Depression Flashcards
What are the core symptoms of depression according to the ICD-10?
Anhedonia
Depressed Mood
Fatigue
What is anhedonia?
Loss of interest or pleasure in daily life, especially in things that previously were enjoyable. May be subjective or observed
How often must symptoms be present for a diagnosis of depression according to the ICD-10?
Everyday or nearly everyday without significant change throughout the day for at least 2 weeks
Must not be attributable to psychoactive substance use or to organic mental disorder
What are some typical symptoms of depression?
Early waking Disturbed and poor quality Loss of appetite Weight loss Psychomotor retardation Difficulty concentrating Decreased libido Ideas or acts of self harm or suicide Feelings of worthlessness or guilt
What must always be asked about in a patient presenting with depression?
Self harm
Thoughts of suicide
How many of each symptom does mild depression have?
2 core
2 typical
How many of each symptom does moderate depression have?
2 core
3+ typical
How many of each symptom does severe depression have?
3 core
4+ typical
What are some medical issues that can cause depression?
Biological causes
Hypothyroidism (hyper is associated with mania)
Heart Disease- Post MI and During Recovery
Parkinsons Disease
Multiple Sclerosis
Alzheimers Disease
Hunnington’s Disease
Excess Cortisol- Cushing Disease
What are some psychological causes of depression?
Low self esteem
Personality traits
Psychological trauma
Temperament
What are some social causes of depression?
Stress
Isolation
Poor housing
When considering a diagnosis of depression what are some differentials you may have?
Bipolar- Ask about fluctuating mood
Anxiety- Leading to -Ve feelings
Dysthmia- state of chronic depression that persists for atleast 2 years
Dementia
Substance misuse
Side effect of some medications- e.g beta blockers
Physical causes of depression (thyroid function, CVD, MS, PD)
Describe the stepwise approach for the management of depression
Step 1- Recognition and diagnosis
Step 2- Treatment of mild depression in primary care
Step 3- Treatment of moderate to sever depression in primary care
Step 4- Treatment by specialist mental health services
What are some good general measures that should be told to depressed patients?
Good sleep hygiene Increase physical activity Methods to reduce anxiety and stress Mindfullness Spend more time outdoors
Describe what is included in step 2 of the stepwise approach for the treatment of depression? Mild to moderate depression.
NOT SSRI routinely
Sleep and anxiety management advice
Low intensity pyschosocial interventions:
- Self help e.g. headspace, books, apps
- Computerised CBT programme
- Group exercise
- CBT therapy if above declined
Anti-depressants if persist for more than 8 weeks or previous hx of moderate/severe depression
Follow up the patient within 2 weeks and call if don’t attend follow up
Describe what is included in step 3 of the stepwise approach for the treatment of depression? Moderate to severe depression (or no response to step 2)
- Anti- depressant therapy (1st line is SSRI)
- High intensity psychosocial therapy such as CBT, IPT, Behavioural couples therapy,
What must you discuss with patients when starting them on an anti-depressant medication?
There is a delay to it’s effect
Do not stop abruptly
Side effects
What are some side effects of SSRIs?
GI disturbance Impotence Sweating Agitation Decreased seizure threshold Discontinuation syndrome- warn not to stop abruptly
Give two examples of SSRIs?
Fluoxetine
Sertraline
Citalopram
Paroxetine
What is included in step 4 of the stepwise approach for the management of depression? (severe depression, risk to life or severe self neglect)
Refer to specialist mental health services
Consider inpatient treatment if significant risk of suicide, self harm or neglect
Continue with antidepressant therapy and high intensity psychosocial interventions
Offer ECT
For which patients should ECT be offered?
Severe depression
A prolonged or severe manic episode
Catatonia
(Consider for patients with mild depression if all else failed)
What is the mechanism of tryptophan?
Increased synthesis of NA/5-HT
What in the mechanism of MAOIs?
Reduce breakdown of 5-HT and NA
What is the mechanism of SSRI, SNRI, TCAs?
Prevent re-uptake of 5-HT and NA
What is a side effect of citalopram?
Increases QT interval
Why should patients of SSRIs not stop them acutely?
Discontinuation syndrome-
Flu like symptoms
Sleep disturbance
Sensory and movement disturbances- imbalance, tremors, vertigo, brain zaps
What is the mechanism of venlafaxine?
SNRI- Serotonin and noradrenaline re-uptake inhibitor (SNRI). It is helpful in more resistant disease.
What is the mechanism of reboxetine?
NA Re-uptake inhibitors
Its not a very good anti-depressant
What are two common side effects of mirtazepine?
Sedation and Weight Gain
It is an alpha 2 antagonist
How do tricyclic anti-depressants work?
Inhibit the uptake of 5HT and NA
Give some examples of TCA
Amitryptyline
Imipramine
Lefepramine
What is a big risk of TCAs in depressed people?
Dangerous in overdose
What are some side effects of TCAs?
Anticholinergic- dry mouth, constipation, blurred vision Histamine- Sedation Alpha 1- Postural hypotension, impotence Quinidine like- ECG Changes, Arrhythmias NA- Tremor 5-HT- GI Upset, Sweating
Now only used in resistant illness and are prescribed by specialists in the area
What is a risk factor of MAOIs?
Cheese reaction- it is a hypertensive crisis, risk of stroke and death
This is because they prevent the breakdown of tyramine which is found in lots of food, including cheese.
What medications should be offered for depression first line?
Fluoxetine
Sertraline
Mirtazapine
What investigations need to be done before starting patients on a TCA or venlafaxine?
ECG/ BP
- Do not prescribe if recent MI or history of severe arrhythmia
- Do not use venlafaxine in uncontrolled HTN
After how long should it be considered to switch anti-depressants?
If no response at four weeks consider switching to a different anti-depressant
If partial response consider switching if partial response by 6 weeks
What are some second line anti-depressants?
Second SSRI
Venlafaxine (SNRI)
Mirtazapine (alpha 2 antagonist)
When should augmentation be considered?
Partial response to first line treatment
Good tolerability of existing treatment
Switching to different anti-depressant agents was unsuccessful
What agents may be added in for augmentation?
Lithium
Anti-psychotic (esp. if psychotic depression)- olanzapine, risperidone, aripiprazole
SSRI/Venlafaxine (SNRI) + Mritazapine (Alpha 2 antagonist which enhances NA and 5-HT transmission)
What are the indications for ECT?
Depression- Severe or resistant
Mania
Schizophrenia- catatonia
Are there any contra-indications to ECT?
No, there are not absolute contra-indications but there are some relative CIs
What are some relative CIs to ECT?
CVD- Recent MI, IHD, HF Uncontrolled HTN Aneurysms- Cerebral, AAA Raised ICP Head injury Issues with anaesthetic agents used
What should be prescribed to patients taking a SSRI and also taking an NSAID?
PPI
Due to risk of GI bleeding
How long should be taken to stop an SSRI?
When stopping and SSRI the dose should be gradually reduced over 4 weeks
(not with fluoxetine as it has a longer half life)
For which type of ECT is more memory impairment seen? Is it more or less effective
Bilateral is associated with more memory impairment than unilateral
Bilateral is also more effective
Can ECT be given to detained patients?
Yes if informed consent or a second opinion by an approved doctor
