Depression

Question 1

What is depression

Answer 1

An affective disorder (impacts emotional behaviour) that causes an abnormally low mood

Question 2

How do you classify depression

Answer 2

Based on
1. Severity

2. Presence or absence of physical features
3. Presence of absence of psychotic features
4. Course (duration and recurrence)
5. Presence or absence of intervening manic phases

Question 3

What are the population that are more likely to get depression

Answer 3

Women

Question 4

What is the aetiology of depression (how does it occur)

Answer 4

1. Drug use: Reserpine (antihypertensive): non specific amine depleter
2. Tricyclic antidepressants: prevent amine reuptake
3. Basically amine deficiency theory, in particular 5-HT serotonin

Question 5

What can set off depression?

Answer 5

1. Single Manic episode

2. Single depressive episode

Question 6

What are the risk factors for depression

Answer 6

Family history- common in depression

Question 7

What are the core features of depression

Answer 7

Depressed mood
Sadness
Dejection
Tearfulness
Pessimism
Negative thought pattern
Reduced pleasure
Cannot concentration

Question 8

What are mild to moderate features of depression

Answer 8

Labile mood
Initial insomnia
Acts or ideas of self harm
Reduce drive, vitality and libido
Apathy, withdrawal

Question 9

What are severe features of depression

Answer 9

Agitation
Fixed mood variation
Early waking 
Weight loss
Self reproach

Question 10

What are the very severe (psychotic features) of depression

Answer 10

Guilty feelings
Delusions of inadequacy
Severe retardation and agitation
Suicidal thought
Hallucinations

Question 11

How do you diagnose depression

Answer 11

Must exhibit low mood and have four of: for at least 2 weeks
Pessimism
negative thoughts
weight change
sleeping disorder
Fatigue
Feelings of guilt
Difficult concentrating 
Suicidal thoughts or actions 

Not consistent to previous behaviour and personality
Not secondary to other treatments

Question 12

What are the treatment aims

Answer 12

Prevent suicide- can be detained under mental heath act 1983 for 28 days

identify primary causes: hypothyroidism

Provide symptomatic therapy

Investigate social, domestic or financial circumstances

Question 13

What is the initial first line management

Answer 13

Watchful waiting
Guided self help programmes based on psychological therapies- using group, martial, family
Cognitive Behavioural therapy (CBT)
Structured supervised exercise programme

Question 14

What is electroconvulsive therapy

Answer 14

Used when all treatments have failed and suicide is a major risk

Involves placing electrodes on patients head and shocking the brain

Duration: short to several months

Question 15

What are the pharmacological treatment methods

Answer 15

1. Tricyclic antidepressants (TCAs)
2. Secondary geernation cyclic (TCAs)
3. Selective Serotonin Reuptake Inhibitors (SSRIs)
4. Monoamine Oxidase Inhibitors (MAOI)

Question 16

What is the first line pharmacological treatment method for depression and what are the side effects, examples, and complications

Answer 16

1. Selective Serotonin Reuptake Inhibitors (SSRIs)
2. Side effects: Nausea, diarrhoea, anorexia, anxiety, agitation, insomnia, anti platelet = risk of GI bleed
3. Examples:
   Citalopram: risk of dose dependent QT prolongation Escitalopram: S enantiomer of citalopram
   Fluoxetine: long half life, has more drug interactions
   Paroxetine: short half life, more drug interactions
   Sertraline: few interactions best choice for MY or angina patients
4. Complication: Hyponatraemia: low sodium

Question 17

What is an SNRI and give examples of it

Answer 17

1. Serotonin and noradrenaline re-uptake inhibitors: inhibits presynaptic reuptake of serotonin and noradrenaline
2. Side effects: similar to SSRI
3. examples: Duloxetine and Venlafaxine

Question 18

What is the maintenance treatment of antidepressant

Answer 18

Patient takes tablets which takes effect after 4-6 weeks for mood changes to occur

Continued at same treatment dose for 6 months after remission from acute episode

12 months for older adults

24 months for those who have had 2 or more depressive episodes

Question 19

How do you stop or change treatment in relation to depression

Answer 19

1. Stopping should not be done abruptly
2. Stop in a planned manner with consultation from prescriber- avoid symptoms of withdrawal
3. Withdrawal can include: anxiety, GI and influenza symptoms, sensory and sleep disturbances

Question 20

How do you treat treatment resistant depression

Answer 20

1. Diagnosed when patient doesn’t respond to monotherpay
2. This could be:
   SSRI + TCA
   TCA + SSRI or cyclic + MAOI
   Lithium + cyclic or Lithium + SSRI

Question 21

What is the only antidepressant that is licensed for 18 year olds and under

Answer 21

SSRI: Fluoxetine 10mg daily

can be used for age 8 or above

Question 22

What do Tricyclic antidepressants do, side effects and examples

Answer 22

1. Block the presynaptic reuptake of serotonin and adrenaline
2. Side effects: antimuscarinic side effects: dry mouth, constipation, blurred vision, urinary retention

3. Examples: all sedating
Amitriptyline
Clomipramine
Dosulepin: increased cardiac risk 
Imipramine
Lofepramine: lower sider effects
Noritriptyline: less sedating
Trazodone
Trimipramine

Question 23

What are the first line treatment options in depression ins someone who is pregnant

Answer 23

TCAs:
Amitriptyline
Imipramine
Noritriptyline

Question 24

How does a MAOI work, side effects and give examples of them

Answer 24

1. MAOI: increase amount of monoamine neurotransmitters (adrenaline, dopamine, noradrenaline, dopamine) in synapses
2. Side effects: Rise in BP- patient should stop eating high in tyramine foods
3. Examples:
   Isocarboxazid: barely used, not tolerated well
   Phenelzine: safest irreversibile MAOI
   Tranylcypromine: most likely to cause BP