Depression Flashcards
Differential Diagnoses for depression
Recent bereavement Alcohol/substance misuse parkinsons dementia eating disorders Anaemia- check FBC hypothyroidism anxiety bipolar psychosis
Measurements which can be used to classify severity
Patient health questionnaire 9, hospital anxiety and depression scale
Assessment of suicide risk
patients under the age of 30 seen ONCE a week until considered a lower risk
patients over 30 2-4 weekly review
Ask some questions
Treatment for mod-severe depression
Trial SSRI - fluoxetine, sertraline over at least 6 weeks. If no response then switch.
Treatment for 1st episode
6 months after symptoms resolve (12 in elderly)
Chronic/recurrent treatment
2 years and lifelong for some
What should be counselled on when initiating antibiotic?
S/Es Time till efficacy duration withdrawal effects and time of follow up consider adding benzodiazepine if anxiety increase SSRIs
Choice of antidepressant in underlying CVD
SSRI, mirtazapine
Choice of antidepressant - Suicide risk
fluoxetine, sertraline, mirtazapine (avoid TCAs, venlafaxine)
Choice of antidepressant - Seizures risk
sertraline - with monitoring
AVOID fluoxetine
Choice of antidepressant in pregnancy
Evaluation of clinical need vs risk Avoid in 1st trimester if possible lowest effective dose unproven that there is teratogenic risk https://www.medicinesinpregnancy.org/bumps/monographs/USE-OF-SERTRALINE-IN-PREGNANCY/
Choice of antidepressant in breastfeeding
Case by case
AVOID lithium and fluoxetine
At risk of anticholinergic side effects
SSRI, mirtazapine, venlafaxine
particularly elderly at risk
Choice of antidepressant in those requiring sedation
without cardiac risk:TCA, mirtazapine
cardiac history, suicide risk: mirtazapine
Choice of antidepressant in those with sexual dysfunction
mirtazapine
AVOID SSRIs
SSRIs pros + cons
Pros - less sedating, lower risk in OD
Cons - may worsen anxiety in short term, GI side effects, headache, discontinuation phenomena (less likely with fluoxetine)
SSRIs increase risk of GI bleed
TCAs pros + cons
Sedation useful for sleep problems
cons
toxicity in OD
CV S/Es - arrhythmias, postural hypotension, tachycardia C/I heart block
Anticholinergic side effects
Mirtazapine pros + cons
Pros
- sexual dysfunction less common
- less likely to be fatal in overdose
- sedating
Cons
- Increased appetite and weight gain
- may rarely cause blood dyscrasias
SNRI pros + cons
pros
useful for depression accompanied with anxiety
cons
CI in uncontrolled hypertension and in those with ventricular arrhythmias
Symptoms of serotonin syndrome - descending in severity
Restlessness excessive sweating tremor shivering myoclonus confusion convulsions death
Discontinuation symptoms
TCAs - flu-like, insomnia, excessive dreaming. Movement disorders, mania, cardiac arrhythmias
SSRIs - flu-like, electric shock like, dizziness, insomnia, excess vivid dreaming, irritability, crying spells
Higher risk antidepressants for discontinuation symptoms
paroxetine, venlafaxine
Counselling points SEs
akasthisia (restless feeling) suicidal ideas, agitation and anxiety
