Depression Flashcards
How long must the low mood and/or anhedonia last to be considered depression?
What does anhedonia mean?
What must you establish as not being a cause?
2 wks of constant symptoms that last throughout the day
Inability to feel pleasure in normally pleasurable activities
Without alcohol/drugs
Without medical disorders
Without bereavement (Was excluded in DSM-4 but now in DSM-5 for major depressive episode)
The patient must have 2 out of 3 core symptoms.
What are the 3 core symptoms?
What is a recurrent depressive disorder?
Low mood for most of the day, every day
Anhedonia - loss of pleasure in pleasurable activities
Fatigue
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2 or more episodes of depression, several months apart
The patient must also have 2 or more typical symptoms.
What are they?
- Biological - 5
- Psychological - 2
What may co-exist with depression?
Poor appetite and weight loss Poor sleep - insomnia or early waking Reduced libido Psychomotor retardation - (slowing of thoughts and movement) Reduced ability to concentrate
Feelings of worthlessness, guilt and/or hopelessness
Thoughts of death and suicide
Anxiety - usually go hand in hand - SO ASK Q’S FOR IN HISTORY
Severity scale:
Subthreshold D - what is the max no of symptoms you have?
Mild D - how many symptoms must they have for diagnosis?
///Moderate D - anything between mild and severe
Severe D - how do you know it is severe?
How is severe depression further classified?
<5
5 - minimal functional impairment
Most symptoms are present + significant functional impairment
With/without psychosis
Psychosis in depression:
What hallucinations do they have?
What sort of delusions do they have? - 3
What is a cotard delusion?
Auditory
Delusions of guilt, inadequacy or disease/hypochondriasis
The belief that they are dead.
Depression in older people:
What is the main difference between younger people?
What are 3 main features of depression in older people?
- GI
- Pseudodementia - define
- One more
What underlying degenerative neurological disease could trigger it?
Why is it important to recognise depression and/or analyse the mood of the elderly?
Less sadness and more apathy (lack of interest, enthusiasm, or concern)
Constipation
Pseudodementia - a situation where a person who has depression also has cognitive impairment that looks like dementia.
Psychomotor agitation or slowing
Parkinson’s Disease
High suicide rate and it is harder to recgonise
When may a patient need to be cared for?
A patient who is very high risk such as those not eating and drinking
History:
2 Q’s used to use to screen for depression?
What to do if both of these Q’s are positive?
In the past month, have you felt down, depressed, or hopeless?
In the past month, have you had little interest or pleasure in doing things?
Proceed to full history and MSE
History of PC:
3 core symptoms to ask about
Other key features - mneumonic - SAFER
Co-morbid features to ask about (both not and in the past)? - 3
Low mood, energy and lack of enjoyment/pleasure
Sleep Appetite Focus - concentration Effects on work, hobbies and relationships (functional impairment - dictates severity) Risk assessment (e.g. violence)
Mania in past - bi-polar
Psychosis
Anxiety
Risk factors:
Mneumonic AFFECT
Anxious/neurotic personality
Female - especially post-pregnancy
FH
Events - bereavement, job loss
Chronic physical illness - RA
Traumatic childhood (e.g. parental loss, sexual abuse)
DDx:
A disorder
Dysthymia - define?
Schizoaffective disorder - define?
What might happen before a period?
What organic disease may cause depression?:
- Thyroid
- Metabolic syndrome - 2
- Elderly
- Neurological, deg
Drugs that may cause depressive symptoms?:
- Drink
- Anti-inflammatory
- Cardiac med
Major depressive disorder
Persistent depressive disorder - a chronic low mood which doesn’t meet criteria for depression.
Schizophrenia and mood disorder occurs during the same episode
Disabling symptoms of low mood preceding menstruation
Hypothyroidism Cushing's Addison's Dementia Parkinson's
Alcohol
Corticosteroids
Propranolol
Investigations - Diagnostic instruments:
PHQ - 9 - what does it stand for?
GDS is used for the elderly. What does it stand for?
EPDS is used postnatally, 4-6 wks post-delivery. What does it stand for?
The HAD scale is used to test for D and A in hospital. What does it stand for?
Patient Health Questionnaire
Geriatric Depression Scale
Edinburgh Postnatal Depression Scale
Hospital Anxiety and Depression scale
Investigations for organic causes or co-morbidities:
Bloods and why? - 2
What should be done to check for illicit drugs?
What should be done for neurological pathology?
TSH - hypothyroidism FBC - Anaemia U+E LFT Glucose CRP ///////////////////////////// Drug screen - urinary //////////////////////////// MRI, CT - neuroimaging
Management:
What should be offered first?
Psychoeducation and continued monitoring and support to all
Management - Low-intensity psychological intervention:
What severity of D should it be used for?
How long should this be done for?
What is available?:
- 2 types of CBT
- What type of therapy can also be offered?
What can be offered if the 3 first ones are declined?
What can be done for those with physical illness?
What can also be done if the doc doesn’t think they psychological therapy is appropriate?
Mild-to-moderate D
3 months
CBT based self-help with 6-8 brief individual sessions
Computerised CBT
Structured group physical therapy
Group-based CBT
Peer support with those with the same illness
2 wks of watchful waiting
Management - High-intensity psychological intervention:
What severity of D should it be used for?
How many sessions of CBT can you get and over how long?
Moderate-to-severe D
20 session over 4 months
Management - Long-term relapse intervention:
What can be given if there is a high risk of relapse despite the use of meds and they don’t want to continue antidepressants?
What can be offered if over 3 previous episodes of D?
Individual CBT
Mindfulness-based CBT
Management - Biological - Antidepressants:
What severity of D should it be used for?
What is it usually done in a combination of?
Moderate-to-severe D
With psychological therapy
Management - Biological - Antidepressants:
First-line?
How long do you trial this for?
Second-line
Third-line
SSRIs - fluoxetine, sertraline, citalopram
4-6 wks
A different SSRI - overlap by a wk
NaSSA - mirtazapine, venlafaxine
TCA or MAOI
Management - Biological - Antidepressants:
Why might Mirtazapine be first line instead of SSRIs?
What can be added in combination/augmentation therapy
It has a sedating effect so can be used for patients with lack of sleep, lack of appetite and agitation - SSRIs have a more stimulating effect.
Add other ADs, lithium (mood stabiliser), antipsychotics or triiodothyronine (T3)
Management - Biological - Antidepressants:
How long does it take for the meds to work?
What warnings should be given to patients? - 3
When should you check for possible side effects?
1-2 wks
Possible side effects
It is non-addictive
May be initial boost which can cause mania, especially in those with BD, or a suicide attempt especially in those under 30.
After 2 wks then 3 months
Management - Biological - Antidepressants:
What should be done if there is a poor response in 2-4 wks? - 3
How long should someone on their 1st episode be on ADs if there is a positive response?
How long should someone on their 2nd episode or with a high risk of relapse be on ADs if there is a positive response?
Ensure adherence and consider increasing dose or switching drugs.
> 6 months
> 2yrs
Management - Biological - Antidepressants:
What about pregnancy?
Not recommended but risk-benefit analysis needs to be done
Management - Biological - Antidepressants:
How long should you take to taper/cross-taper the ADs?
How long do discontinuation symptoms last?
What if symptoms are severe?
4 wks
1 wk
Reintroduce and wean more gradually
FROM CASE:
Why would you add antipsychotics with the ADs?
What needs to be monitored with antipsychotics?
What should be monitored throughout care regardless of the medication they are on?
If they present with psychosis
Metabolic monitoring
Physical health monitoring
CBT
What is the purpose of CBT?
How can CBT be delivered?
Identifying harmful thoughts and behaviours and to replace them with helpful ones
Individuals
Groups
Written or computer materials with guidance
Interpersonal therapy
What is it?
Based on ideas that distress is rooted in our response to difficult relationships.
Aims to improve people’s ability to engage more healthily with others.
Psychodynamic therapy
What is it?
Explores emotions, beliefs and early-life experiences to uncover and remedy the unconscious thoughts which lie behind mental illness.
What is St Johns Wort?
Why is used discouraged?
Herbal remedy for depression
It can affect the metabolism of drugs (e.g. reducing the effectiveness of contraceptive pill)
ECT:
What does it stand for?
What situation is it used in? - 3
Side effects
Contraindications?
Electroconvulsive Therapy (ECT)
For life treatment-resistant or life-threatening severe depression
Treatment-resistant mania
Catatonic schizophrenia
Memory loss
Headache
Myalgia
Cardiac pathology - Cardiac surgery, valve disease, AAA
