Depression Flashcards
How many women and how many men will develop depression severe enough to require treatment at some point in their lives?
1 in 4 women and 1 in 10 men
How many primary care consultations does it account for?
5-10%
What are the biological factors for the aetiology of depression?
o Estimate of heritability for major depression is 37%
o Monoamine theory of depression decreases monoamine function may cause depression
o Structural brain changes ventricular enlargement and raised sucal prominence
What are the psychological factors for the aetiology of depression?
o Personality traits – neuroticism suggests mood lability, autonomic hyper arousal and negative biases in attention and processing
o Low self-esteem
What are the social factors for the aetiology of depression?
o Disruption due to life events e.g. births, job less, divorce, illness in 60% of cases
o Stress associated with poor social environment and social isolation can precipitate and perpetuate depression
o Social drift to lower social class
What are risk factors of depression?
- Female sex – women have higher prevalence, incidence and morbidity
- Past history of depression
- Significant physical illness causing disability or pain
- Other mental heath problems e.g. dementia
- Depression is much more common in people from Afro-Caribbean, Asian, refugee and asylum seeker communities.
What are the CORE SYMPTOMS of depression?
low mood, loss of energy and anhedonia
Definition of anhedonia
Loss of pleasure (in particular with things they previously enjoyed)
What are the typical symptoms of depression?
- Poor appetite +/- marked weight loss without dieting (Rarely increased appetite and weight gain)
- Disrupted sleep – initial insomnia or early waking (3+ hours earlier than usual)
- Psychomotor retardation - limited spontaneous movement and sluggish thought processes
- Agitation
- Decreased libido
- Loss of concentration
- Loss of confidence and self-esteem
- Feelings of worthlessness, hopelessness, inappropriate guilt (may be delusional), or self reproach (not just about current illness but also about past decisions or events)
- Recurrent thoughts of death, suicidal ideation or suicide attempts – may be PASSIVE (I wish I could disappear) or ACTIVE (my plan to overdose is…)
What is the classification of depression?
- Sub threshold depressive symptoms - <5 depressive symptoms
- Mild depression – core symptoms + 2-3 others, mild functioning impairment
- Moderate depression – Core + 4 others and function is impaired on the spectrum from mild to severe
- Severe Depression without psychotic symptoms – most symptoms present and the symptoms markedly interfere with normal functioning, suicidal.
- Severe Depression with psychotic symptoms – as above plus mood congruent nihilistic, guilty delusions, derogatory auditory hallucinations.
What tools can you use for assessment of depression?
- PHQ-9
* HAD scale
What are the DDx of depression?
• Psychiatric disorders: o Bipolar disorder o Schizophrenia o Anorexia nervosa o Anxiety • Dysthymia • Substance misuse • Dementia • Sleep disorders • Neurological disorders • Physical illness • Medication side effects e.g. beta-blockers
What is the monoamine hypothesis of depression?
- Serotonin is a vasoconstrictor and important in digestion
- Larger volumes of serotonin is linked to confidence and high self-esteem
- Serotonin and noradrenaline are thought to be reduced in depression, this is supported by reduced serotonin levels found in CSF of suicide victims
- Mode of most antidepressants are to increase serotonin and noradrenaline
What Ix would you do?
- Blood tests – FBC, U&Es, LFTs, TFTs, calcium levels, blood glucose and inflammatory markers.
- Drug testing
- Imaging may be needed if atypical presentation
What are the types of antidepressants?
SSRIs, SNRIs, tricyclic antidepressants, Monoamine Oxidase Inhbitors
2 examples of SSRIs
fluoxetine, sertraline, citalopram
how do SSRIs work?
o Inhibits the reuptake pumps and serotonin transporters and increases free serotonin
What are red flag side effects to look out for in people taking SSRIs?
o RED FLAGS: serotonin syndrome, hyponatraemia (usually seen in older adults), GI bleeding
give an example of a Selective noradrenaline Reuptake inhibitors (SNRIs)?
Venlafaxine, Duloxetine
How do SNRIs work?
o Inhibits reuptake pumps and inhibits noradrenaline transporters
Side effects of SSRIs?
nausea, anxiety, weight loss, diarrhoea, insomnia, sexual dysfunction, agitation
Side effects SNRIs?
nausea, sexual dysfunction, headache, insomnia, anxiety, sweating, and dose related hypertension.
Example of tricyclic antidepressant?
Amitriptyline
Which antidepressant can lead to cardio toxicity?
Tricyclic antidepressants
Which antidepressants are good for management of neuropathic pain?
Tricyclic antidepressants
side effects of tricyclic antidepressants?
postural hypotension, blurred vision, urinary retention, constipation, dry mouth, weight gain and drowsiness
Give an example of a monoamine oxidase inhibitor (MAOIs)
Phenelzine, Isocarboxazid
How do MAOIs work?
o MAOIs prevent the monoamine oxidase enzyme from removing serotonin, noradrenaline and dopamine from the brain. But also affects other neurotransmitters and that causes the side effects.
which antidepressant has a lot of dietary restrictions?
MAOIs (and don’t forget a lot of drug interactions)
side effects of MAOIS
Postural hypotension, dizziness, constipation, dry mouth, GI upset
How long does it take on average for the antidepressants to start working?
3-6 weeks (but side effects can occur straight away)
what is necessary to assess for when starting antidepressants initially?
suicidal ideation - can provide a ‘pick-me-up’, which means they have motivation to attempt suicide
In order to prevent relapses, when is it recommended to stop antidepressants?
6 months after remission
What are psychological treatments for depression?
Mindfulness, CBT, interpersonal therapy
How would you treat mild depression?
Low intensity psychotherapy focused on sleep hygiene, anxiety management and problem-solving techniques. Antidepressants are not routinely used for mild depression unless it has an 8+ week history or previous diagnosis of depression.
How would you treat moderate depression?
Combination of antidepressant and high-intensity psychological intervention (8-12 weeks CBT or interpersonal therapy), can use IAPT programme for this. For first episode of depression, SSRI is recommended.
How would you treat severe depression?
(includes psychotic depression, high risk suicide and atypical depression) need rapid mental health assessment and consideration of inpatient hospitalisation (may need MHA) or ECT.
What lifestyle changes are recommended in order to help improve depression?
- Exercise
- Good routine
- Healthy, balanced diet
- Smoking cessation
- Social interaction
- Reading clubs
- Meditation
What does the SUICIDE acronym stand for with regards to severe depression?
Suicide plan or ideas of self-harm Unexplained guilt or worthlessness Inability to function (e.g. psycho-motor retardation or agitation) Concentration impaired Impaired appetite Decreased sleep/early waking Energy low/ unaccountable fatigue
What are causes of secondary depression?
• Medical disorders o Hypothyroidism o Chronic disease o Mental illness e.g. schizophrenia • Drug induced • Life event Bereavement, divorce, illness
How may depression present in the elderly?
- Somatic Concerns hypochondriasis or could be exaggerated or over-valued ideas
- Psychotic Symptoms hypochondriacal delusions
- Anxiety
- Subjective memory Complaints
- Suicidal ideation
- Lack reactivity
- Weight loss and self-neglect
What may be causes of depression in the elderly?
• Loss bereavement, role and occupation, independence, mobility
• Change in physical health + pain
• Attachments change in ‘parental’ role (they are being looked after by children)
• New diagnosis of terminal/incurable disease e.g. dementia
• Previous life events leading to vulnerabilities
• Chronic depression
• Insomnia
• Anxiety
• Feeling a burden to family/friends
• Social isolation
People with a rigid personality may be unable to cope with adaptation after event e.g. bereavement
What is DDx of depression in the elderly?
Hypoactive delirium
What can deliberate self-harm be treated as in those aged over 65?
suicide attempt
How many more time likely is it that older adults will die of suicide following deliberate self harm?
3x more likely than those under 65
