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
What questionnaire is used to screen for depression?
- PHQ-9 - A nine-item, self-administered scale, which scores severity using DSM-IV
- HADS - hospital anxiety and depression scale –> used when considering intervention
Antidepressants side effects - general
- Suicidal thoughts and suicide attempts esp in young adults
- Anxiety, agitation, or insomnia
- Sexual dysfunction — if erectile dysfunction is a problem sildenafil maybe considered
- Hyponatraemia — may occur with all antidepressants, especially in elderly. May present with dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures
SSRI - key facts
- less sedating and have fewer antimuscarinic adverse effects than TCA
- fluoxetine has a long half life so good if unsure that pt will be compliant. fluoxetine is prescribed for children and adolescents
- Ideally, SSRIs should be avoided in people taking NSAIDs, aspirin, or warfarin - consider giving PPI
- sertraline is useful post myocardial infarction
- When stopping a SSRI the dose should be gradually reduced over a 4 week period
SSRI - side effects
- GI disturbance = nausea, vomiting, abdominal pain, dyspepsia, constipation, and diarrhoea
- CNS = dizziness, agitation, anxiety, insomnia, and tremor; headache;
- sexual dysfunction
- hyponatremia
- increased risk of bleeding, especially in older people
- QT prolongation, and/or ventricular arrhythmias have been reported with citalopram or escitalopram
TCA - side effects
- used less commonly for depression as they are more dangerous in OD –> cardiac side effects
- anticholinergic side effects = dry mouth, blurred vision, constipation, urinary retention, postural hypotension (also from alpha adrenergic blockade)
- histamine blockade = sedation, weight gain
- cardiac = ECG changes, arrhythmias, heart block, tachycardia, and syncope
Mirtazapine
- usually a lower dose can be more effective
- A/E of mirtazapine include increased appetite, constipation, weight gain, oedema, and sedation
- Drowsiness often occurs during the first few weeks
- rare side effect: infections and agranulocytosis
Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite
SSRI monitoring
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
Switching antidepressants
- Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI: SSRI should be withdrawn over 4 weeks before the alternative SSRI is started
- Switching from fluoxetine to another SSRI: withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
- Switching from a SSRI to a TCA: cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
