Depression

Question 1

What is depression?

Answer 1

symptoms including low mood, reduction of energy and decreased activity

Question 2

What is the prevalence of depression?

Answer 2

depression affects 2 - 5% of the population

Question 3

What is the female to male ration of depression?

Answer 3

2:1 (female to male ratio of depression)

Question 4

What could be the presentation of depression in the elderly population?

Answer 4

Somatic:

• pain
• bowel change
• weight change
• decreased energy
• lack of motivation
• poor compliance
• poor appetite
• weight loss
• debility

Question 5

What is the prevalence of depression in patients with parkinson’s disease and alzheimer’s?

Answer 5

40% = parkinson’s

20% = Alzheimer’s

Question 6

What are the symptoms of depression?

Answer 6

• loss of interest (anhedonia)
• Lack of emotional reactivity
• loss of energy / fatigue
• Insomina and early morning wakening
• Diurnal variation of mood
• psychomotor retardation

Question 7

What is the negative cognitive triad?

Answer 7

1) Self : worthless
2) Future : hopeless
3) World : critical, guilt

Question 8

What are the screening tools for depression?

Answer 8

• PHQ-9
• geriatric depression scale (GDS)
• hospital anxiety and depression scale (HAD)

Question 9

What are some conditions that may present as depression?

Answer 9

• PTSD (post-traumatic stress disorder)
• anxiety
• other neurotic disorder

Question 10

What is are the somatic presentations of depression?

Answer 10

• back pain

- headache

Question 11

What 9 questions would you ask in a depression history?

Answer 11

1) Little interest
2) feeling down, depressed, hopeless
3) sleep
4) appetite (poor / overeating)
5) Tired / little energy
6) feeling bad about yourself / failure
7) lack of concentration - cant watch tv or read
8) Moving / speaking slowly or being fidgetry or restless
9) Suicide/self harm

Question 12

How long must symptoms be present before a depression diagnosis be made?

Answer 12

at least 2 weeks

Question 13

What 3 factors are part of depression risk assesment?

Answer 13

1) Suicide / self harm
2) Risk to self (able to cope at home)
3) Risk to others (identified targets)

Question 14

What are the medical treatments for depression?

Answer 14

1) SSRIs e.g. fluoxetine, citalopram, sertaline
2) Tricyclics e.g. amitriptyline, nortriptyline, lofepramine
3) NaSSA e.g. mirtazapine
4) SNRI e.g. venlafaxine, duloxetine

Question 15

What are the bio-psycho-social treatments for depression?

Answer 15

• Talking therapy

- CBT

Question 16

What are the risk factors for suicide?

Answer 16

• drugs alcohol
• unemployement
• social isolation
• poverty
• chronic illness
• family / relationship breakdown
• previous attempt
• mental disorder

Question 17

Give an example of an SSRI

Answer 17

• setraline
• citalopram
• fluoxetine

Question 18

Give an example of an tricyclic anti depressant?

Answer 18

• amitriptyline
• nortriptyline
• lofepramine

Question 19

Give an example of NaSSA

Answer 19

mirtazapine

Question 20

Give an example of an SNRI

Answer 20

• venlafaxine

- duloxetine

Question 21

what demographic is more likely to be affected by depression?

Answer 21

• lower socio-economic background
• live in urban areas
• unemployed

Question 22

Depression can be classified as severe with psychotic symptoms. Describe the psychotic features which may present.

Answer 22

Delusions and/or hallucinations congruent with the low mood.

• delusions may include ideas of guilt, illness, poverty, nihilistic delusions. can develop cotard’s syndrome (belief that they are dead)
• hallucinations tend to be 2nd auditory. voices telling individual they are worthless etc.

Question 23

What are the predisposing factors for depression?

Answer 23

1) genetic (3X increased risk if family history of depression) –> Monoamine theory of depression (decrease in brain Noradrenaline &/or 5HT (serotonin))
2) hypothyroidism and Cushing’s disease / other chronic health condition.
3) past physical, emotional, sexual abuse
4) low self esteem
5) isolation
6) drug use / alcohol abuse

7) “vulnerability” factors in working women:
- 3+ children under age of 14
- no work outside home
- no confiding relationship

Question 24

What might be the precipitating and maintaining factors for depression?

Answer 24

Precipitating:

• adverse life event
• childbirth

Maintaining:

• chronic social difficulties ( poverty, unemployement)
• drug / alcohol abuse.

Question 25

What could be the differential diagnosis of depressed mood?

Answer 25

1) anxiety disorder 2) schizophrenia 3) alcohol dependance 4) hypothyroid 5) drug induced depression (steroids, b-blockers, l-dopa, reserpine) 6) neuro (dementia , CVA, PD, MS) 7) infections (influenza, mono) 8) carcinoma 9) endocrine disorders (cushing's, addison's)

Question 26

What is the ICD-10 criteria for mild, moderate and severe depression?

Answer 26

Mild = 2 core symptoms + 2 other Moderate = 2 core + 3 other Severe = 3 core + 4 other Core symptoms: 1) low mood 2) anhedonia 3) low energy Other symptoms: - sleep disturbance - change in appetite - reduced concentration - reduced sex drive - loss of confidence - guilt feelings - suicidal thoughts

Question 27

What is the monoamine theory of depression ?

Answer 27

Depression is associated with decrease in brain NAd (noradrenaline) and/or 5HT (serotonin). *antidepressants rapidly inhibit uptake or breakdown of monoamines but clinical improvement takes up to 4-6 weeks.*

Question 28

What are the classes of antidepressants?

Answer 28

1) Mono-amine reuptake inhibitors - tricyclics - SSRIs (1st line) - NARI - SNRI - NaSSa 2) Receptor Antagonists 3) Monoamine oxidase inhibitors

Question 29

Give 2 examples of tricyclic antidepressants. What are the main side effects? and dosage?

Answer 29

Tricyclics are Nad and 5HT reuptake inhibitors. They have a long half life so are usually taken once a day. more sedative: - clomipramine, - doxepin, - mianserin, - trazodone - trimipramine - dosulepin (dangerous in overdose so not recommended) - amitriptyline (dangerous in overdose so not recommended) Less sedative: - Lofepramine (less side effects) - imipramine, - nortriptyline. Side effects: - toxicity in overdose - Anticholinergic (dry mouth, blurred vision, photophobia, tachycardia, difficulty in urination, hyperthermia, glaucoma, and mental confusion (elderly). - Arrhythmias (QT prolongation) - Sedation

Question 30

SSRIs are first line in the treatment of depression. Give examples of some SSRIs, the side effects and risks.

Answer 30

``` SSRI examples: citalopram fluoxetine sertraline paroxetine ``` Side effects: - * hyponatraemia - * Serotonin syndrome - * Increased suicidal thoughts + behaviour (caution in young people) - GI upset - lower seizure threshold (therefore caution with epilepsy) - increases risk of bleeding (caution with peptic uclers) - skin rash - appetite / weight loss or gain

Question 31

What is the association between hyponatraemia and antidepressants?

Answer 31

1) Hyponatraemia should be considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant. 2) can occur with any antidepressant but reported more frequently when on SSRIs.

Question 32

How often should patients be reviewed once starting an antidepressant and how long should they remain on it?

Answer 32

1) patients should be reviewed every 1-2 weeks at the start of the treatment. 2) treatment should be tried for at least 4 weeks before switching to another antidepressant. 3) once in remission the drug should be continued at the same dose for at least 6 months.

Question 33

How often should patients be reviewed once starting an antidepressant and how long should they remain on it?

Answer 33

1) patients should be reviewed every 1-2 weeks at the start of the treatment. 2) treatment should be tried for at least 4 weeks before switching to another antidepressant. 3) once in remission the drug should be continued at the same dose for at least 6 months. 4) the drug should be reduced over 4 weeks to stop it.

Question 34

What is serotonin syndrome?

Answer 34

Serotonin syndrome is a relatively uncommon reaction to excess serotonin activity. It is characterised by: 1) neuromuscular hyperactivity (e.g tremor, hyperreflexia, clonus, myoclonus, rigidity), 2) autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea) 3) altered mental state (agitation, confusion, mania) Treatment involves withdrawal of serotonergic medication (get specialist advice)

Question 35

What would you do if a depressed patient fails to respond to the initial 1st line treatment : SSRI ?

Answer 35

1) try a higher dose of the same drug / switch to another SSRI 2) try mirtazipine (NaSSA) or other drug classes e.g. lofepramine (Tricyclic), moclobemide(MOAI), and reboxetine (NARI) 3) other tricyclics and venlaflaxine (SNRI) should be considered for more severe depression. 4) specialists may try augmenting an antidepressant with a mood stabiliser such as lithium 5) ECT for very severe depression.

Question 36

Which SSRI is known to prolong the QT interval and can predispose to arrhythmias?

Answer 36

Citalopram

Question 37

where are SSRIs metabolised?

Answer 37

liver

Question 38

What are the important drug interactions for SSRIs

Answer 38

Be cautious when prescribing SSRIs with: 1) monoamine oxidase inhibitors (both increase serotonin --> serotonin syndrome) 2) NSAIDS or Aspirin ---> give PPI to avoid gastric bleeding. 3) anticoagulants (due to increased bleeding risk) 4) antipsychotics (both prolong QT interval)

Question 39

What is the typical starting dose for SSRIs

Answer 39

20mg orally daily, at the same time everyday. | dose is increased as necessary

Question 40

Why should SSRIs not be stopped suddenly?

Answer 40

``` They are not addictive but you can get discontinuation symptoms : flu like symptoms, sleeplessness, GI upset, mood swings ```

Question 41

Give 2 examples of SNRIs (Serotonin and Norepinephrine reuptake inhibitors)

Answer 41

- venlaflaxine | - duolexetine

Question 42

What antidepressant may be given to a patient experiencing insomnia and loss of appetite?

Answer 42

Mirtazipine - because the side effects include sedation and increased appetite/

Question 43

What antidepressant causes painful and persistent penile erection (priapism)?

Answer 43

Trazadone (TCA)

Question 44

name 2 drugs which have particularly bad discontinuation symptome?

Answer 44

1) Venlafaxine (SNRI) | 2) Paroxetine (SSRI)