Depression Flashcards
ICD-10 criteria for diagnosis
- symptoms should last for at least 2 weeks
- bipolar disorder and other causes (substance misuse, organic) excluded
- At least 2 of the 3 core symptoms:
1. Low mood
2. Anhedonia
3. Decreased energy levels (anergia).
What additional symptoms might they have?
- Loss of confidence / self esteem
- Guilt - feelings of self reproach
- Recurrent thoughts of death, recurrent suicidal ideation
- Diminished ability to think or concentrate, indecisive
- Psychomotor agitation or retardation
- Sleep disturbances (of any type)
- Appetite changes - decreased (anorexia) or increased (leading to hyperphagia)
- Loss of libido.
- Physical complaints (i.e. somatic symptoms), e.g. aches, constipation, increased worry about medical problems
- Diurnal variation of mood (worst in the morning, improves as the day progresses).
- Irritability, anxiety, worry, dread, catastrophising
- Thoughts: helpless, worthless, useless, like a burden
Mild Depression - features
- 2 core + 2 additional symptoms
- patient is distressed but probably capable of continuing with the majority of their activities
- managed in primary care.
- non-pharmacological treatment only.
Moderate Depression - features
- 2 core + 4 additional symptoms
- probably have difficulties continuing with their ordinary activities.
- may require secondary care.
- combination of treatment (i.e. medication and psychological therapy).
Severe Depression - features
- 3 core + at least 5 additional symptoms
- symptoms that are marked and distressing.
- Suicidal thoughts and acts are common.
- Psychotic symptoms may be present, e.g. hallucinations, delusions, psychomotor retardation or severe stupor
- Usually require secondary services.
- May require treatment in hospital.
- May require detention under Mental Health Act
Other key points in diagnosis
- Symptoms should be present nearly every day.
- They cause clinically significant distress or impairment
- Not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism).
- Severe depression may occur with psychotic symptoms - usually “mood congruent”, i.e. nihilistic delusions, persecutory hallucinations etc.
Management - when to use antidepressants
Consider when:
- A history of moderate or severe depression.
- Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years).
- Mild depression that is complicating the care of a chronic physical health problem
What are the different types of Psychological therapies?
- Low Intensity Psychological Intervention: includes individual guided self-help, computerized CBT, group based physical activity programmes
- High Intensity Psychological Intervention: includes individual or group CBT, interpersonal therapy, couples therapy
- Counselling
Management - mild depression
- low intensity psychological intervention
- group based CBT for people who decline first option
Management - moderate or severe
- antidepressant
- high-intensity psychological intervention
Which antidepressant?
- first episode of depression, consider: SSRI, such as citalopram, fluoxetine, paroxetine, or sertraline.
- recurrent episode of depression: antidepressant that the person has had a good response previously
- person has a chronic physical health problem:
Sertraline may be preferred, because it has a lower risk of drug interactions. If an SSRI is prescribed, consider gastroprotection in older people on NSAIDs or aspirin.
Antidepressants - key points
- A single episode of depression should be treated for at least 6 to 9 months after remission.
- A/E early in treatment with an SSRI or SNRI may include increased anxiety, agitation, and sleeping problems
- in a minority of people aged under 30 years of age, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm
- risk of discontinuation/withdrawal symptoms if the antidepressant is stopped abruptly or in some instances if a dose is missed. Needs gradual discontinuation
Second Line Antidepressant?
BNF: Failure to respond to initial treatment with an SSRI may require an increase in the dose, or switching to a different SSRI or mirtazapine. Other second-line choices include lofepramine (TCA), moclobemide (MOAI), and reboxetine. Other tricyclic antidepressants and venlafaxine should be considered for more severe forms of depression;
Vital slides: for augmentation of antidepressant, could give SSRI + mirtazapine, or sometimes lithium or quetiapine depending on symptoms
ECT
NICE Guidelines
Recommended that ECT is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
- severe depressive illness
- catatonia
Social aspects of treatment
Exercise Healthy diet Sleep hygiene Signposting Housing Finances Social Services
