depression Flashcards
what are the risk factors for depression?
Risk factors include
- prior depression
- FH of depression.
- Recent bereavement
- stress
- medical illness may contribute
- older age (>65)
- medications e.g corticosteroids, propranolol, oral contraceptives and interferon
- female
- postnatal status
what can depressive symptoms include?
Depressive symptoms
- depressed mood
- anhedonia
- weight changes
- libido changes
- sleep disturbance
- psychomotor problems
- low energy
- excessive guilt
- poor concentration
- suicidal ideation.
In some cases the mood is not sad, but anxious or irritable or flat.
what characterises a major depressive disorder?
the presence of at least 5 symptoms
can be classified along. spectrum of mild to severe
what can severe major depressive disorders include?
psychotic symptoms such as paranoia, hallucinations, or functional incapacitation.
what characterises sub threshold/minor depression?
the presence of two to four depressive symptoms, including depressed mood or anhedonia, lasting longer than 2 weeks.
what is persistent depressive disorder?
characterised by at least 2 years of three or four dysthymic symptoms for more days than not.
Dysthymic symptoms include depressed mood, appetite change, sleep disturbance, low energy, low self-esteem, poor concentration, and hopelessness.
what is the pathophysiology of depression?
things that can be involved include
- dysregulation of HPA axis, supported by dexamethasone suppression test
- abnormal neurotransmitter conc e.g
1) abnormalities in dopamine may be related to impaired motivation and concentration
2) low levels of noradrenaline (norepinephrine) and dopamine may play a role in the fatigue and hypersomnia
3) impaired noradrenaline and serotonergic regulation may contribute to physical symptoms
what categories can depression be divided into?
Major depressive disorder
Persistent depressive disorder (dysthymia)
Premenstrual dysphoric disorder
Other depressive disorders (due to substance abuse, medication side effects, medical conditions, or other specified or unspecified causes).
what is the major criteria for diagnosis for depression?
depressed mood most of the day, nearly every day for a period of 2 weeks
(for a major depressive episode, need 5 symptoms, for threshold/minor depression, 2-4 other symptoms)
what investigations can be done into depression?
depression is a clinical diagnosis. to rule out any differentials, can do
- metabolic panel
- FBC
- TFT
- Patient health questionnaire 2 (PHQ-2) to screen for depression. consists of 2 questions (Have you felt down/depressed/hopeless over the last 2 weeks and have you felt little interest or pleasure in doing things over the last 2 weeks?)
- Patient health questionnaire 9 (PHQ-9). Classifies symptoms on a scale of 0 (no symptoms)-3 (everyday)
- Edinburgh postnatal depression scale 4-6 weeks post delivery
- Geriatric depression scale
- Cornell scale for depression in dementia
- 24 Hour free cortisol (elevated suggests bushings)
- Vit B12
- folic acid
how should patients be monitored?
- if on medication, follow up in first 2 weeks to address ADR’s, compliance , suicidality, and reinforce educational message
- monitor monthly in person or by telephone. use PHQ-9 to asses changes in symptoms
what are the complications of depression in adults?
1) sexual adverse effects of selective serotonin-reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs)
2) risk of self injurious behaviour
3) undesired weight gain from anti depressants
4) agitation/excessive activation from antidepressants
6) unmasking mania
7) mania due to antidepressant withdrawal
8) antidepressant discontinuation syndrome (abrupt discontinuation after taking for at least 6 weeks)
how can patients with mild depression or sub threshold depressive symptoms be treated in primary care?
consider period of active monitoring
discuss problems and their concerns
provide information about the nature and course of depression
arrange follow up within 2 weeks
how can people with persistent subthreshold depressive symptoms or mild to moderate depression be treated?
Consider offering a low-intensity psychosocial intervention — this is accessed by referral or self-referral to IAPT (Improving Access to Psychological Therapies).
Consider group-based CBT for people who decline low intensity psychosocial interventions.
Avoid the routine use of antidepressants, but consider this for people with:
- A history of moderate or severe depression.
- Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years).
- Subthreshold symptoms or mild depression that persists after other interventions.
- Mild depression that is complicating the care of a chronic physical health problem.
how can people with moderate to severe depression be treated?
offer an antidepressant and a high-intensity psychological intervention. Psychological interventions are accessed by referral or self-referral to IAPT.
The type of intervention offered will depend on the severity of depression, the response to any previous treatment, the likelihood of adherence to treatment and potential adverse effects, and the person’s preferences and priorities.
