Depression

Question 1

Medications that can induce depression that is common in children (3)

Answer 1

1. Steroids (commonly used with asthma and many other disorders)
2. OCPs
3. Accutane

Question 2

Environmental risk factors for depression (6)

Answer 2

1. Abuse or neglect
2. Parental substance abuse
3. Parental marital problems
4. Low SES
5. Loss of parent, sibling, or close friend
6. Stress related to adolescent development or sexuality

Question 3

Other/Genetic risk factors for depression (2)

Answer 3

1. Family hx of depression or suicide

2. Medications or chronic illnesses

Question 4

Symptoms of Depression: Birth-2 years (5)

Answer 4

1. Whining
2. Decreased growth
3. Disruptive sleep
4. Fearful
5. Lack of responsiveness

Question 5

Symptoms of Depression: 3 to 5 years old (5)

Answer 5

1. Anxiety with sadness
2. Tantrums and somatic symptoms
3. Anger and irritable
4. Apathy
5. Social withdrawal

Question 6

Symptoms of Depression: Child (5)

Answer 6

1. Sadness
2. Anhedonia (flat mood)
3. Decreased Energy
4. Low self esteem
5. Irritable (masks depression)

Question 7

Symptoms of Depression: Adolescent (5)

Answer 7

1. Vague physical complaints
2. Sleep or appetite disturbance
3. Volatile mood
4. Rage, acting out
5. Self-conscious

Question 8

Major Depression Disorder (MDD) Criteria DSM V (5)

Answer 8

1. 5 or more of the following symptoms have been present for 2 weeks with at least one of the symptoms being either (1) depressed mood or (2) diminished interest or pleasure in all or almost all activities (anhedonia)
   a. Depressed mood most of the day
   b. Diminished interest or pleasure in all activities
   c. Significant weight loss when not dieting
   d. Insomnia or hypersomnia nearly every day
   e. Psychomotor agitation or retardation nearly every day
   f. Fatigue or loss of energy
   g. Feeling of worthlessness or excessive or inappropriate guilt
   h. Diminished ability to think or concentrate/indecisiveness
   i. Recurrent thoughts of death, suicidal ideation without a specific plan
2. Symptoms cause clinically significant distress or impairment in social, occupational or other area of function
3. Not attributable to physiological effects of a substances
4. The occurrence of the major depressive episode is not explained by another psychotic disorder
5. There has never been an episode of mania or hypomaniac episode
   (Because this would indicate bipolar)

Question 9

Major Depression Disorder (MDD) Symptoms (2)

Answer 9

1. The symptoms are not better accounted by bereavement or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
2. Cultural comment: Insomnia and loss of energy are most uniformly reported and in many cultures somatic symptoms is the most common complaint

Question 10

Differential Dx of MDD: Neurological (5)

Answer 10

1. Migraine
2. MS
3. Brain neoplasm
4. Epilepsy
5. Head trauma

Question 11

Differential Dx of MDD: Endocrine (2)

Answer 11

1. Thyroid disease

2. Pheochromocytoma

Question 12

Differential Dx of MDD: Metabolic and systemic (3)

Answer 12

1. Hepatic encephalopathy
2. Hypoxemia
3. Hepatolenticular degeneration

Question 13

Differential Dx of MDD: Autoimmune

Answer 13

SLE

Question 14

Differential Dx of MDD: Infectious (3)

Answer 14

1. HIV
2. Infectious mono (alice in wonderland syndrome)
3. brain abscess

Question 15

Differential Dx of MDD: Adverse effects (2)

Answer 15

1. Environmental toxin

2. Adverse medication effects

Question 16

Persistent Depression Disorder (Dysthymia) DSM V Criteria (5)

Answer 16

1. One year of persistent depressed or irritable mood (in children and adolescents) with 2 or more of the following symptoms
   a. Appetite disturbance
   b. Sleep disturbance
   c. Decreased energy level/fatigue
   d. Low self esteem
   e. Poor concentrating
   f. Feeling of hopelessness
2. During the one year period, the patient has never been without symptoms for more than two months, and there has never been a hypomanic or manic episode
3. Not better explained by schizoaffective disorder, schizophrenia, delusional disorder or other disorder
4. No signs of another medical conditions or that the condition is due to drugs of abuse
5. Significant impairment in social occupational or other areas of functioning

Question 17

PDD Dysthymia specify the following (5)

Answer 17

1. With anxious distress; with mixed features, with melancholic features, with atypical features, with mood congruent psychotic features, with mood incongruent psychotic features, with peripartum onset
2. If partial remission or in full remission
3. Early or late onset
4. With pure dysthymic symptoms, with persistent major depressive episodes; with intermittent major depressive episodes with current episode or without current episodes
5. Severity—mild, moderate or severe

Question 18

Premenstrual Dysphoric Disorder: DSM V Criteria (3 with symptom criteria)

Answer 18

1. Five symptoms in the week before the onset of menses and improve within a few days after onset
   a. Marked affective lability (mood swings)
   b. Marked irritability or anger, increased interpersonal conflicts
   c. Marked depressed mood feeling of hopelessness or self-deprecating thoughts
   d. Marked anxiety
2. B. One or more of the following symptoms
   a. Decreased interest in activities
   b. Subjective difficulty in concentration
   c. Lethargy, easy fatigability, marked lack of energy
   d. Marked change in appetite
   e. Hypersomnia or insomnia
   f. A sense of being overwhelmed or out of control
   g. Physical symptoms such as breast tenderness
3. C. Must impair function, must be present for two cycles and must not be the result of another medical problem or medication. It should not be an exacerbation of another disorder
   a. Medications such as Singulair can induce mood changes
   b. Some anti-epileptics can induce mood changes

Question 19

Suicide risk management/warnings (9)

Answer 19

1. Safety planning is key!
2. No suicide contract has not been show to prevent subsequent suicide, safety planning
3. needs to be discussed with the family
4. Warning signs and potential triggers for a recurrence of suicidal ideation
5. Coping strategies for the patient
6. Health activities that could provide distractions for the patient
7. If the urge to commit suicide occurs, responsible social supports
8. Contact information for both emergencies services and professional support
9. “Means restriction” is to make sure the guardian is aware about restricting access to firearms. Lock up medications, secure knives, guns, temporary relocate firearms, and restrict access to alcohol.

Question 20

Management of depression (11)

Answer 20

1. Counseling can take several forms
2. Psychoeducational approach is used to inform the patient and the family about the mental illness, it’s possible etiologies, and the available treatments, be they pharmacological, non-pharmacological or a combination of both.
3. It is important to set realistic goals for treatment as a means of staying focused on desired outcomes.
4. Goal setting also provides a means to measure outcomes of treatment as part of the nursing process.
5. Once a course of action is agreed upon and goals have been agreed to, treatment commences.
6. Good relationship skills can instill hope, provide explanations, demonstrate empathy and acceptance as well as engage in collaborative effort toward improvement.
7. It is important to set reasonable goals, address barriers to achieving those goals, and to reframe the process of change
8. Cognitive Behavioral Therapy
9. Exercise Therapy
10. Bright light therapy –
    Sunshine and light help
11. St. John’s Wort

Question 21

St. John’s Wart warnings

Answer 21

Interacts with many drugs that are used to treat heart disease, depression, seizures, certain cancers, as well as drugs that prevent transplant rejection and pregnancy.

Question 22

Level 1 Pharmacology (5)

Answer 22

Stimulants

1. Methylphenidate (e.g. Ritalin, Concerta, Adderall, Focalin)
2. Amphetamine based (Dexedrine)
3. Selective Norepinephrine Reuptake Inhibitors [SNRIs] (e.g. Strattera)

Antidepressants (SSRI) –
4. Α2 adrenergic receptor Agonists (e.g. Clonidine, guanfacine)

5. Level 1 is safe to be prescribed by PCPs

Question 23

Level 2 Pharmacology (7)

Answer 23

1. First generation and second generation anti-psychotics (e.g. risperidone, quetiapine, olanzapine, aripiprazole)

Mood stabilizers

2. Lithium, divalproic acid formulation, (DVPX)
3. carbamazepine
4. Lamotrigine oxcarbazepine
   * *No Lithium and NSAIDs / be very careful with Lithium
5. Anxiolytics (Clonazepam (benzodiazepine), Buspirone (azaspirone anxiolytic
6. Tricyclic antidepressants
   * Elavil = tricyclic; overdose of Elavil can lead to deadly cardiac arrhythmias
7. Level 2 is not supposed to be prescribed by PCPs, but PCPs should monitor for side effects