Depression Flashcards
What is depression?
symptoms including low mood, reduction of energy and decreased activity
What is the prevalence of depression?
depression affects 2 - 5% of the population
What is the female to male ration of depression?
2:1 (female to male ratio of depression)
What could be the presentation of depression in the elderly population?
Somatic:
- pain
- bowel change
- weight change
- decreased energy
- lack of motivation
- poor compliance
- poor appetite
- weight loss
- debility
What is the prevalence of depression in patients with parkinson’s disease and alzheimer’s?
40% = parkinson’s
20% = Alzheimer’s
What are the symptoms of depression?
- loss of interest (anhedonia)
- Lack of emotional reactivity
- loss of energy / fatigue
- Insomina and early morning wakening
- Diurnal variation of mood
- psychomotor retardation
What is the negative cognitive triad?
1) Self : worthless
2) Future : hopeless
3) World : critical, guilt
What are the screening tools for depression?
- PHQ-9
- geriatric depression scale (GDS)
- hospital anxiety and depression scale (HAD)
What are some conditions that may present as depression?
- PTSD (post-traumatic stress disorder)
- anxiety
- other neurotic disorder
What is are the somatic presentations of depression?
- back pain
- headache
What 9 questions would you ask in a depression history?
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
How long must symptoms be present before a depression diagnosis be made?
at least 2 weeks
What 3 factors are part of depression risk assesment?
1) Suicide / self harm
2) Risk to self (able to cope at home)
3) Risk to others (identified targets)
What are the medical treatments for depression?
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
What are the bio-psycho-social treatments for depression?
- Talking therapy
- CBT
What are the risk factors for suicide?
- drugs alcohol
- unemployement
- social isolation
- poverty
- chronic illness
- family / relationship breakdown
- previous attempt
- mental disorder
Give an example of an SSRI
- setraline
- citalopram
- fluoxetine
Give an example of an tricyclic anti depressant?
- amitriptyline
- nortriptyline
- lofepramine
Give an example of NaSSA
mirtazapine
Give an example of an SNRI
- venlafaxine
- duloxetine
what demographic is more likely to be affected by depression?
- lower socio-economic background
- live in urban areas
- unemployed
Depression can be classified as severe with psychotic symptoms. Describe the psychotic features which may present.
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.
What are the predisposing factors for depression?
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
What might be the precipitating and maintaining factors for depression?
Precipitating:
- adverse life event
- childbirth
Maintaining:
- chronic social difficulties ( poverty, unemployement)
- drug / alcohol abuse.
What could be the differential diagnosis of depressed mood?
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)
What is the ICD-10 criteria for mild, moderate and severe depression?
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
What is the monoamine theory of depression ?
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.
What are the classes of antidepressants?
1) Mono-amine reuptake inhibitors
- tricyclics
- SSRIs (1st line)
- NARI
- SNRI
- NaSSa
2) Receptor Antagonists
3) Monoamine oxidase inhibitors
Give 2 examples of tricyclic antidepressants. What are the main side effects? and dosage?
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
SSRIs are first line in the treatment of depression. Give examples of some SSRIs, the side effects and risks.
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
What is the association between hyponatraemia and antidepressants?
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.
How often should patients be reviewed once starting an antidepressant and how long should they remain on it?
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.
How often should patients be reviewed once starting an antidepressant and how long should they remain on it?
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.
What is serotonin syndrome?
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)
What would you do if a depressed patient fails to respond to the initial 1st line treatment : SSRI ?
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.
Which SSRI is known to prolong the QT interval and can predispose to arrhythmias?
Citalopram
where are SSRIs metabolised?
liver
What are the important drug interactions for SSRIs
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)
What is the typical starting dose for SSRIs
20mg orally daily, at the same time everyday.
dose is increased as necessary
Why should SSRIs not be stopped suddenly?
They are not addictive but you can get discontinuation symptoms : flu like symptoms, sleeplessness, GI upset, mood swings
Give 2 examples of SNRIs (Serotonin and Norepinephrine reuptake inhibitors)
- venlaflaxine
- duolexetine
What antidepressant may be given to a patient experiencing insomnia and loss of appetite?
Mirtazipine - because the side effects include sedation and increased appetite/
What antidepressant causes painful and persistent penile erection (priapism)?
Trazadone (TCA)
name 2 drugs which have particularly bad discontinuation symptome?
1) Venlafaxine (SNRI)
2) Paroxetine (SSRI)
