Depression Flashcards
Define depressive episode
Depressed mood, loss of interest (anhedonia), and fatigue - persisting for at least two weeks.
Must have 5/8 defining symptoms including low mood or less of interest/pleasure.
What is a major depressive disorder?
Presence of a major depressive episode lasting at least two weeks, with specific criteria regarding mood, cognition and physical symptoms.
What is persistent depressive disorder (dysthymia)?
A chronic form of depression lasting for at least two years.
What are the different severities of depression?
Mild - few if any symptoms more than those required for diagnosis - minor functional impairment
Moderate -
Severe - greatly increased symptom number, intensity and functional impairement
What is the relevant epidemiology of depression?
Higher in females
Peak 40-50yrs
More common mental health disorder
What are the key contributing factors to the aetiology of depression?
Interaction of genetic and environmental factors:
History of mental illness
Physical illness
Social challenges - divorce, poverty, unemployement.
How often must depressive symptoms occur to have depression according to DSM?
Must have 5/9 symptoms for nearly every day for at least 2 weeks.
One of which must be low mood or lack of pleasure/
What are the defining symptoms of depression?
Depressed moor or irritability - subjective or objective
Anhedionia - loss interest/pleasure
Significant weight change (5%) or appetite
Sleep alterations
Activity changes
Fatigue
Guilt or worthlessness
Cognitive issues - concentration, indecisiveness
Suicidality.
What are some additional features that may be seen in severe depression?
Psychotic features - nihilistic delusions (Cotards syndrome) and hallucinations
Depressive stupor - immobility, mutism, refusal to eat or drink, may require ECT.
What are some key organic differentials for depression?
Neurological - parkinsons, dementia, MS
Endocrine - thyroid, adrenal
Substance use or medication
Chronic conditions - DM or obstructive sleep apnea
Long standing infections - mononucleosis
Neoplasm and cancers - pancreatic
What ‘medical’ tests may be done to help investigate depression?
FBC - anaemia
TFT - hypo
Urea and electrolytes -
LFTs
Glucose - hypos
B12/folate - anaemia
Cortisol levels - mood and arousal
Toxicology screen
CNS imaging.
What questionnaires may be used to assess depressive symptoms?
Hospital Anxiety and Depression Scale -
Patient Health Questionnaire -
When do GPs typically refer depression to secondary care?
High suicide risk
Symptoms of bipolar disorder
Symptoms of psychosis
Severe depression unresponsive to initial treatment.
What is the typical first-line management for subthreshold or mild-to-moderate depression?
Low-intensity psychological interventions such as self help or computerised CBT
What is the typical treatment progression for subthreshold and mild-to-moderate depression?
1st - low intesitiy psychological interventions
2nd line - high intensity psychological interventions
3rd - consider anti-depressants
What is the first line treatment for mild unrepsonsive depression and moderate to severe depression?
High intensity psychological interventions + antidepressant (typically SSRI)
What is the treatment escalation for mild depression unresponsice and moderate to severe depression?
1st - high intense psychological interventions + SSRI
2nd - switch antidepressant then adjuncts
What is the first line treatment for severe depression and poor oral intake/psychosis/stupor?
ECT
What are the risks of ECT?
Short term = headache, muscle aches, nausea, temporary memory loss, confusion
Long term - persistent memory loss
Risk of oral damage, death (from seizure + local anaesthetic)
What is the typical treatment for recurrent depression?
Antidepressant + lithium
What are the dangers of anitdepressants in young people?
How should this be managed?
18-25yrs - risk of impulsivity and suicidal thoughts
Follow up one week after starting to monitor progress
When should patients starting anti-depressants be reviewed?
18-25yrs - after 1week
Older than 25yrs - 2to4 weeks later
How long should antidepressants be continued for after remission?
At least six months - reduce risk of relapse
Should then be gradually tapered over four weeks.
What are the different classifications of depression via the PHQ-9 scores?
Less severe - ‘subthreshold and mild’ - PHQ-9 score less than 16
More severe - moderate and severe disease - score equal to or greater than 16.
What two questions are often used when screening for depression?
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?
What are some essential factors to explore in a depression history?
Caring responsibilities
Social support
Drug use
Alcohol use
Forensic history
Self=harm/neglect/suicide
Harm to others
What do the different PHQ-9 scores indicate?
Rank severity of depression
5 to 9 = mild
10 to 14 = moderate
15-19 = moderately severe
20-27 = severe
What are the different post natal depression conditions?
baby blues - 50% mothers, first week after, mild few days to two weeks - no treatment
Postnatal depression - as depression around 3m after birth
Puerperal psychosis - severe, 2w after, psychosis - urgent support and assessment often mother+baby unit, meds, ECT.
What screening tool is used for post natal depression?
Edinburgh postnatal depression scale.
10/30 plus indicates postnatal depression.
What are the different classes of anti-depressants?
SSRIS
SNRIs
MAOIs
Tricyclic
Atypical
Noradrenaline and specific serotonin reuptake inhibitors (NASSA).
What is important about MAOIs?
Also inhibit MAO in gut - can cause gut medication interactions
Avoid tyrosine risch food such as cheese - risk of rapid rise in blood pressure
What is the risk of overdose on anti-depressant medication?
Seratonin syndrome
Most common with multiple anti-depressants or when first starting/changing.
What is the PHQ-9 scale used for depression?
Very commonly used
Rates depression as mild, moderate and severe - with cutt off points
Used in primary care and IAPT (CBT services)
What is the use of HADS scale for depression?
Adapted for hospitals - as PHQ-9 score would be skewed by hospital environment anyway.
What are some vulnerabilities for depression?
Genetics - family history
Adverse childhood advents
Female sex
Substance abuse
What stress factors can trigger a depressive episode?
Cumulative stress:
Bereavement
Loss events (jobs, roles, partner)
Situations of trapped or powerless - domestic violence, poverty, debt, carer stress
Chronic illness
What concept is often used to explain vulnerability and stress to patients?
Stress bucket
Vulnerability = size of bucket
Stress flows into buckt
Tap = lets water out = good coping, bad coping the tap is not working
If bucket overflows then problems develop
What is the basic mechanism of action of SSRIs?
Act on the presynpatic nerve ending - block seratonin receptors to prevent reuptake of seratonin
This increases seratonin in the synaptic cleft - inc activity at the post synaptic neuron.
What are the key principles of using medication to treat depression?
- Check no physical/health contraindications or interaction
- Go low and go slow
- Make sure drug at max dose before changing to another
- Recongise that drugs can take time to work - explain this to patient
What patient education is needed when starting anti-depressant medication?
- Take 4-6weeks to work
- Side effects - risk of inc in suicidality in first 4-6weeks
- May need to stay on 6 month or 2 years (if recurrent) after back to norma;
- Withdrawl symptoms when stopping - slowly and with medical advice
- Reassure that not addictive or tolerance
What are some important safety points about anti-depressant medication?
Risk of overdose - avoid toxic TCAs in high risk patients
Conditions - cardiac, epilepsy, pregnancy
Sertraline considered the safest
E;der;y - lower doses and risk of hyponatremia
Requires step down process not sudden stop of can cause delirium/withdrawl
What is the only licensed anti-depressant in children?
Fluoxetine
Is an SSRI
What are the key signs to look for when diagnosing seratonin syndrome?
Cognitive changes - agitation, confusion, euphoria, insomina, hypomania, hallucinations
Autonomic changes - tachycardia, HTN, fever, diaphoresis, mydriasis, arrythmias, tachypnea
Neuromuscular - tremor, hyperreflexia, clonus, ataxia, incoordination, seizures
What are the key difference between static and dynamic risk factors?
Static - long term
Dynamic - fluctuate with time/emerge recently to precipitate risk
What is the link between autism and suicide?
More vulnerable to self harm and suicide, particularly females
May be due to difficulties accessing healthcare, being assessed by health care, communicating emotions and understanding emotions.
Masking of symptoms or not understanding broader scope of questions
Give some examples of TCA
Amitriptylline
Nrtrip
Lofepramine
Clomipramine
Give some examples of NASA
Mirtazapine
Give some examples of SSRIs
Sertraline
Fluoxetine
Citalopram
Escitalopram
Give some examples of SNRIs
Duloxetine
Venlafaxine
Give an example of SARI
Trazadone
What are the three defining symptoms of depression?
Low mood
Anhedonia
Lack of energy
How do you determine the severity of depression?
Mild = 2 key and 2 other
Moderate = 2 key and 3 other
Severe = 2 key and 4 others, automatically severe if signs of psychosis
