Depression Flashcards
Depression
depression is characterized by ;
- persistent low mood
- anhedonia - loss of pleasure or interest
Diagnostic criteria of depression ( 9 )
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
diagnosis of mild depression
Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
diagnosis of moderate depression
Symptoms or functional impairment are between ‘mild’ and ‘severe’
diagnosis of severe depression
- Most symptoms
- symptoms markedly interfere with functioning
- Can occur with or without psychotic symptoms
tools to assess the degree of depression
- Hospital anxiety and depression scale (HADscale)
2. Patient health questionaire (PHQ)
Patient health questionaire
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
HAD scale
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
Etiology of depression
- Biological factors -reducedlevels of neurotransmitters such as seratonin, noradrenaline and dopamine
- increased levels of stress hormones
- psychosocial - traumatic or stressful experiences
risk factors for depression
- genetic
- history of other mental health problem
- male < 30
- prior suicide attempt or family history of suicide
atypical depression
characterised by > 2 of
- weight gain
- increased appetite
- leaden paralysis - weight down of arms and legs
- brightening of mood in response to positive events
psychotic depression
- major depressive disorder characterized by the presence of psychotic symptoms
- delusions or hallucinations which are often mood congruent
postpartum depression
- occurs during pregnancy or in the first 4 weeks
management of depression
- mild to moderate
- Cognitive behavioral therapy - moderate to severe
- first line : SSRI
- Tricyclic / MAO inhibitors - Very severe depression
Electroconvulsive therapy to stimulate increase of neurotransmitter in the brain
SSRI
- 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
citalopram’s contraindication
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
SSRI interactions
- NSAIDs: if given co-prescribe a proton pump inhibitor but try to avoid if you can
- warfarin / heparin / Asprin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
- triptans: avoid SSRIs
Managing SSRI use
- Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks.
- For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.
- 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.
Discontinuing SSRI
- When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine).
- 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
SSRI in pregnancy
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
- 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
Mirtazapine
- Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.
- 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.
side effects of mirtazapine
Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.
Tricyclic antidepressats
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.
side effects of tricyclc antidepressants
Common side-effects - drowsiness - dry mouth - blurred vision - - constipation urinary retention
choice of tricyclic antidepressants
- low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
- lofepramine has a lower incidence of toxicity in overdose
- amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose
