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PAN- Psychiatry > Depression > Flashcards

Depression Flashcards

1
Q

What are the core symptoms of depression according to the ICD-10?

A

Anhedonia
Depressed Mood
Fatigue

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2
Q

What is anhedonia?

A

Loss of interest or pleasure in daily life, especially in things that previously were enjoyable. May be subjective or observed

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3
Q

How often must symptoms be present for a diagnosis of depression according to the ICD-10?

A

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

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4
Q

What are some typical symptoms of depression?

A 
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
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5
Q

What must always be asked about in a patient presenting with depression?

A

Self harm

Thoughts of suicide

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6
Q

How many of each symptom does mild depression have?

A

2 core

2 typical

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7
Q

How many of each symptom does moderate depression have?

A

2 core

3+ typical

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8
Q

How many of each symptom does severe depression have?

A

3 core

4+ typical

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9
Q

What are some medical issues that can cause depression?

Biological causes

A

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

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10
Q

What are some psychological causes of depression?

A

Low self esteem
Personality traits
Psychological trauma
Temperament

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11
Q

What are some social causes of depression?

A

Stress
Isolation
Poor housing

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12
Q

When considering a diagnosis of depression what are some differentials you may have?

A

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)

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13
Q

Describe the stepwise approach for the management of depression

A

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

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14
Q

What are some good general measures that should be told to depressed patients?

A 
Good sleep hygiene
Increase physical activity
Methods to reduce anxiety and stress
Mindfullness
Spend more time outdoors
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15
Q

Describe what is included in step 2 of the stepwise approach for the treatment of depression? Mild to moderate depression.

A

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

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16
Q

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)

A
  • Anti- depressant therapy (1st line is SSRI)

- High intensity psychosocial therapy such as CBT, IPT, Behavioural couples therapy,

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17
Q

What must you discuss with patients when starting them on an anti-depressant medication?

A

There is a delay to it’s effect
Do not stop abruptly
Side effects

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18
Q

What are some side effects of SSRIs?

A 
GI disturbance
Impotence
Sweating
Agitation
Decreased seizure threshold
Discontinuation syndrome- warn not to stop abruptly
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19
Q

Give two examples of SSRIs?

A

Fluoxetine
Sertraline
Citalopram
Paroxetine

20
Q

What is included in step 4 of the stepwise approach for the management of depression? (severe depression, risk to life or severe self neglect)

A

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

21
Q

For which patients should ECT be offered?

A

Severe depression
A prolonged or severe manic episode
Catatonia

(Consider for patients with mild depression if all else failed)

22
Q

What is the mechanism of tryptophan?

A

Increased synthesis of NA/5-HT

23
Q

What in the mechanism of MAOIs?

A

Reduce breakdown of 5-HT and NA

24
Q

What is the mechanism of SSRI, SNRI, TCAs?

A

Prevent re-uptake of 5-HT and NA

25
Q

What is a side effect of citalopram?

A

Increases QT interval

26
Q

Why should patients of SSRIs not stop them acutely?

A

Discontinuation syndrome-
Flu like symptoms
Sleep disturbance
Sensory and movement disturbances- imbalance, tremors, vertigo, brain zaps

27
Q

What is the mechanism of venlafaxine?

A

SNRI- Serotonin and noradrenaline re-uptake inhibitor (SNRI). It is helpful in more resistant disease.

28
Q

What is the mechanism of reboxetine?

A

NA Re-uptake inhibitors

Its not a very good anti-depressant

29
Q

What are two common side effects of mirtazepine?

A

Sedation and Weight Gain

It is an alpha 2 antagonist

30
Q

How do tricyclic anti-depressants work?

A

Inhibit the uptake of 5HT and NA

31
Q

Give some examples of TCA

A

Amitryptyline
Imipramine
Lefepramine

32
Q

What is a big risk of TCAs in depressed people?

A

Dangerous in overdose

33
Q

What are some side effects of TCAs?

A 
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

34
Q

What is a risk factor of MAOIs?

A

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.

35
Q

What medications should be offered for depression first line?

A

Fluoxetine
Sertraline
Mirtazapine

36
Q

What investigations need to be done before starting patients on a TCA or venlafaxine?

A

ECG/ BP

  • Do not prescribe if recent MI or history of severe arrhythmia
  • Do not use venlafaxine in uncontrolled HTN
37
Q

After how long should it be considered to switch anti-depressants?

A

If no response at four weeks consider switching to a different anti-depressant
If partial response consider switching if partial response by 6 weeks

38
Q

What are some second line anti-depressants?

A

Second SSRI
Venlafaxine (SNRI)
Mirtazapine (alpha 2 antagonist)

39
Q

When should augmentation be considered?

A

Partial response to first line treatment
Good tolerability of existing treatment
Switching to different anti-depressant agents was unsuccessful

40
Q

What agents may be added in for augmentation?

A

Lithium
Anti-psychotic (esp. if psychotic depression)- olanzapine, risperidone, aripiprazole
SSRI/Venlafaxine (SNRI) + Mritazapine (Alpha 2 antagonist which enhances NA and 5-HT transmission)

41
Q

What are the indications for ECT?

A

Depression- Severe or resistant
Mania
Schizophrenia- catatonia

42
Q

Are there any contra-indications to ECT?

A

No, there are not absolute contra-indications but there are some relative CIs

43
Q

What are some relative CIs to ECT?

A 
CVD- Recent MI, IHD, HF
Uncontrolled HTN
Aneurysms- Cerebral, AAA
Raised ICP
Head injury
Issues with anaesthetic agents used
44
Q

What should be prescribed to patients taking a SSRI and also taking an NSAID?

A

PPI

Due to risk of GI bleeding

45
Q

How long should be taken to stop an SSRI?

A

When stopping and SSRI the dose should be gradually reduced over 4 weeks

(not with fluoxetine as it has a longer half life)

46
Q

For which type of ECT is more memory impairment seen? Is it more or less effective

A

Bilateral is associated with more memory impairment than unilateral
Bilateral is also more effective

47
Q

Can ECT be given to detained patients?

A

Yes if informed consent or a second opinion by an approved doctor

PAN- Psychiatry (7 decks)

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