Depression Flashcards
1
Q
What are 2 questions that can be used to screen for depression?
A
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
2
Q
What are 2 key assessment tools that can be used to assess the degree of depression?
A
- Hospital Anxiety and Depression (HAD) scale
- Patient Health Questionnaire (PHQ-9)
3
Q
What does the HAD score consist of?
A
14 questions, 7 for anxiety and 7 for depression, each item score 0-3.
Produces score out of 21 for both anxiety and pression
4
Q
How should the results of the HAD score be interpreted?
A
- score out of 21 for both anxiety and depression
- 0-7 normal
- 8-10 borderline
- 11+ case
5
Q
How should you advise patients to answer the HAD scale?
A
encourage to answer the questions quickly
6
Q
What does the PHQ-9 consist of?
A
asks patients over the last 2 weeks, how often have you been bothered by any of the following problems?
- 9 items which can be scored 0-3
7
Q
How should the results of the PHQ-9 be interpreted?
A
- out of 27
- 0-4 none
- 5-9 mild
- 10-14 moderate
- 15-19 moderately severe
- 20-27 severe
8
Q
What are the 9 DSM-IV criteria used by NICE to grade depression?
A
- Depressed mood most of day
- Markedly diminished interest or pleasure in all, or almost all, activities
- Significant weight loss of weight gain when not dieting or decrease or increase in appetite
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings or worthlessness or excessie or inappropriate guilt
- Diminished ability to think or concentrate, or indecisiveness
- Recurrent thoughts of death, recurrent suicidal ideation without specific plan, or suicide attempt or specific plan for suicide
9
Q
How do the 9 DSM-IV criteria translate to a diagnosis or categorisation of depression?
A
- subrethresold symptoms: <5 symptoms
- mild depression: few symptoms in excess of 5 symptoms. only minor functional impairment
- moderate depression: symptoms are between mild and severe
- severe depression: most symptoms, and they markedly interfere with functioning. ± psychotic symptoms
10
Q
What are 3 approaches to the management of subthreshold depressive symptoms or mild depression?
A
- General measures
- Drug treatment
- Low-intensity psychosocial interventions
11
Q
What are 2 general measures to aid the management of persistent subthreshold depressive symptoms or mild to moderate depression?
A
- Sleep hygiene
- Active monitoring for people who do want an intervention
12
Q
What are 4 situations when you should consider the use of antidepressants for subthreshold or mild depression?
A
- Past history of moderate or severe depression
- Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)
- Subthreshold symptoms or mild depression that persists after other interventions
- Chronic physical health problem and mild depression complicates care of the physical health problem
13
Q
What is the general advice about management of mild/subthreshold depression with drug treatment?
A
should not be routinely used
14
Q
What are 4 types of low-dose psychosocial interventions for mild/subthreshold depression?
A
- Individual guided self-help based on CBT principles
- Computerised CBT
- Structured group physical activity programme
- Group-based CBT
15
Q
What are the 2 things that individual guided self-help based on CBT principles includes?
A
- Behavioural activation
- Problem-solving techniques
16
Q
What are 2 things that individual guided self-help based on CBT should include?
A
- Include written materials (or alternative media)
- Be supported by a trained practitioner who reviews progress
17
Q
Over what time course and number of sessions sohuld individual guided self-hep based on CBT occur?
A
- 6-8 sessions (face to face and by telephone)
- over 9-12 weeks, including follow up
18
Q
What are 3 things that computerised CBT should involve for mild/subthreshold depression?
A
- Explain the CBT model
- Encourage tasks between sessions and use thought-challenging and active monitoring of behaviour, thought patterns and outcomes
- Be supported by trained practitioner who reviews progress
19
Q
Over what time should computerised CBT occur?
A
9-12 weeks including follow-up
20
Q
What should structured group physical activity programmes involve for mild/subthreshold depression, in terms of number of sessions and time course?
A
consist of 3 sessions per week (lasting 45 minutes to 1 hour) over 10-14 weeks
21
Q
What are 2 things that group-based CBT should include?
A
- Based on model such as ‘Coping with depression’
- Be delivered by two trained and competent practitioners
22
Q
What group size and over what time course should group-based CBT take place?
A
8-10 participants
consist of 10-12 meetings, over 12-16 weeks including follow up
23
Q
What in an additional intervention that NICE recommend for patients with chronic physical health problems who have mild/sub-threshold depression?
A
- Consider group-based peer support programme
- focus on sharing experiences and feelings associated with chronic health problem
- usually 1 session per week over 8-12 weeks
24
Q
What are 2 key management aspects for unresponsive, moderate or severe depression?
A
- Antidepressant (normally SSRI)
- high-intensity psychological interventions
25
What are 4 forms of high-intensity psychosocial interventions that should be considered to patients with unresponsive, moderate or severe depression?
1. Individual CBT
2. Interpersonal therapy (IPT)
3. Behavioural activation
4. Behavioural couples therapy
26
What do sessions and time frames for individual CBT for unresponsive/moderate/severe depression involve?
* 16-20 sessions over 3-4 months
* 2 sessions per week for first 2-3 weeks
* 3-4 follow-up sessions over next 3-6 months
27
What do sessions and time frames for behavioural activation for unresponsive/moderate/severe depression involve?
* 16-20 sessions over 3-4 months
* 2 sessions per week for first 3-4 weeks
* 3-4 follow up sessions over next 3-6 months
28
What do sessions and time frames for interpersonal therapy (IPT) for unresponsive/moderate/severe depression involve?
* 16-20 sessions over 3-4 months
* for sevre depression, consider 2 sessions per week for first 2-3 weeks
29
What do sessions and time frames for behavioural couples therapy for unresponsive/moderate/severe depression involve?
* 15-20 sessions over 5-6 months
30
If people with unresponsive/moderate/severe depression decline high-intensity psychological interventions what are 2 further options?
1. Counselling - if persistent, subthreshold depresion symptoms or mild to moderate depression
2. Short-term psychodynamic psychotherapy - if mild to moderate
31
Over what time frame and number of sessions should counselling be offered?
* 6-10 sessions over 8-12 weeks
32
Over what time frame and number of sessions should short-term psychodynamic psychotherapy be offered?
16-20 sessions over 4-6 months
33
What are 2 things you should offer to patients with chronic health problems and moderate/severe or unresponsive threshold?
* group-based CBT
* individual CBT
34
What should be done when switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI?
first SSRI should be withdrawn (gradually reduced and stop) before the alternative SSRI is started
35
What should be done when switching from fluoxetine to another SSRI?
withdraw (gradually reduce then stop) then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternatives SSRI
36
How do you switch from an SSRI to a tricyclic antidepressant (TCA)?
**cross-tapering** is recommended (current drug dose reduced slly, whilst dose of new drug is increase slowly)
exception is fluoxetine - withdraw prior to TCAs being started
37
How do you switch from citalopram, escitalopram, sertraline or paroxetine to venlafaxine?
cross-taper catiously; start venlafaxine 37.5mg daily and increase very slowly
38
How do you switch from fluoxetine to venlafaxine?
withdraw (gradually reduce and stop) fluoetine then start venlafaxine at 37.5mg each day and increase very slowly
39
What are 6 factors suggesting diagnosis of depression over dementia?
1. short history, rapid onset
2. biological symptoms e.g. weight loss, sleep disturbance
3. patient worried about poor memory
4. reluctant to take tests, disappointed with results
5. mini-mental test score: variable
6. global memory loss (dementia characteristically causes recent memory loss)
40
What are 6 common side effects of TCAs?
1. Drowsiness
2. Dry mouth
3. Blurred vision
4. Constipation
5. Urinary retention
6. Lengthening of QT interval
41
Which form of TCA has the lowest incidence of toxicity in overdose?
Lofepramine
42
Which 2 types of TCAs are considered the most dagerous in overdose?
amitriptyline and dosulepin (dothiepin)
43
What are the 3 less sedative types of TCA?
1. Imipramine
2. Lofepramie
3. Nortriptyline
44
What does PassMed say is the first line SSRI to choose for depression?
Citalopram or fluoxetine (in practice often sertraline)
45
What is the first line SSRI in patients post-myocardial infarction?
sertraline: more evidence for its safe use in this situation
46
What is the drug of choice for first-line treatment for depression in children and adolescents?
Fluoxetine
47
What are 4 common adverse effects of SSRIs?
1. Gastrointestinal symptoms (most common)
2. Increased risk of GI bleeding; prescribe PPI if also taking NSAID
3. Hyponatraemia
4. Increased anxiety and agitation
48
What SSRI is first choice if the patient has a chronic physical health problem?
Sertraline
49
What additional medication sohuld you prescribe if an SSRI is taken by someone also taking NSAIDs or aspirin?
gastroprotection with PPI
50
What are 2 SSRIs with a higher propensity for drug interactions?
1. Fluoxetine and Paroxetine
51
What is a key risk of citalopram?
QT prolongation
52
What are 3 contraindications to prescribing citalopram/ escitalopram?
1. Those with congenital long QT syndrome
2. Known pre-existing QT interval prolongation
3. In combination with other medicines that prolong the QT interval
53
What are 5 drugs that SSRIs interact with?
1. NSAIDs - if given co-prescribe PPI
2. Warfarin/heparin
3. Aspirin
4. Triptans
5. Monoamine oxidase inhibitors
54
What type of interaction occurs when either triptans or monoamine oxidase inhibitors are prescribed with SSRIs?
increased risk of serotonin syndrome
55
When should patients be reviewed by a doctor following initiation on antidepressant therapy?
after 2 weeks; if \<30 years or at increased risk of suicide, review after 1 week
56
What is the minimum period a patient should continue on antidepressant therapy?
**6 months after remission**, as this reduces risk of relapse
57
How should an SSRI be stopped and why?
gradually reduced over 4 week period (not necessary with fluoxetine)
risk of discontinuation syndrome
58
What are 7 features of SSRI discontinuation syndrome?
1. Increased mood change
2. Restlessness
3. Difficulty sleeping
4. Unsteadiness
5. Sweating
6. GI symptoms: pain, cramping, diarrhoea, vomiting
7. Paraesthesia
59
Which SSRI has a higher incidence of discontinuation symptoms?
Paroxetine
60
How long should you advise a patient that is usually takes for symptoms to improve once they've started antidepressant thearpy?
2-4 weeks
61
What is there a risk of with use of SSRIs in the first trimester of pregnancy?
small risk of congenital heart defects
62
What can use of SSRIs in the third trimester of pregnancy lead to?
Persistent pulmonary hypertension of the newborn
63
Which SSRI has increased risk of congenital malformations when used in pregnancy?
Paroxetine
64
How should you decide whether to use SSRIs in pregnancy?
weigh up benefits and risk to make decision
65
What is the mechanism of action of mirtazapine?
works by blocking alpha 2-adrenergic receptors, which increases the release of neurotransmitters
66
Which group of patients is mirtazapine often a useful antidepressant for and why?
older people, as it has fewer side effects and interactions than many other antidepressants, and older people may be taking many other medications
also sedation and increased appetite can be useful if insomnia and poor appetite
67
What are the 2 main side effects of mirtazapine?
1. Sedation
2. Increased appetite
68
When should mirtazapine generally be taken?
evening - can be sedative
69
How effective is St John's Wort for treating mild-moderate depression?
shown to be as effective as tricyclic antidepressants
70
What is believed to be the mechanism by which St John's Wort works?
thought to be similar to SSRIs, but noradrenaline uptake inhibition has also been demonstrated
71
Why don't nice recommend prescribing or advising St John's Wort?
uncertainty about appropriate doses, variation in the nature of preparations, and potential serious interactions with other drugs
72
What are 2 adverse effects of St John's Wort?
1. Can cause serotonin syndrome - must avoid taking if using other antidepressants
2. Inducer of P450 system so decreased levels of drugs e.g. warfarin, ciclospporin, reduced effectiveness of COCP
73
What are the 2 key examples of SNRIs?
1. Venlafaxine
2. Duloxetine
74
What is the mechanism of action of SNRIs?
inhibit reuptake of sertonin and noradreline, so increases their concentration in the synaptic cleft leading to effects
75
What are 4 types of drug that can cause sertonin syndrome?
1. Monoamine oxidase inhibitors
2. SSRIs (St John's Wort can react and cause it with these)
3. Ecstasy
4. Amphetamines
76
what are 3 features of sertonin syndrome?
1. Neuromuscular excitation (e.g. hyperreflexia, myoclonus, rigidity)
2. Autonomic nervous system excitation e.g. hyperthermia
3. Altered mental state
77
Wat are 3 aspects of the management of serotonin syndrome
1. Supportive including IV fluids
2. Benzodiazepines
3. More severe cases managed using sertonoin antagonists such as cyproheptadine and chlorpromazine
78
What are 6 symptoms of hyponatraemia that may develop with antidepressants?
1. Dizziness
2. Drowsiness
3. Confusion
4. Nausea
5. Muscle cramps
6. Seizures
79
If a patient is at risk of relapse of depression, how long should you advise they continue their antidepressant medication?
2 years
80
What are 3 options if response to antidepressant medication is absent or minimal after 3-4 weeks of treatment with a therapeutic dose of antidepressant?
1. Increase dose in line with product recommendations (if no side effects)
2. Switch antidepressants to SSRI or different SSRI
3. Switch to different class e.g. TCA, lofepramine, trazodone, venlafaxine
81
What are 4 questions to assess whether a patient is at risk of suicide?
1. Do you have thoughts about death or suicide?
2. Do you feel that life is not worth living?
3. Have you made a previous suicide attempt?
4. Is there a family history of suicide?
82
What are 3 things to ask about if someone is identified as at risk of suicide?
1. Plans for suicide
2. Protective factors
3. Factors that increase risk
83
What are 3 questions to ask about plans for suicide?
1. Have you considered a method?
2. Do you have access to the materials?
3. Have you made any preparations (for example, written a note)?
84
What are 2 ways to ask about protective factors against suicide?
1. What keeps you from harming yourself?
2. Is there anything that would make life worth living?
85
What are 11 factors that increase the risk of suicide?
1. Previous suicide attempts or self-harm
2. Active mental illness
3. Family history of mental disorder, suicide or self-harm
4. Male gender
5. Unemployed
6. Physical health problems
7. Living alone
8. Being unmarried
9. Drug/alcohol dependence
10. Feelings of hopelessness
11. Exposure to suicidal behaviour
86
What are 3 high risk groups for suicide?
1. Young and middle-aged men
2. People in contact with the criminal justice system
3. Specific occupational groups, e.g. doctors, nurses, veterinary workers, farmers, agricultural workers
87
What should you do if a person with depression presents considerable immediate risk to themselves or others?
refer urgently to specialist mental health services
88
How can you manage suicide risk if you deem it to be low?
discuss and/or create safety plan with them, detailing steps they would take if their situations deteriorates
