Depression Flashcards
What are the symptoms fo depression?
Duration of 2 weeks Reduced concentration Loss of interest and enjoyment (anhedonia) Reduced confidence and self-esteem Reduced energy (anergia) Ideas of guilt and unworthiness Pessimism about the future Ideas/acts of self-harm/suicide Disturbed sleep Changes in appetite Low mood
What is the somatic syndrome?
Markedly reduced appetite
Weight loss (>5% of normal body weight in 1 month)
Early morning wakening (at least 2 hours before usual time)
Diurnal variation in mood (depression worse in the morning, improving through the day)
Psychomotor retardation/agitation
Loss of libido
Marked anhedonia
Lack of emotional reactivity
What are psychotic symptoms that can occur with depression?
Delusions:
Tend to be mood congruent i.e. their content is in line with low mood. Worthlessness, guilt, ill health, poverty, imminent disaster. Nihilistic
Hallucinations:
2nd person auditory, olfactory (decomposing flesh)
What is a mild depressive episode?
At least two of the three core symptoms
Plus additional symptoms, giving a total of at least four
With or without the somatic syndrome
What is a moderate depressive episode?
At least two of the three core symptoms
Plus additional symptoms, giving a total of at least six
With or without the somatic syndrome
What is a severe depressive episode?
All three core symptoms
Plus additional symptoms, giving a total of at least eight
What is a severe depressive episode with psychotic symptoms?
All three core symptoms
Plus additional symptoms, giving a total of at least eight
Plus delusions, hallucinations or depressive stupor
What are organic differentials for depression?
Neurological: Multiple sclerosis, Parkinson’s disease, Huntington’s disease. spinal cord injury, CVA, head injury, cerebral tumours
Endocrine: Thyroid and parathyroid disorders (especially hypothyroidism), Cushing’s/Addison’s disease
Infections: HIV/AIDS, syphilis, typhoid, brucellosis, infectious mononucleosis, herpes simplex
Iatrogenic: Secondary to prescription of opiates, L-dopa, steroids
Others: Malignancies (especially pancreatic), SLE, rheumatoid arthritis, renal failure, porphyria
What is the epidemiology of depression?
M:F = 1:2
Lifetime prevalence of depressive symptoms 10 to 20%
Point prevalence of major depressive illness 5%. Of these:
10% are referred to a psychiatrist
0.1% admitted to hospital
What is the aetiology of depression?
Biological: genetics hormonal changes substance misuse serious illness Psychological: negative thoughts learned helplessness psychodynamic defence mechanisms Social: life events social isolation bereavement loss childhood abuse social adversity
What is the prognosis for depression?
50-60% will recover within a year
Chronic depression (more than 2 years) occurs in 10-25%
5-15% will die by suicide
Relapse:
After 1 year, 25% will have had a further episode
After 10 years, 75% will have had a further episode
What is the management for mild/moderate depression?
Low-intensity psychological interventions
Medication - First line treatment would usually be an SSRI, such as citalopram, sertraline, fluoxetine or paroxetine
What is the management for moderate/severe depression?
Medication
High-intensity psychological interventions
Consider secondary care referral
What is the management for severe complex depression?
Secondary care Medication: venlafaxine, an SNRI mirtazapine, a NASSA tricyclics, like imipramine MAOIs, like phenelzine adjunctive medications, such as antipsychotics or lithium High-intensity psychological interventions ECT Crisis Resolution and Home Treatment (CRHT) Multidisciplinary (MDT) approach Inpatient care
How long should treatment be continued to prevent relapse?
Following recovery from a single episode of depression, treatment should be continued for 6 months
Following recovery from recurrent depression, treatment should be continued for 2 years
What are the indications for antidepressants?
Depressive illness (more effective in moderate and severe depression) Anxiety disorders Neuropathic pain Insomnia Bulimia nervosa Impulsivity Migraines Chronic fatigue syndrome Irritable bowel syndrome Narcolepsy
What are commonly used SSRIs?
Fluoxetine Paroxetine Citalopram Sertraline Fluvoxamine Escitalopram
What are the side effects of SSRIs?
Nausea Insomnia Apathy and fatigue Diarrhoea Dizziness Sweating Restlessness (akathesia) Sexual dysfunction Cardiac defects with 1st trimester exposure (Paroxetine)
What are the side effects of SNRIs?
Venlafaxine
Duloxetine
Comparable to SSRIs but patients may notice more sedation and greater discontinuation symptoms when stopped.
What are commonly used TCAs?
Amitriptyline Imipramine Clomipramine Dosulepin Lofepramine
What are the side effects of TCAs?
Antimuscarinic: Dry mouth Blurred vision Constipation Urinary retention Others: Sedation Weight gain Dizziness Hypotension Delirium
What are commonly used MAOIs?
Phenelzine
Tranylcypromine
Isocarboxazid
Moclobemide (reversible MAOI)
What are the side effects of MAOIs?
Dry mouth Nausea, diarrhea or constipation Headache Sleep disturbance Postural Hypotension significant interaction with certain food (tyramine containing food - cheese reaction)
What are the side effects of NaSSA?
Mirtazapine Sedation Weight gain and increased appetite Drowsiness Dizziness Headache
What is St Johns wort?
unlicensed herbal remedy for the treatment of depression
Induces cytochrome P450 leading to loss of therapeutic effect of:
Oral contraceptive
Digoxin
Warfarin
HIV protease inhibitor
Anticonvulsants (e.g phenytoin, carbamazepine)
What are withdrawal symptoms associated with antidepressants?
dizziness, numbness, tingling, nausea, vomiting, headache, sweating, anxiety, sleep disturbance, strange dreams, shaking and electric-shock like sensations.
More common with paroxetine and venlafaxine
Taper dose gradually over a period of least 4 weeks
In which order are antidepressants most likely to cause weight gain?
NaSSA (most)
TCA
SSRI/SNRI (no effect)
In which order are antidepressant most likely to cause sexual dysfunction?
SSRI (most)
SNRI and TCA
NaSSA
