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Primary care > Depression > Flashcards

Depression Flashcards

1
Q

Indications for antidepressant medications

A

moderate-severe depression OR Hx of moderate-severe depression

Dysthymia >2y

Mild depression persisting after non-pharma interventions

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2
Q

Core symptoms of depression

A

Present most of the day, nearly every day

Low mood

Anergia

Anhedonia

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3
Q

Time criterion for depression

A

Persistent (diurnal variation allowed) for >=2w

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4
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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5
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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6
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)

Severity depends on functional impairment > than symptom count

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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

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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9
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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10
Q

Screening tools for depression

A

Primary care: PHQ-9

Secondary care: HADS

Postnatal: EPDS

Baseline: BDI

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11
Q

Systemic causes of depressive symptoms

A

Infection: HIV, syphilis, Lyme disease, influenza

Carcinoma (paraneoplastic effects, chemotherapy meds)

Sleep apnoea

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12
Q

Neurological causes of depressive symptoms

A

Head injury

Epilepsy

Huntington’s

PD

Dementia

MS

CVA

vCJD

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13
Q

Endocrine causes of depressive symptoms

A

Hyper/hypothyroidism

Addison’s, Cushing’s

Hyperparathyroidism

Diabetes mellitus (hypoglycaemia)

Prolactinoma

Perimenstrual/menopausal

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14
Q

Autoimmune cuases of depressive symptoms

A

Rheumatoid arthritis

SLE

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15
Q

Standard Ix for depression (to rule out)

A

FBC

U+Es

Calcium

LFTs

TFTs

ESR

glucose

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16
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

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17
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)

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18
Q

Drug interactions for SSRIs

A

NSAIDs

Aspirin

Warfarin/Heparin

Sertraline, citalopram have lower interaction profiles

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19
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)

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20
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

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21
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

22
Q

Definition of adequate trial of antidepressant

A

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

23
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

24
Q

Relapse rate for depression

A

50% for first episode

70% if 2 episodes

90% if >2 episodes

25
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)

26
Q

Conditions that one should be aware of for prescribing antidepressants

A

Renal/hepatic impairment

Coronary artery disease - avoid TCAs

Epilepsy - lowered seizure threshold

Bipolar - mania

GI bleeding/NSAIDs - avoid fluoxetine, sertraline, paroxetine

MAO-I/Lithium + SSRI –> serotonin syndrome

27
Q

Alternative antidepressants for GI bleeding

A

Prescribe gastroprotection (PPI, antihistamine) w/ SSRI

Alternatively use mirtazapine or nortriptyline

28
Q

Examples of SSRIs

A

Citalopram

Fluoxetine

Paroxetine

Sertraline

Fluvoxamine

29
Q

Examples of SNRIs

A

Venlafaxine

Duloxetine

30
Q

Examples of TCAs

A

Nortriptyline

Amitryptiline

Clomipramine

Imipramine

Amoxapine

Doxepin

31
Q

Drug class of mirtazapine

A

NAergic and specific serotonin antagonist (NaSSA)

32
Q

Short-term side effects of SSRIs

A

Dry mouth

Postural hypotension

GI disturbance

Insomnia

Tremor

Suicidality/agitation (esp in young people!)

33
Q

Long-term side effects of SSRIs

A

Platelet dysf(x)

Sexual dysf(x)

Hyponatraemia

Postural hypotension

P450 inhibition –> check drug interactions

Discontinuation syndrome (rare but well-characterised)

34
Q

SSRI side effects in pregnancy

A

Increased risk of post-partum haemmorhage

Increased risk of persistent pulmonary hypoplasia (3 per 1000)

Withdrawal symptoms in baby –> increase length of hospital stay but not permanent

35
Q

TCA contraindications

A

Neuro: Epilepsy, glaucoma

Psych: Suicidality (dangerous in OD)

Cardiovascular: Recent MI, heart block, arrhythmia, ischaemic heart disease

Endocrine: Prostatism, diabetes (use caution)

36
Q

TCA toxicity

A

Prolonged QT, tachyarrhythmias

Seizures

Serotonin syndrome

37
Q

Common side effects of TCAs

A

Anticholinergic: ++ (esp dry mouth/eyes, urinary retention/constipation)

Antihistaminergic: +++ (esp sedation, weight gain, advice on driving/machinery)

Cardiac: ++ (toxicity)

Metabolic/neuro: +

38
Q

Preferred antidepressant class for cardiac pts

A

Sertraline - beware antiplatelet drugs

39
Q

Antidepressant class if sexual dysf(x) is an issue

A

Bupropion (NDRI), mirtazapine (NASSA)

40
Q

Seratonin syndrome features

A

Autonomic: Shivering, sweating, hyperthermia,

Cardiac: vasoconstriction/hypertension, tachycardia

GI: nausea/diarrhoea

Neuro: Headache, agitation, confusion, hallucinations

Muscular: Myoclonus, clonus, hyperreflexia, tremor

41
Q

Management of serotonin syndrome

A

Fluids: Cause of mortality

Temperature control: cooling blankets, antipyretics

Muscle relaxant: Lorazepam

42
Q

Rare but dangerous complication of mirtazapine

A

Agranulocytosis

Look for sore throat, stomatitis, fever, other infx acccompanied by neutropaenia

43
Q

Prevalence of antidepressant discontinuation syndrome

A

30%

44
Q

Timecourse of antidepressant discontinuation syndrome

A

Abrupt onset (2-5d after withdrawal) + short duration of symptoms (1d -3 weeks), usually self-limiting

45
Q

Risk factors for antidepressant discontinuation syndrome

A

Personal: Young age, Hx of discontinuation

Medication: Short half-life (e.g. paroxetine), high dose, duration <8wk, variable compliance

46
Q

Symptoms of discontinuation syndrome

A

SD GASS

Sensory: Paraesthesia, visual disturbance

Disequilibrium: Light-headedness, dizziness

both of the above less common with TCAs

GI: nausea + vomiting, diarrhoea

Affective: Irritability, low mood

Sleep: Insomnia, nightmares

Somatic: Flu-like symptoms, fatigue + headache

47
Q

Common side effects of SNRIs

A

Hypertension

48
Q

Common side effects of mirtazapine

A

Antiemetic, antipruritic, sedating

Oversedation, hyperphagia (paradoxical disappearance at higher doses)

possible recreational abuse/street value

49
Q

High-risk SSRIs for drug interactions

A

Fluoxetine

Fluvoxamine

Paroxetine

50
Q

SSRIs that especially prolong Q-T interval

A

Citalopram and escitalopram

51
Q

Antidepressants for breastfeeding

A

Paroxetine

Sertraline

TCAs

Not doxepin, not fluoxetine, not citalopram

Primary care (8 decks)

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