Depression

Question 1

What are some risk factors for depression?

Answer 1

• Neurotransmitter or hormonal imbalance
• A negative perception of life events (trauma, loss, stress)
• Medical disorders, chronic conditions, or poor prognosis
• Medication adverse reactions
• Loss of significant others
• Lack of a social support system

Question 2

Who is at highest risk for suicide?

Answer 2

1. Highest risk: elderly white males with comorbidities lacking social support
2. Previous suicide attempt
3. Family history of suicide
4. Feeling of hopelessness

Question 3

What Mnemonic is used when assessing a patient for suicide risk?

Answer 3

S: sex (males more successful, women attempt suicide more, less successful)

U: past attempt history

I: family history of suicide

CI: Chronic medical illnesses

D: depression, substance abuse, alcohol abuse

A: age of patient (elderly more successful, teenagers make more attempts)

L: Lethal method available (gun most lethal, followed by hanging and drug overdose)

If any signs are noted in the above assessment follow-up with the below questions should occur:

• Have you ever thought about death or dying?
• Have you ever thought that life was not worth living?
• Have you ever thought about ending your life?
• Have you ever attempted suicide?
• Are you currently thinking about ending your life?
• What are your reasons for wanting to die and your reasons for wanting to live?

Question 4

What are some subjective findings associated with depression?

Answer 4

• Hopelessness
• Increased or decreased appetite or weight
• Decreased libido
• Guilt
• Worthlessness
• Sleep disturbances- insomnia or hypersomnia
• Fatigue – lack of energy

Question 5

What lab/diagnostic tests should be ordered on a patient suspected of depression?

Answer 5

• Thyroid function tests
• Vitamin B12 and folate levels
• Blood glucose
• CBC- r/o anemia, infection
• EKG- prior to starting any tricyclic antidepressants as they may exacerbate preexisting condition
• Toxicology – drug screen, etoh levels
• Renal function

All these tests are used to rule out medical causes for depression

Question 6

What 3 classes of medications are used for patients in the treatment of depression

Answer 6

• All anti-depressants equally effective with approximately 2/3 of patients responding to treatment
• Treatment should be continued for a minimum of 6-8 weeks to be effective.

1. Selective serotonin reuptake inhibitors (SSRIs)

• Citalopram (Celexa) or Escitalopram (Lexapro). Use cautiously in elderly! and those with liver disease; may cause QT prolongation; get baseline EKG and LFTs prior to initiation of therapy
• Sertraline (Zoloft)- PREFERRED FOR ELDERLY due to short half life
• Fluoxetine (Prozac) – long half-life (48 hours)
• SSRIs are the most commonly prescribed medications due to lower danger of overdose and less adverse effects

2. Selective norepinephrine and serotonin reuptake inhibitors,

• Mirtazapine or bupropion
• May be used for those who have not had adequate improvement with SSRIs
• Venlafaxine (Effexor or Effexor XR) – divided dosing preferred due to sedation effects
• Duloxetine (Cymbalta) – Use cautiously in elderly! And those with history of glaucoma, liver disease and alcohol abuse

3. Tricyclic antidepressants and MAO inhibitors

• Are NOT used often due to more adverse side effects and high overdose potential.

Question 7

What is the most common initial presenting symptoms in the depressed older adult?

Answer 7

Weight loss