysis - Renal failure/ metabolic acidosis - Seizures

What is the management of serotonin syndrome?

- Severe cases managed in hospital - Stop the offending medications - Supportive measures (A-E) - Consider benzodiazepine (eg. clonazepam)

Mild-moderate depression mx

- Seep hygiene - Self help guidance - FU 2 weeks After 2 weeks: - Individual-guided self-help based on CBT - Computerised CBT - Structured group physical activity programme If low intensity psychological intervention is delined: - Group CBT

What is individual-guided self-help based on CBT?

- Provision of writeen materials, supported by trained practitioner who reviews progress and outcomes - 6-8 sessions (face-to-face or telephone) over 9-12 weeks

What is computerised CBT?

- Explains CBT - Encourages tasks between sessions, thought-challenging and active monitoring of behaviour and thought patterns - Trained practitioner reviews - 9-12 weeks

What is structured group physical activity programme?

- Groups by a trained practitioner - 3 sessions per week (45-60 mins) over 10-14 weeks

What is group CBT?

- 2 trained practitioners - 10-12 meetings of 8-10 participants - 12-16 weeks

What is the follow up for antidepressants?

- 1 week 18-25, or at risk of suicide - 2 weeks, >25 no suicide risk Review every 2-4 weeks for 3 months

Which antidepressants can cause overdose and death from overdose?

- Venlafaxine - TCA (except lofepramine)

Which antidepressants worsen hypertension?

Venlafaxine and duloxetine

Which antidepressants cause postural hypotension and arrhythmia?

TCAs

How long is individual CBT?

16-20 sessions over 3-4 months Follow up during the following 3-6 months

How long is interpersonal therapy?

- 16-20 sessions over 3-4 months

Which drugs is a 2 week washout period required for?

Switching from a non-reversible MAOI

When would TCAs be started at a lower dose?

If switching from fluoxetine or paroxetine to TCA (they inhibit TCA metbaolism therefore increase risk of serotonin syndrome)