Depression

Question 1

Depression

Answer 1

depression is characterized by ;

1. persistent low mood
2. anhedonia - loss of pleasure or interest

Question 2

Diagnostic criteria of depression ( 9 )

Answer 2

DM-5 classification by presence of 5 out of 9 possible symptoms
SIG - E CAP
1. Sleep - insomina or hypersomnia
2. Interest loss - anhedonia
3. Guilt - low self esteem
4. Energy - fatigue
5. Concentration - poor concentration
7. Appetite
8. Psychomotor agitation + physical movements can increase or decrease
9. Suicidality

Question 3

diagnosis of mild depression

Answer 3

Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment

Question 4

diagnosis of moderate depression

Answer 4

Symptoms or functional impairment are between ‘mild’ and ‘severe’

Question 5

diagnosis of severe depression

Answer 5

• Most symptoms
• symptoms markedly interfere with functioning
• Can occur with or without psychotic symptoms

Question 6

tools to assess the degree of depression

Answer 6

1. Hospital anxiety and depression scale (HADscale)

2. Patient health questionaire (PHQ)

Question 7

Patient health questionaire

Answer 7

asks patients 'over the last 2 weeks, how often have you been bothered by any of the following problems?'
- 9 items which can then be scored 0-3
- includes items asking about thoughts of self-harm
depression 
severity: 0-4 none, 
5-9 mild, 
10-14 moderate, 
15-19 moderately severe, 
20-27 severe

Question 8

HAD scale

Answer 8

consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly

Question 9

Etiology of depression

Answer 9

1. Biological factors -reducedlevels of neurotransmitters such as seratonin, noradrenaline and dopamine
2. increased levels of stress hormones
3. psychosocial - traumatic or stressful experiences

Question 10

risk factors for depression

Answer 10

1. genetic
2. history of other mental health problem
3. male < 30
4. prior suicide attempt or family history of suicide

Question 11

atypical depression

Answer 11

characterised by > 2 of

• weight gain
• increased appetite
• leaden paralysis - weight down of arms and legs
• brightening of mood in response to positive events

Question 12

psychotic depression

Answer 12

1. major depressive disorder characterized by the presence of psychotic symptoms
2. delusions or hallucinations which are often mood congruent

Question 13

postpartum depression

Answer 13

1. occurs during pregnancy or in the first 4 weeks

Question 14

management of depression

Answer 14

1. mild to moderate
   - Cognitive behavioral therapy
2. moderate to severe
   - first line : SSRI
   - Tricyclic / MAO inhibitors
3. Very severe depression
   Electroconvulsive therapy to stimulate increase of neurotransmitter in the brain

Question 15

SSRI

Answer 15

1. Fluoxetine is the SSRI of choice
   citalopram (although see below re: QT interval) and fluoxetine are currently the preferred SSRIs
   sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants

Question 16

citalopram’s contraindication

Answer 16

talopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval

Question 17

SSRI interactions

Answer 17

1. NSAIDs: if given co-prescribe a proton pump inhibitor but try to avoid if you can
2. warfarin / heparin / Asprin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
3. triptans: avoid SSRIs

Question 18

Managing SSRI use

Answer 18

1. Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks.
2. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.
3. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.

Question 19

Discontinuing SSRI

Answer 19

1. When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine).
2. Paroxetine has a higher incidence of discontinuation symptoms.

3. Discontinuation symptoms
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia

Question 20

SSRI in pregnancy

Answer 20

BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
1. Use during the first trimester gives a small increased risk of congenital heart defects

2. Use during the third trimester can result in persistent pulmonary hypertension of the newborn
   - Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Question 21

Mirtazapine

Answer 21

1. Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.
2. Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications.

Question 22

side effects of mirtazapine

Answer 22

Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.

Question 23

Tricyclic antidepressats

Answer 23

Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose.

They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.

Question 24

side effects of tricyclc antidepressants

Answer 24

Common side-effects
- drowsiness
- dry mouth
- blurred vision
- - constipation
urinary retention

Question 25

choice of tricyclic antidepressants

Answer 25

1. low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
2. lofepramine has a lower incidence of toxicity in overdose
3. amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose