Depression

Question 1

What two questions should you ask to screen for depression?

Answer 1

In the last two weeks, how often have you been troubled by:

• Feeling down depressed or hopeless (depressed mood)
• Loss of interest or pleasure in doing things (anhedonia)

This is the PHQ2 screening questionnaire

Score 0 for not at all, 1 for some days, 2 for more days than not, 3 for nearly every day

A score of 3 is 80%+ sensitive for major depression, 60% sensitive for any depressive disorder

Question 2

How do you confirm the diagnosis of depression?

Answer 2

5 symptoms of SAD-FACES (but must include 1 major - anhedonia and low-mood).

Suicidal

Anhedonia - find no pleasure in doing anything

Depressive mood

Fatigue

Anorexia

Concentration difficulties

Esteem low/guilt

Sleep difficulty

Psychomotor retardation

Question 3

Depression - PRICMCP (brief)

Answer 3

P: when

R: FH, chronic illnesses, medications (alcohol, steroids, propranolol, interferon), female

C: work, medical adherence, relationship, previous suicidal***

M: current Tx, any non-pharm measures before (e.g. counselling/CBT)

Current: PHQ2

Question 4

What are the 2 DDx for depression? (excluding organic)

Answer 4

Dysthymia - fluctuant mood, ≥2y induration, but does not meet the criteria for major depression

Adjustment disorder/Reactive depression: period of emotional disturbance which interferes with social functioning - often follows a life-event.

Question 5

What is your approach to managing this patient’s depression?

Answer 5

Multidisciplinary & multimodal approach

Goals: improve mood, function, prevent complications including medical non-adherence

Confirm dx: DSM-V criteria

A: screen & rule out secondary causes - hypothyroid, substance abuse, B12 deficiency, cognitive impairment.

T: Non-pharm

• *** Address social determinants of depression - e.g. income, housing, domestic violence
• Lifestyle changes: ETOH moderation, smoking cessation, exercise, good sleep hygiene (David caffeine), healthy-balanced diet, body-mind programs like Yoga
• Engage family & friends for their support
• Community groups, peer/support groups
• Inform them of resources: Lifeline (crisis support), Black dog institute (general MH support)
• Counselling - structural problem solving & stress management
• CBT: medicare subsides 10 sessions - identify, challenge, modify maladaptive thoughts/behaviours

T: Pharm

• For moderate-severe depression use psychological + pharmacological therapy
• Choice
  
  • Mirtazapine for weight gain
  • TCA/SNRIs for chronic pain
• ECT for refractory disease

Involve: family, friends, GP and psychiatrist

Ensure F/U and review of progress & complications (including QTc prolongation, sexual dysfunction with medications)

Question 6

What is a good antidepressive agent if patient is malnourished/under weight?

Answer 6

Mirtazapine for Mass gainint

Good for sleep and appetite stimulation → weight gain

Question 7

TCA main side effects (3)?

Answer 7

Anticholinergic side effects (dry mouth, blurred vision, constipation, urinary retention)

Prolonged QRS

Lowers seizure threshold

Question 8

What are some of the common side effects of SSRIs and SNRIs? (4)

Answer 8

Central: Lower seizure threshold, insomnia, sedation

GI: nausea, vomiting, constipation

Sexual dysfunction (loss of libido, anorgasmia)

Hyponatraemia (SIADH)

Question 9

What medications can lead to depressive symptoms (or worsen existing depression)? 3

Answer 9

Steroids

Interferons

Beta-blockers: especially non-selective ones (e.g. propranolol)

Question 10

How might you address social determinants of mental health in a depressed long case patient? (4)

Answer 10

• Address housing concerns – supported accommodation application, transfer to more appropriate accommodation etc
• Address income concerns – difficult! Disability support pension is NOT a good answer as it may exacerbate mood and feelings of hopelessness. Consider referral to employment services, discuss (re)training options or career change if indicated; enlist family or friends if possible
• Take an interpersonal violence history and refer for domestic violence support if present
• Assess nutrition and refer for/commence intervention (thiamine, B12 and other supplementation; reduction in sugar and processed foods)

Question 11

Which antideppressant would you use for obese people?

Answer 11

SNRI generally are the best, better than SSRIs. Minimal weight gain. Avoid Mirtazapine (worst for weight gain)

Duloxetine (also good for back pain)

Venlafaxine (but causes ++ sexual dysfunction)