Depression

Question 1

Suicidal Risk Assessment

Answer 1

A) Determine the severity of the risk- high or medium based on: SADPERSONS medium is 5-6 strongly consider hospitalisation and high is 7 or more (hospitalise or commit).
B) Determine the: IIP
1. Ideation: content of thoughts and durations of these thoughts
2. Intent: is it really suicide or self-harm
3. Plan: detail, lethality, concealment and preparations

Question 2

What is the SADPERSONS suicide risk assessment?

Answer 2

Sex- Male
Age- <19 >45 (<20 >44)
Depression (depression or hopeless 2)
Previous attempt (previous attempt or psychiatric care)
Ethanol use (excess alcohol or substance)
Rational thinking loss 2
Social support lacking separated/single/divorced/widowed
Organised Plan (organised or serious attempt)
No spouse or no social support
Sickness (stated future suicidal attempts 2

Question 3

Atypical Depression symptoms 5

Answer 3

Found in BD Depression
Rapidly shifting mental state
Hypersomnia, hyperplasia, hypersensitivity to rejection
Retarded psychomotor activity (leaded paralysis)
Psychotic symptoms
Suicidalilty

Question 4

How to treat depression

Answer 4

ASSESS SEVERITY AND SETTING
-Mild: recent onset is not debilitating, CBT, interpersonal psychotherapy, individual guided self-help or exercise. Antidepressants not first line of choice
-moderate to severe: antidepressants first line of choice with or without psychotherapy
-Complex: suicide and psychotic features may require admission to hospital

MEDICATION
1.Discuss choice of antidepressants
-SSRI preferred, sedating mirtizapine (tetracycline)
2.Start antidepressants
-Titrate dose and assess over 2 weeks
-if no effect
3.Assess over further 1or 2 weeks
-increase dose
-if no effect
4.Switch antidepressants to a different
-titrate and assess over 3-4 weeks
-if no effect, increase dose
-if no response
5.Consider 3rd choice options
-Mirtazapine- tetracycline
If no response after 4-6 or maximum 16weeks consider resistant depression (adding lithium or adding a second antidepressants also ECT if severe and debilitating)
6. Continue treatment for 6-9 months at full dose 1 episode or 2 years 2episodes
7.Switch if not tolerating

PSYCHOTHERAPY
1. CBT
2. Interpersonal psychotherapy
3. Psychodynamic psychotherapy

Question 5

List different classes of antidepressants

Answer 5

SSRI
SNRI
TCA
MAOI

Question 6

Antidepressant (SS): MOA, SE, example

Answer 6

SSRI- serotonin selective reuptake inhibitors
MOA: inhibit the reuptake of serotonin at the presynaptic neurone by binding to transporter resulting in the increase the synaptic activity and transmission
SE:
C: headache, ear pain, tinnitus, agitation, insomnia
C: QT prolongation or Torsades de pointes
G: nausea and vomiting, appetite changes GI bleeding or bleeding in general
R: sexual dysfunction
A: anxiogenic initially/ abrupt withdrawal symptoms
M: hyponatremia
S: serotonin syndrome
= altered mental state: confusion and agitation
= abnormal neuromuscular system: hot hyperreflexia, tremor, ocular clonus
= autonomic hyperactivity: tachycardia, hypertension
EXAMPLE:
Citalopram, fluoxetine

Question 7

Antidepressant (SN): MOA, SE, example

Answer 7

Serotonin Noradrenaline Reuptake inhibitor
MOA: inhibit the reuptake of serotonin and noradrenaline at the presynaptic neurone by binding on their respective transporters resulting in the increase of their synaptic activity and transmission
SE:
Body weight changes/Blood pressure changes hypertension
Anorexia
Drowsiness and dizziness

Suicidal
Nausea, diarrhoea and constipation
Reproductive sexual dysfunction
Insomnia

EXAMPLE
Duloxetine may be used for chronic pain
Venlafaxine

Question 8

Antidepressant (T) MOA, SE, example CI

Answer 8

TCA
Tricyclic Antidepressant
Also used for migraine prophylaxis, enuresis and chronic
neurogenic pain
MOA: does not have a specific receptor but blocks the reuptake of serotonin and noradrenaline. Antagonistic to histaminic, alpha adrenergic and muscarinic adrenergic
SE
Tachycardia and thrombocytopenia
Cardiac: QT prolongation and arrhythmia
Anticholinergic: dry mouth and urinary retention, confusion, tachycardia, blurred vision, constipation
Antihistaminic:sedation and drowsiness and weight gain
Antiadrenergic: hypotension, arryhmia

EXAMPLE:
Amitriptilline, imipramine desipramine

CI
C: recent MI, heartblock arrhythmia
Suicidal Risk
Epilepsy
Elderly, BPH

Question 9

Antidepressant (M): MOA, SE, example

Answer 9

Monoamine Oxidase Inhibitor

MOA: inhibits the breakdown of serotonin and noradrenaline by binding to the monoamine A and B, resulting increased synaptic availability and transmission by these neurotransmitters
SE
C: sedation
C: hypertension crisis due simultaneous ingestion of tyramine rich foods that are not metabolised resulting in the surge of NA resulting in hypertension, palpitations
G: nausea
O: muscle rigidity, sweating and serotonin

Example
Trancypramine