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Psychiatry > Depression > Flashcards

Depression Flashcards

1
Q

Core symptoms of depression

A

Present most of the day, nearly every day

Low mood

Anergia

Anhedonia

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2
Q

Time criterion for depression

A

Persistent (diurnal variation allowed) for >=2w

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3
Q

Biological secondary symptoms of depression

A

Change of appetite +/- weight change (usualy low)

disturbed sleep (insomnia, early morning waking >2h)

Diurnal mood variation

reduced libido

Psychomotor agitation/retardation

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4
Q

Psychological secondary symptoms of depression

A

Past: Low self-esteem, guilt, worthlessness

Present: Poor concentration, reduced motivation + interest

Future: Hopelessness + helplessness, suicidal thoughts

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5
Q

Determining severity of depression

A

Mild: 2 core symptoms + 2 secondary symptoms (able to continue w/ most daily activities)

Moderate: 2 core symptoms + 3+ secondary symptoms + great difficulty coping with daily activities

Severe: 3 core symptoms + 4+ secondary symptoms (or psychosis, marker of severity)

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6
Q

Indication for emergency ECT in depression

A

Depressive stupor due to psychomotor retardation

Risk of death from dehydration

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7
Q

Definition of dysthymia

A

Prolonged period of low mood (>2 years) during which no episode fulfills the criteria for mild/moderate/severe depressive episode

May have days/weeks of wellness

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8
Q

Lifetime prevalence rate of depression

A

10-20%

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9
Q

M:F ratio for depressive disorders

A

1: 2 for unipolar/dysthymia
1: 1 for bipolar

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10
Q

Heritability of depressive disorder

A

40%, overlap with anxiety but not bipolar

two-fold risk in FDRs

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11
Q

Risk factors for depression

A

Female

Chronic/severe physical illness

Major life events

Cumulative childhood disadvantage

Lack of confiding relationship

FHx of anxiety or depression

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12
Q

% of suicides with depressiv disorder

A

>40%

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13
Q

Biological aetiological factors of depressive disorder

A

Genetics (Two-fold risk in first degree relatives)

HPA axis dysregulation (raised cortisol)

Monoamine dysregulation

Medical conditions: stroke, IHD, flu, Parkinson’s, endocrine disorders

Medications

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14
Q

Psychological aetiological factors of depressive disorder

A

Childhood: Parental loss, deprviation, adverse events

Personality: Neurotocism, low self-esteem

Cognition: Negative bias, learned helplessness

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15
Q

Social aetiological factors for depression

A

Unemployment

Stressful life events (e.g. disruption of relationships)

Social isolation

Lower socioeconomic status, education

Substance misuse

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16
Q

Whooley questions for screening depression

A

During the past month, how often have you been bothered by:

  1. feeling down, depressed, or hopeless?
  2. Little interest/pleasure in doing things?
  3. Do you want help?
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17
Q

Screening tools for depression

A

Primary care: PHQ-9

Secondary care: HADS

Postnatal: EPDS

Baseline: BDI

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18
Q

Differntial for depressive symptoms

A

Physical cause

Depressive episode

Recurrent depressive disorder

Bipolar affective disorder, depressive episode

Dysthymia

Adjustment disorder

Psychoactive substance use (incl alcohol)

Dementia

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19
Q

Physical causes of depressive symptoms, categories

A

Systemic

Neurological

Autoimmune

Endocrine

Iatrogenic

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20
Q

Systemic causes of depressive symptoms

A

Infection: HIV, syphilis, Lyme disease, influenza

Carcinoma (paraneoplastic effects, chemotherapy meds)

Sleep apnoea

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21
Q

Neurological causes of depressive symptoms

A

Head injury

Epilepsy

Huntington’s

PD

Dementia

MS

CVA

vCJD

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22
Q

Endocrine causes of depressive symptoms

A

Hyper/hypothyroidism

Addison’s, Cushing’s

Hyperparathyroidism

Diabetes mellitus (hypoglycaemia)

Prolactinoma

Perimenstrual/menopausal

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23
Q

Autoimmune cuases of depressive symptoms

A

Rheumatoid arthritis

SLE

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24
Q

Common meds leading to depression

A

VVV common, check BNF

Anticonvulsants

PD meds

Benzodiazepines

NSAIDs

Antihypertensives

Anithistamines

Corticosteroids

Combined OCP

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25
Q

Criteria for use of MHA

A

Evidence of mental disorder

Risk to self/others

Refusal of community treatment

26
Q

Management plan categories for depression

A

General: Where, by whom?

Physical: Exercise, sleep hygiene, drugs (incl alcohol, anxiolytics), ECT

Pharmacological: Antidepressants

Psychological: Self-help, online CBT, individual/group CBT, IPT/counselling

Social: Day hospital, hobbies, employment, support networks

27
Q

Subtypes of depression (ICD-10)

A

Without somatic symptoms

With somatic symptoms

With psychotic symptoms

Atypical depression

28
Q

Common psychotic symptoms in depression

A

Mood congruent (if incongruent, suspect schizoaffective)

Delusions: poverty, inadequacy, guilt over misdeeds, responsibility for disasters, nihilism, hypochondriasis

Hallucinations: Auditory (usually 2nd person, accusatory/defamatory voices, screaming), olfactory (rotting flesh, faeces)

29
Q

Standard Ix for depression (to rule out)

A

FBC

U+Es

Calcium

LFTs

TFTs

ESR

glucose

30
Q

Special investigations for depressive symptoms (dep on Hx)

A

Syphilis serology

ANA

Addison’s/Cushing’s tests

UDS, breath/blood alcohol

CT/MRI, EEG

31
Q

Poor prognostic factors for depressive disorder

A

Demographic: Older age, lack of social support, younger age of onset

Personal Co-morbidity, neuroticism, low-self esteem

Illness: Insidious onset, residual symptoms, neurotic (cf endogenous/somatic), severe/psychotic symptoms, number of previous episodes

32
Q

Timecourse for depressive disorder, mild-moderate cases

A

4-30 weeks, most 2-3mo

33
Q

Timecourse for severe depression

A

Average 6 months

34
Q

Timecourse for recurrent episodes of depressive disorder

A

Generally shorter, 4-16 weeks

35
Q

Rate of chronicity in depression

A

10-20% chronic course lasting >2years

36
Q

Clinical features of atypical depressive episode

A

Depressed but reactive mood

Hypersomnia

Hyperphagia + weight gain

‘Leaden’ limbs

Reversed diurnal mood variation

37
Q

Prevalence of dysthymia

A

3-5%, M:F 1:2

38
Q

Age of onset of dysthymia + atypical depression

A

Early 20s, median 25

39
Q

Prognosis of dysthymia

A

25% chronicity

10-20% remission within 1 year

40
Q

Pharmacological management of dysthymia

A

SSRI (esp citalopram, fluoxetine)

May take several months to show benefit

41
Q

Management of mild-moderate depression, first episode

A

Psychoeducation + advice on sleep hygiene, physical activity, graded return to activity

Low intensity psychological intervention: CCBT, group CBT, individual CBT (esp self-help)

Follow up within 2-4 weeks (watch out for mania)

42
Q

Indication for antidepressant treatment

A

Severe depression

Hx of moderate-severe depression

Subthreshold symptoms >2 years

Subthreshold/mild symptoms persisting after other interventions

43
Q

Indications for hospital admission with depression

A

Serious risk of suicide, or risk to others (e.g. children)

Severe psychotic symptoms

Depressive stupor

Initiation of ECT

Treatment of physical comorbidity

Significant self-neglect (esp weight loss)

Lack of supportive home environment

44
Q

Drug interactions for SSRIs

A

NSAIDs

Aspirin

Warfarin/Heparin

Sertraline, citalopram have lower interaction profiles

45
Q

Follow-up frequency following initiation of antidepressant

A

Every 2-4 weeks for 3mo (suicide risk higher in pts discharged from hospital for 2-4w)

Monitor suicidality, response, side effects, MANIA, compliance (main reason for non-response)

46
Q

Interactions of St John’s Wort

A

Induction of cytochrome P450 –> reduction in drug levels

OCP

Warfarin

Anti-retrovirals

Anti-rejection therapies

Digoxin

Anticonvulsants

47
Q

Prescription of TCAs vs SSRIs

A

TCAs:

  • More sedating
  • More dangerous in OD (avoid if suicidal)
  • More SEs, less safe for elderly w/ physical comorbidities
  • Better evidence for pregnancy safety profile

Prescribe SSRIs as first line, similar efficacy for both though

48
Q

Definition of adequate trial of antidepressant

A

4-6 weeks at maximum tolerated dose, necessary before switching antidepressants

49
Q

Maintenance antidepressant therapy

A

4-6mo post-recovery for first episode before slow withdrawal (4-week period)

Recurrent episode within 3 years: Minimum 2, preferable >5 years therapy

50
Q

Risk of relapse if meds stopped in recurrent depressive disorder

A

70-90% within 5 years

51
Q

Augmentation strategies for partial responders

A

Lithium

T3

52
Q

Treatment of depression with psychotic symptoms

A

Admission

Low-dose antipsychotic for a few days –> differentiate from 1ry psychotic disorder + improve compliance (30-50% improve on antipsychotic alone)

Initiation of antidepressant

Common combination: Olanzapine-fluoxetine

Consider ECT if stupor/very severe

53
Q

Approach for treatment-resistant depression

A

Check compliance

Check diagnosis (esp bipolar)

Check perpetuating factors

Switch class

Augment: Li, T3, quetiapine

54
Q

Relapse rate for depression

A

50% for first episode

70% if 2 episodes

90% if >2 episodes

55
Q

Change in prevalence of depression from 1ry care to hospital inpatient

A

Primary: 5%

Outpatients: 10%

Inpatient: 20%

56
Q

Features of depression in hospital settings

A
  • Pervasiveness of low mood/anhedonia: e.g. family visits no pleasure
  • Diurnal variation: Worse in morning
  • Hopelessness: + loss of interest in any potential improvement
57
Q

Management of depression in hospital settings

A

Practical: Clarify prognosis, improve pain, mobility

Psychological: Liaison psych, theraeutic support by nursing staff

Pharmacological: Consider antidepressants, but caution in liver/renal impairment

58
Q

Average age of onset for mood disorders

A

Depressive episode: 27 (2nd peak at 60-70)

Dysthymia: 25

Bipolar: 17

59
Q

Prognosis of depressive disorders

A

Individual episode: On treatment, typically 2-3 months

Recurrence: 60-80% lifetime relapse, 30% at 10y

Suicide: Up to 10% in severe depression, higher than general population

General morbidity/mortality: Worse, higher rates of substance abuse, worse respiratory/CV/cancer outcomes

60
Q

Management of moderate-severe depression

A

Antidepressants (first-line SSRIs)

Referral to secondary/specialist care

Safety planning

High-intensity psychological intervents (e.g. CBT)

Psychiatry (20 decks)

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