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Psychiatry > Depression > Flashcards

Depression Flashcards

1
Q

Definition of depression?

A

Core symptoms for at least 2 weeks not secondary to the effects of drug/alcohol misuse, organic illness or bereavement

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2
Q

Sub-types of depression?

A

Post-natal depression
Atypical depression
Pre-menstrual dysphoric disorder
Seasonal affective disorder

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3
Q

Organic causes of depression?

A

Endocrine - addisons, cushings, hypothyroidism
Metabolic - Fe/B12/folate deficiency, Hypercalcarmia, hypomagnesia
Neurological - alzheimer’s, HD, epilepsy, MS, IC tumours, parkinson’s
Drugs - L-dopa, steroids, B-blockers, digoxin
Illicit drugs - cocaine, amphetamines, opioids, alcohol
Delirium - UTIs, infection

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4
Q

ICD-10 criteria for severity of depression?

A 
Mild = 2 core, 2 other
Moderate = 2 core, 3 other
Severe = 3 core, 4 other
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5
Q

ICD-10 core symptoms?

A

Anhedonia
Low energy/fatigued (Anergy)
Low mood

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6
Q

Other ICD-10 symptoms?

A 
Guilt
Reduced appetite
Reduced libido
Reduced confidence (Low self-esteem)
Disturbed sleep
Reduced Concentration
Suicidal thoughts
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7
Q

Indirect presentation of depression?

A

Mostly somatic presentations: headache, Gi disturbance, weight change, chronic pain syndrome

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8
Q

What is pseudo-dementia?

A

A cognitive impairment (confusion, memory loss, decline in normal function) as result of a lack of motivation and mood disturbances

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9
Q

What is first line SSRI treatment for depression?

A

Citalopram and fluoxetine = 1st line

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10
Q

Biological management ladder for depression

A
  1. SSRI
  2. Increase dose of SSRI –> switch SSRI
  3. 2nd line drugs SNRI (venlafaxine), TCA, MOA-I
  4. Augmentation with lithium or another class NASSA (mirtazapine)
  5. ECT (severe refractory depression)
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11
Q

Common SSRI side effects?

A

Blurred vision, dizziness, dry mouth, sweaty, headaches
GI: GI upset, nausea, loss of appetite, bleeds
Head: headache, agitated/restless, insomnia
Loss of libido/erectile dysfunction

Hyponatremia (anorexia, nausea, malaise –> headache, confusion, seizures) - can occur in other A/D medication
Prolonged QTc

NB. milder than TCAs, worse than SNRI but less toxic and reduced risk of OD
May feel worse/anxious in first couple of weeks

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12
Q

What is serotonin syndrome?

A

A common complication of anti-depressants (SSRI, TCA, MAO-I, st johns wort) that result in an increase in 5HT
–> fever, restlessness, tremor –> arrhythmias, confusion, seizures

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13
Q

What is occurs in treatment withdrawal?

A

Occurs within 5 days of stopping anti-depressant
Mild and self limiting - restlessness, mood changes, sleep disturbance, unsteadiness, sweating

Most severe in venlafaxine and paroxetine

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14
Q

What is ECT?

A

Inducing seizures under GA x 2 weekly for 12 weeks
70-80% response
S.E. = headache, nausea, muscle pain, memory loss

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15
Q

What should you check if antidepressants are not working?

A

Compliance
Enough time?
Alcohol and other depressant drugs?
Perpetuating factors

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16
Q

When would sertraline or paroxetine be used as first line treatment for depression?

A

Sertraline - post MI

Paroxetine - post natal depression

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17
Q

Contraindications for SSRIs?

A 
Manic episode (increase in 5HT exacerbates symptoms)
Epilepsy and peptic ulcer - risk of S.E.
18
Q

How can Gi disturbance/bleeds be limited when SSRIs are used?

A

PPI

Also give PPI when using NSAIDS

19
Q

Drug interactions of SSRIs

A

Increased cardiotoxicity with TCA/MAO-i - never combine!
NSAIDS - increased risk of GI bleed (prescribe PPI if required)
Warfarin/heparin/aspirin –> bleeds (prescribe mirtazapine instead)

20
Q

Sensible starting dose of SSRI e.g. citalopram?

A

20mg (increase as required)

Max dose of citalopram = 40mg (due to QTc prolongation
20mg in elderly and hepatic impairment)

21
Q

What drugs can be given second line for depression?

A

SNRIs e.g. venlafaxine
NARI e.g. Reboxetine
Tricyclics (2nd/3rd line) e.g. amitriptyline

22
Q

Indications for SSRIs and SNRIs?

A

Depression
Anxiety
Panic disorder
OCD

23
Q

Contraindications for SNRI?

A

Elderly
Do not give with TCA/MAO-i

Caution in hepatic/renal impairment and CVD

24
Q

S.E. of SNRI?

A

Similar to SSRI + HTN

Increased risk of withdrawal symptoms

25
Q

Indications for NARIs?

A

Severe depression

26
Q

Cautions for NARIs?

A

CVD, epilepsy
BAD
Prostatic hypertrophy

27
Q

S.E. of NARI?

A

Anti-adrenergic - sexual dysfunction, drowsy –> postural hypotension
Anti-ACh - blurred vision, dry mouth, dizzy, sweaty, urinary retention/constipation, palpitations, tachycardia

28
Q

Possible interactions of NARI?

A

Rarely interacts with other drugs

29
Q

Mechanism of tricyclics?

A

Prevent re-uptake of serotonin and NA

Also blocks muscarinic, histamine, adrenergic and DA reuptake –> hence many S.E.

30
Q

Indications for amitriptyline?

A

Mod-severe depression
Neuropathic pain
IBS
Poor sleep and appetite

31
Q

Caution for tricyclics

A

CVD, prosthetic hypertrophy, elderly
Glaucoma
pregnancy
Constipation

V. toxic –> high risk of OD

32
Q

Side effects of tricyclics?

A

Anti-muscarinic - Blurred vision, dry mouth, sweaty, urinary retention/constipation, drowsy, confusion, memory problems, tachycardia, palpitations

33
Q

3rd line treatments for depression?

A

MAOI - Maclobemide, phenelzineu, isocarboxacid
NASSA (Noradrenaline serotonin antagonists) - mertazapine
(tricyclics)

34
Q

Indications for MAO-i?

A 
Treatment resistant depression
Rarely used (poor tolerability and diet restrictions)
35
Q

Contraindications of MAOi?

A

CVD,
HTN (poorly controlled)
Liver failure
Hyperthyroid

36
Q

S.E. of MAOi?

A

Risk of HTN crisis –> SAH (avoid products high in tyramine - cheese, meat extracts, amphetamines

Anti-ACh SE
Paraesthesia of limbs, peripheral oedema
Insomnia, ansiti, appetite suppression, weight gain

37
Q

Cautions when using mertazapine?

A

CVD, elderly, hypotensive
Glaucoma
Diabetes
Psychosis (may exacerbate symptoms)

38
Q

SE of mertazapine?

A 
Antiadrenergic and anti-ACh
Sedative (so take at night)
Increased appetite --> weight gain
Pain (arthralgia and myalgia)
Risk of withdrawal symptoms
39
Q

General lifestyle changes for depression?

A 
Sleep hygiene
Regular exercise (join group)
40
Q

Psychological management of depression?

A

CBT - 6-8 sessions

IPT (interpersonal therapy) 16-20 sessions over 3-4 months (mod-severe depression) - focuses on conflicts, grief, life change etc)

Behavioural activation - 16-20 sessions, over 3-4 months - get patient to act according to plan , rather than how they feel

41
Q

When should patients be reviewed after starting A/D treatment?

A

After 2 weeks
or if they are <30, after 1 week

Counsel on increased anxiety and agitation when starting medication

42
Q

What is the drug of choice if A/D have to be used in children/adolescents?

A

Fluoxetine

Psychiatry (9 decks)

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