Depression Flashcards
What are the Questions you should ask for Depression?
SIG E CAPS + Mood
• S - sleep (↑/↓)
• I - ↓interest (anhedonia)
• G - guilt
• E - ↓energy
• C - ↓concentration
• A - appetite (↓/↑)
• P - psychomotor agitation / retardation
S - suicidal ideation (+ risk of harm to self / others)What is the Diagnostic Criteria for Depression?
A. ≥5 of the following during the same ≥2wks representing a Δ from previous fx (≥1 of the syx must be 1/2) - major criteria
1. Depressed mood = most of the day, nearly everyday
2. Anhedonia = most of the day, nearly everyday
3. Δ weight / Δ appettie = >5% in a month
4. Δ sleep
5. Psychomotor retardation / agitation
6. Fatigue
7. Worthlessness, guilt = nearly everyday
8. ↓concentration, indeciseveness
9. Recurrent thoughts of death / suicidal ideation / suicide attempt
B. Syx cause significant distress / fx impairment
C. Ø due to other substance abuse / GMC / grief
D. Ø due to other psychiatric condition
Ø previous manic / hypomanic episodes
What are some Screening tools for Depression?
• K10 = Ø able to Δ anxiety / depression
• DASS-21,42 = able to Δ anxiety + depression – preferred by psychologists
GAD
What are some questions you should ask about suicide?
• Suicidality = ○ Passive / active ○ Intent § Previous attempts § Planning § Execution § Method § Regrets § Timeframe? § How fixed + immediate is the plan? § Writing will/other demonstration that they are preparing to die ○ Access to lethal methods ○ What is stopping you? ○ Need for admission? --- pt safety • Self-harm • Harm / neglect to others -- children involved?
What are some other Investigations you should consider if you suspect depression?
• Looking for organic mimics • TFTs = hypothyroidism, hyperthyroidism • Anemia • B12/folate • Renal failure • Ca++ derangement = can cause psychiatric syx (↑ → usually more like "mania") • Tumour = • Stroke / cerebrovascular disease • Medications ○ Steroids ○ Substance abuse -- may be self-medicating ± perpetuating the illness § Alcohol § Benzos § Opiates ○ β-blockers
Pharmacological Treatment for Depression?
• Pharmacological = start low, go slow, lots of monitoring
• Rx principles
○ Takes 1-2wks to take effect. May not get full benefit for up to 4-6wks (sometimes longer).
○ If there is favourable response, antidepressants should be continued for at least 6-12mo (longer-term prophylaxis if hx of recurrence)
○ If Ø response in 2-4 wks → switch to Δ drug
○ Try 2x 1st line rx → before moving to 2nd line
○ WARN PTs = will feel worse b/f they feel better (↑risk of suicide after starting rx)
○ Must taper down dose when ceasing
• Short-term = can give benzo in the ST until the antidepressant takes effect if necessary
• First line
○ SSRI = preferred
§ Escitalopram = prolonged QTc - v. hard to come off (done slowly)
§ Citalopram = prolonged QTc
○ Fluoxetine
○ Paroxetine
○ Sertraline
○ SNRI
○ Desvenlafaxine
○ Venlafaxine
Duloxetine
Others (Mirtazapine, MAOI, TCAs, etc…)
What are the step by step principles of Treatment?
Principles • Mild = psychological rx more helpful • Moderate = psychological + meds • Severe = meds ± psych ± ECT • Psychotic = meds ± ECT ± antipsychotics ○ Urgent specialist r/v ○ 90% respond to all 3 rx together
What are the Melancholic (biological) features that are a bad prognostic sign in Depression?
• Melancholic features ○ worse in morning ○ early morning wakening (≥2hr) ○ psychomotor retardation/agitation ○ significant LOW/LOA ○ ↑↑guilt ○ distinct quality to depressed mood ○ anhedonia
Different Classifications of Depression?
Major Depressive disorder (see definition)
- mild
- moderate
- severe
Minor Depression (sub-threshold 2-4sxs for >2weeks)
Dysthymic Disorder - enduring often fluctuating decreased mood
Adjustment disorder -
period of distress with emotional disturbance
Premenstrual dystrophic disorder
How to Prescribe SSRIs?
Counselling: NPS ‘COUNSELLING PATIENTS on SSRIs
1. Some side effects are likely (nausea - will go away in 1-2 weeks)
2. Feel anxious or agitated at first - mood may get worse. Suicide. (particularly adolescents)
3. You may not feel better immediately - can take 4-6 weeks
4. May have to try more than one treatment that works for you. Efficacy. (placebo is high)
5. Antidepressants are not addictive, don’t stop them abruptly -
Some herbal/natural medicines not safe to take with it (St John’s and cough meds)
What are some of the reasons to prescribe different Antidepressants?
Considerations: Sleep: If poor - mirtazapine, fluvoxamine, TCAs If oversleeping - fluvoxetine Appetite: If poor - consider mirtazapine, TCAs If renal or hepatic disease: Refer and get consult. If sexual dysfunction: If SSRI causes sexual dysfunction can use periactin (cyproheptadine - serotonin antagonist) on the night of romance
Other reasons to use them?
Sertraline/fluoxetine in PMDD (post-menopausal) and OCD
Duloxetine in Diabetic peripheral neuropathy
Paroxetine in PTSD
What do you do in an Emergency Depressive Episode?
- CAT team referral (only for adults 18-65 yo)
○ Indications
- Suicidal ideation with a plan
- Plans to hurt others
- If they don’t have any protective factors - CAM service (>65) or RCH (<18)
Go through some Depression differences for different populations?
Postnatal Depression:
- suicide the leading cause of death in UK mothers
- 4-12weeks post partum
- impacts attachment and development
- 50% recurrence
Depressed children:
- match behaviour and mood with age
- usually preceeded by dysthymia and anxiety for >3 years
Depression in the Elderly:
- increased suicide risk
- somatic complaints often
- irritable
What are some dangers of treatment?
1) Something to overdose one - 1-2wk supply at a time
2) Apathetic - don’t have energy, get them better have energy to suicide.
3) Loss to follow-up
4) Stigma
5) Bipolar vunerablitiy - precipitate a manic state.
Start bringing up really emotional things.
Explain ECT for a patient, what are some of the Indications and Concerns?
Indication
• Severe / melancholic / psychotic depression
• Catatonic schizophrenia
• Bipolar
• Mania = best evidence in mania + catatonic schizophrenia
should cease benzos, taper failed antidepressants, lithium fine but may increase confusion, withdraw antiepileptics (decrease efficacy).
types:
- bitemporal
- brfrontal
- unilateral 3x the charge needed for seizure.
Duration - 8-10courses 3x a week. usually 10.
Process:
1) attach leads
2) insert canula
3) sedate with bag and mask
4) mouth guard block bite)
5) monitor
Risks:
- memory loss STM
- muscle soreness
- irregular HR, BP
- sometimes stroke/HA
- N/V, headache, pain/bruising, soreness, blurred vision
Counsel:
- fast night before
- loose clothes
- no hair products
- toilet beforehand.
- in hospital to monitor for at least 2 hrs after.
