Depression

Question 1

What are the indications for ECT?

Answer 1

Treatment-resistant depression
Life-threatening severe depression
Treatment-resistant mania
Catatonia

Question 2

What are the core symptoms of depression?

Answer 2

1. low mood
2. reduced energy/ fatigue (anergia) - universal symptom
3. Loss of interest and enjoyment (anhedonia)
   Usually expect them to last for at least 2w to merit a diagnosis

Question 3

What are additional symptoms of depression?

Answer 3

Reduced concentration, slowing of thinking and speech.
Reduced confidence and self-esteem
Ideas of guilt and unworthiness
Pessimism about the future
Ideas/acts of self-harm/suicide
Disturbed sleep- usually patient wakes early in AM but is ok getting to sleep. Can also see difficulty falling asleep.
Changes in appetite- mostly appetite loss and associated weight loss

Question 4

What is the somatic syndrome?

Answer 4

The biological symptoms of depression:

(1) marked loss of interest or pleasure in activities that are normally pleasurable (anhedonia)
(2) lack of emotional reactivity
(3) waking in the morning 2 hours or more before the usual time;
(4) depression worse in the morning;
(5) objective evidence of marked psychomotor retardation or agitation
(6) marked loss of appetite;
(7) weight loss (5% or more of body weight in the past month);
(8) marked loss of libido

Question 5

Describe depression with psychosis.

Answer 5

Delusions: Tend to be mood congruent. e.g. Worthlessness, guilt- that they have committed awful sin/ crime, hypochondriacal - ill health, poverty, imminent disaster
Nihilistic delusions - belief in the absence of something vitally important- that the self, part of the self, part of the body, other people, or the whole world has ceased to exist/ is dead/ not working. “my body is empty, my organs are dead”
Persecutory delusions can also occur - belief that others are trying to harm/ persecute patient.
Think of Mary
Depressive delusion: belief that you are to blame for catastrophes/ accidents etc that you clearly have no link with.
Hallucinations
2nd person auditory - often accusatory or defamatory
Olfactory - e.g. filth, or rotting/decomposing flesh

Question 6

What are some of the risk factors for suicide?

Answer 6

Depression, self-harm, feelings of hopelessness, anxiety + depression / agitated depression high risk.
5-15% depressed patients commit suicide.

Question 7

Define mild depression

Answer 7

At least two of the three core symptoms: anhedonia, anergia, low mood
Plus additional symptoms, giving a total of at least four
With or without the somatic syndrome

Question 8

Define moderate depression

Answer 8

At least two of the three core symptoms
Plus additional symptoms, giving a total of at least six
With or without the somatic syndrome

Question 9

Define severe depression

Answer 9

All three core symptoms

Plus additional symptoms, giving a total of at least eight

Question 10

Define severe depression with psychotic symptoms

Answer 10

All three core symptoms
Plus additional symptoms, giving a total of at least eight
Plus delusions, hallucinations or depressive stupor

Question 11

What are the organic differentials for depression?

Answer 11

• Neurological: Multiple sclerosis, Parkinson’s disease, Huntington’s disease. spinal cord injury, CVA, head injury, cerebral tumours
• Endocrine: Thyroid and parathyroid disorders (especially hypothyroidism), Cushing’s/Addison’s disease
• Infections: HIV/AIDS, syphilis, typhoid, brucellosis, infectious mononucleosis, herpes simplex
• Iatrogenic: Secondary to prescription of opiates, L-dopa, steroids
• Others: Malignancies (especially pancreatic), SLE, rheumatoid arthritis, renal failure, porphyria

Question 12

What are the psych ddx for depression?

Answer 12

Depression can occur as a consequence of another illness, such as schizophrenia, an anxiety disorder, an eating disorder, dementia, and so on.

Question 13

Epidemiology of Depression

Answer 13

M:F 1:2
10-20% lifetime risk of developing depression. Point prevalence (in pop at any given pt in time) of major depressive illness 5%.

Question 14

Aetiology of Depression?

Answer 14

Biological: genetics, hormonal changes, substance misuse, serious illness
Psychological: negative thoughts, learned helplessness, psychodynamic defence mechanisms
Social: life events, social isolation, bereavement, loss, childhood abuse, social adversity

Question 15

Prognosis and Relapse in Depression.

Answer 15

Prognosis:
50-60% recover within 1 year. 10-25% suffer for more than two years, “chronic”
5-15% will die by suicide

Relapse: 25% will have had a further episode after 1 year, After 10 years, 75% will have had a further episode. Therefore NICE recommends continuing anti-depressants for 6m post depressive episode remission, and 2 years after remission of recurrent depression.

Question 16

What is the NICE recommendation for treating known and suspected depression? (i.e. STEP 1)

Answer 16

Assessment, active monitoring, computerised CBT, psychoeducation e.g. sleep hygiene, guided self-help,
info on depression, referral for further assessment + intervention

Question 17

What is the NICE recommendation for treating moderate/severe depression or mild- moderate depression that is not responding to tx? STEP 3

Answer 17

Primary care:
Medication
High-intensity psychological interventions
Consider secondary care referral

Question 18

What is the NICE recommendation for treating severe complex depression/ life threatening presentation/ severe self-neglect? STEP 4

Answer 18

Secondary Care:
Medication - here, other meds might be considered, including:
venlafaxine, an SNRI
mirtazapine, a NASSA
TCAs, like imipramine
MAOIs, like phenelzine
adjunctive medications, such as antipsychotics (augment response to SSRI) or lithium (mood stabilizer)
High-intensity psychological interventions
ECT
Crisis Resolution and Home Treatment (CRHT)
Multidisciplinary (MDT) approach
Inpatient care

Question 19

What is the NICE recommendation for treating mild/moderate depression? STEP 2

Answer 19

Primary Care:
Low-intensity psychological interventions
If moderate depression, + Medication - First line treatment would usually be an SSRI, such as citalopram, sertraline, fluoxetine or paroxetine

Question 20

What is cyclothymia?

Answer 20

A persistent instability of mood with a number of periods of mild depressive symptoms or mild elation, where no episode meets the threshold for a depressive or a manic episode

Question 21

What is dysthymia?

Answer 21

mild depression for 2y or longer where the person is able to function. Usually it is not recognized until “Double Depression” occurs in which a depressive episode occurs on a background of dysthymia and on taking the history, low mood has been a persistent feature for the individual for some time prior to this event. They respond well to antidepressants.

Question 22

What is double depression?

Answer 22

“Double Depression” occurs when a depressive episode occurs on a background of dysthymia and on taking the history, low mood has been a persistent feature for the individual for some time prior to this event.

Question 23

What are the indications for antidepressants? What NT are primarily targetted by antidepressants? What are their general MOA?

Answer 23

• Depressive illness (more effective in moderate and severe depression)
• Anxiety disorders (for initial 2w use with Benzodiazepine cover to reduce initial risk of increased anxiety associated w/ SSRIs)
• Neuropathic pain
• PTSD
• Insomnia
• Bulimia nervosa
• Impulsivity
• Migraines
• Chronic fatigue syndrome
• Irritable bowel syndrome
• Narcolepsy (suddenly fall asleep)
  5HT (Raphe Nuclei), NA (Locus Coeruleus), DA
  Inhibition of reuptake usually of Serotonin from synaptic cleft increasing [ ] in the cleft and 5HT transmission but rarely totally specific therefore also affects NA/ DA

Question 24

Describe the SE of SSRIs. Name some SSRIs.

Answer 24

Fluoxetine, paroxetine, citalopram, sertraline, Fluvoxamine
SE: sexual dysfunction (++++), insomnia, headache, nausea, apathy and fatigue, agitation - initially i.e. first 2w, increased suicide ideation + anxiety- initially, diarrhoea/ GI pain and fullness- initially, dizziness, sweating, akathesia (restlessness). Weight gain is not a SE of SSRIs.
Caution Paroxetine: cardiac defects if exposure in Trimester 1
MOA: Selective serotonin reuptake inhibitors (inhibiting transporters on presynaptic neurone)

Question 25

Describe the SE of SNRIs. Name some SNRIs.

Answer 25

Block 5HT and NA reuptake transporter.
Venlafaxine, Duloxetine
SE: sedation +, discontinuation symptoms
similar SE to SSRIs includ sexual dysfunction (+++), nausea, insomnia, apathy + fatigue, dizziness, sweating, akathesia, diarrhoea. Weight gain is again not a SE of SNRIs.

Question 26

Describe the MOA of TCAs. Describe common SE and imp cautions. Name some TCAs.

Answer 26

MOA: Inhibitors of 5HT and NA reuptake transporters
Common SE: antimuscarinic- dry mouth, constipation, blurred vision, urinary retention. weight gain (++) , sedation (++), hypotension, dizziness, delirium, sexual dysfunction (+++)
sedation - helpful if suffering from insomnia
Caution: Toxic in OD therefore assess patient’s suicide risk
First line in pregnancy, no known teratogenicity.
Amitriptyline, Imipramine, Clomipramine, Dosulepin, Lofepramine

Question 27

Describe the MOA of MAOI. Describe common SE and imp cautions. Name some MAOIs.

Answer 27

Moclobemide, Phenelzine
Likely don’t need to know this in big detail
Mainly used for treatment resistant depression and atypical depression.
Cheese reaction- imp interaction with food.
SE: dry mouth, Nausea, diarrhea or constipation, Headache, Sleep disturbance, Postural Hypotension

Question 28

What is the MOA of Mirtazapine? What are it’s SE?

Answer 28

Useful in the tx of various depressive disorders and can be used in combination. some evidence better than SSRIs. Also used anxiety disorders. NaSSA: Noradrenergic and Specific Serotonergic Antidepressant.
SE: significant sedation (+++) and weight gain (+++) (and increased appetite), headache, dizziness

Question 29

What are the imp interactions of St John’s Wort?

Answer 29

Oral contraceptive, Digoxin, Warfarin, HIV protease inhibitor,
Anticonvulsants (e.g phenytoin, carbamazepine)

Question 30

What is the expected response time to antidepressants? When should antidepressants be stopped?

Answer 30

Effect may be evident within first week but it is recommended to wait 3-4w before deciding to stop meds. In elderly this should be 12w. If there has been some response after 4w, another 2 weeks are advised before deciding to change meds. 70% will respond to first medication.
They should be continued at same dose for 6m following resolution of symptoms.

Question 31

What are the withdrawl symptoms of antidepressants? Which antidepressants are most associated with these symptoms?

Answer 31

paroxetine (SSRI) and venlafaxine (SNRI)
symptoms are usually mild and transient but can be very severe and disabling.
They include dizziness, numbness, tingling, nausea, vomiting, headache, sweating, anxiety, sleep disturbance, strange dreams, shaking and electric-shock like sensations.

Question 32

Define self-harm.

Answer 32

A deliberate non fatal act of injuring oneself that is done with the knowledge that it will potentially cause harm. According to WHO, “it is aimed at realising changes which the subject desired via the actual or expected physical consequences”

Question 33

Define suicide

Answer 33

An act of intentionally killing onself with the aim of dying.

Question 34

What is the aetiology and epidemiology of self-harm?

Answer 34

Epi- M:F 1:2, 2/3 are under 35 yo, cutting and ODs most common methods.
•Divorced > Single > Widowed > Married
Aetiology:
Biological: genetics, substance misuses, age (young)
Psych: trauma- abuse/bullying, grief, endings/change, relationship breakdown
Social: housing/finance concerns, friends who self harm, isolation, endings/change, crisis of faith

Question 35

What are the NICE recommend for management of self-harm?

Answer 35

1. assessment of physical health, mental state, safeguarding concerns, social circumstances and risks of repetition or suicide
2. be referred to secondary care for a comprehensive psychosocial assessment
3. while in hc setting be monitored and provided safe physical env to reduce risk of repeat self-harm
4. develop risk management plan with the patient and discuss psychological interventions with their cco

Question 36

What factors predict repeated self-harm episodes?

Answer 36

PD, history of violence, alcohol misuse, being unmarried, number of previous episodes

Question 37

Describe the risk assessment of someone who has attempted suicide.

Answer 37

1. Impulse / Planned?
2. Final acts? e.g. finances, notes
3. Attempts to avoid discovery?
4. Method- how violent?
5. perceived lethality?
6. Intention- to die?
7. How do they feel about their attempt now?
8. Further plans?

Question 38

What is the aetiology and epidemiology of suicide?

Answer 38

Epi M:F 3:1 , second leading cause of death in 15-30yr olds. Most vuln groups: asylum seekers, prisoners, LGBTQ+, veterans.
Aetiology:
Biol- genetics, fhx, mental illness, meds, sex, physical illness
Social- alcohol/ substance misuse, exposure to suicide, availability of firearms, economic instability, trauma/ abuse
- People who self-harm are 66 times more likely to die by suicide than the general population.

Question 39

How would you explain CBT to a patient?

Answer 39

CBT is a talking therapy that is done with a qualified therapist. It can be done individually, in groups, or virtually using the computer. CBT involves discussing your thoughts, what feelings these thoughts produce, and what behaviours result from your feelings. CBT aims to challenge unhelpful/ negative automatic thoughts that lead to negative/ anxious feelings and behaviours of withdrawal or avoidance. The therapist will challlenge you to consider other ways of interpreting situations - to provide other thought options rather than the automatic unhelpful thoughts you are currently having. After looking at the situation from another perspective- it may change the way you feel and therefore behave. For example if you have prepared dinner for your loved one and they don’t immediately compliment you on the food/ they reach for the salt and you think “ah, the food must be rubbish– I am such a hopeless cook. I guess this is no surprise I can’t succeed at anything” these thoughts would make you feel sad and hopeless and may make you behave despondently, cry, withdraw or be less likely to try to cook again. You are given HW to record thoughts etc during the week and work on certain things. The sessions are structured and you meet your therapist weekly for 12-16 sessions in primary care. CBT can be combined with medication safely however there is a long waiting list. This is an empowering therapy where you are given the tools to change your thoughts, feelings and behaviours. No one will tell you what to do- it is more of a “guided discovery” of your thoughts and feelings.
Adv- you understand the issues, you develop strategies to improve things, empowering- allowing you to deal with future issues.
Disadv- patient engagement required, HW, may feel worse at the start as you talk about difficult experiences, waiting list.

Question 40

What is psychodynamic psychotherapy?

Answer 40

Talk therapy, same place same time over 20 sessions. Free flow fashion where you do most of the talking. The therapist will try to interpret your feelings towards them and the feelings the therapist has towards you. Therapist is a “blank slate” they don’t ask lots of questions and expect you to talk lots. They aim to uncover childhood difficulties which affect how you form relationships now and identify “unconscious issues”.
GO BACK THROUGH!!
Countertransference- how therapist feels about how patient feels towards them and how it relates to childhood.
Transference- patient feels about therapist how they feel about person from childhood who they had difficulties with