Depression Flashcards
Core symptoms of depression
Present most of the day, nearly every day
Low mood
Anergia
Anhedonia
Time criterion for depression
Persistent (diurnal variation allowed) for >=2w
Biological secondary symptoms of depression
Change of appetite +/- weight change (usualy low)
disturbed sleep (insomnia, early morning waking >2h)
Diurnal mood variation
reduced libido
Psychomotor agitation/retardation
Psychological secondary symptoms of depression
Past: Low self-esteem, guilt, worthlessness
Present: Poor concentration, reduced motivation + interest
Future: Hopelessness + helplessness, suicidal thoughts
Determining severity of depression
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)
Indication for emergency ECT in depression
Depressive stupor due to psychomotor retardation
Risk of death from dehydration
Definition of dysthymia
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
Lifetime prevalence rate of depression
10-20%
M:F ratio for depressive disorders
1: 2 for unipolar/dysthymia
1: 1 for bipolar
Heritability of depressive disorder
40%, overlap with anxiety but not bipolar
two-fold risk in FDRs
Risk factors for depression
Female
Chronic/severe physical illness
Major life events
Cumulative childhood disadvantage
Lack of confiding relationship
FHx of anxiety or depression
% of suicides with depressiv disorder
>40%
Biological aetiological factors of depressive disorder
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
Psychological aetiological factors of depressive disorder
Childhood: Parental loss, deprviation, adverse events
Personality: Neurotocism, low self-esteem
Cognition: Negative bias, learned helplessness
Social aetiological factors for depression
Unemployment
Stressful life events (e.g. disruption of relationships)
Social isolation
Lower socioeconomic status, education
Substance misuse
Whooley questions for screening depression
During the past month, how often have you been bothered by:
- feeling down, depressed, or hopeless?
- Little interest/pleasure in doing things?
- Do you want help?
Screening tools for depression
Primary care: PHQ-9
Secondary care: HADS
Postnatal: EPDS
Baseline: BDI
Differntial for depressive symptoms
Physical cause
Depressive episode
Recurrent depressive disorder
Bipolar affective disorder, depressive episode
Dysthymia
Adjustment disorder
Psychoactive substance use (incl alcohol)
Dementia
Physical causes of depressive symptoms, categories
Systemic
Neurological
Autoimmune
Endocrine
Iatrogenic
Systemic causes of depressive symptoms
Infection: HIV, syphilis, Lyme disease, influenza
Carcinoma (paraneoplastic effects, chemotherapy meds)
Sleep apnoea
Neurological causes of depressive symptoms
Head injury
Epilepsy
Huntington’s
PD
Dementia
MS
CVA
vCJD
Endocrine causes of depressive symptoms
Hyper/hypothyroidism
Addison’s, Cushing’s
Hyperparathyroidism
Diabetes mellitus (hypoglycaemia)
Prolactinoma
Perimenstrual/menopausal
Autoimmune cuases of depressive symptoms
Rheumatoid arthritis
SLE
Common meds leading to depression
VVV common, check BNF
Anticonvulsants
PD meds
Benzodiazepines
NSAIDs
Antihypertensives
Anithistamines
Corticosteroids
Combined OCP
Criteria for use of MHA
Evidence of mental disorder
Risk to self/others
Refusal of community treatment
Management plan categories for depression
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
Subtypes of depression (ICD-10)
Without somatic symptoms
With somatic symptoms
With psychotic symptoms
Atypical depression
Common psychotic symptoms in depression
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)
Standard Ix for depression (to rule out)
FBC
U+Es
Calcium
LFTs
TFTs
ESR
glucose
Special investigations for depressive symptoms (dep on Hx)
Syphilis serology
ANA
Addison’s/Cushing’s tests
UDS, breath/blood alcohol
CT/MRI, EEG
Poor prognostic factors for depressive disorder
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
Timecourse for depressive disorder, mild-moderate cases
4-30 weeks, most 2-3mo
Timecourse for severe depression
Average 6 months
Timecourse for recurrent episodes of depressive disorder
Generally shorter, 4-16 weeks
Rate of chronicity in depression
10-20% chronic course lasting >2years
Clinical features of atypical depressive episode
Depressed but reactive mood
Hypersomnia
Hyperphagia + weight gain
‘Leaden’ limbs
Reversed diurnal mood variation
Prevalence of dysthymia
3-5%, M:F 1:2
Age of onset of dysthymia + atypical depression
Early 20s, median 25
Prognosis of dysthymia
25% chronicity
10-20% remission within 1 year
Pharmacological management of dysthymia
SSRI (esp citalopram, fluoxetine)
May take several months to show benefit
Management of mild-moderate depression, first episode
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)
Indication for antidepressant treatment
Severe depression
Hx of moderate-severe depression
Subthreshold symptoms >2 years
Subthreshold/mild symptoms persisting after other interventions
Indications for hospital admission with depression
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
Drug interactions for SSRIs
NSAIDs
Aspirin
Warfarin/Heparin
Sertraline, citalopram have lower interaction profiles
Follow-up frequency following initiation of antidepressant
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)
Interactions of St John’s Wort
Induction of cytochrome P450 –> reduction in drug levels
OCP
Warfarin
Anti-retrovirals
Anti-rejection therapies
Digoxin
Anticonvulsants
Prescription of TCAs vs SSRIs
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
Definition of adequate trial of antidepressant
4-6 weeks at maximum tolerated dose, necessary before switching antidepressants
Maintenance antidepressant therapy
4-6mo post-recovery for first episode before slow withdrawal (4-week period)
Recurrent episode within 3 years: Minimum 2, preferable >5 years therapy
Risk of relapse if meds stopped in recurrent depressive disorder
70-90% within 5 years
Augmentation strategies for partial responders
Lithium
T3
Treatment of depression with psychotic symptoms
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
Approach for treatment-resistant depression
Check compliance
Check diagnosis (esp bipolar)
Check perpetuating factors
Switch class
Augment: Li, T3, quetiapine
Relapse rate for depression
50% for first episode
70% if 2 episodes
90% if >2 episodes
Change in prevalence of depression from 1ry care to hospital inpatient
Primary: 5%
Outpatients: 10%
Inpatient: 20%
Features of depression in hospital settings
- Pervasiveness of low mood/anhedonia: e.g. family visits no pleasure
- Diurnal variation: Worse in morning
- Hopelessness: + loss of interest in any potential improvement
Management of depression in hospital settings
Practical: Clarify prognosis, improve pain, mobility
Psychological: Liaison psych, theraeutic support by nursing staff
Pharmacological: Consider antidepressants, but caution in liver/renal impairment
Average age of onset for mood disorders
Depressive episode: 27 (2nd peak at 60-70)
Dysthymia: 25
Bipolar: 17
Prognosis of depressive disorders
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
Management of moderate-severe depression
Antidepressants (first-line SSRIs)
Referral to secondary/specialist care
Safety planning
High-intensity psychological intervents (e.g. CBT)
