Depression

Question 1

Differential Diagnoses for depression

Answer 1

Recent bereavement
Alcohol/substance misuse
parkinsons
dementia
eating disorders
Anaemia- check FBC
hypothyroidism
anxiety
bipolar
psychosis

Question 2

Measurements which can be used to classify severity

Answer 2

Patient health questionnaire 9, hospital anxiety and depression scale

Question 3

Assessment of suicide risk

Answer 3

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

Question 4

Treatment for mod-severe depression

Answer 4

Trial SSRI - fluoxetine, sertraline over at least 6 weeks. If no response then switch.

Question 5

Treatment for 1st episode

Answer 5

6 months after symptoms resolve (12 in elderly)

Question 6

Chronic/recurrent treatment

Answer 6

2 years and lifelong for some

Question 7

What should be counselled on when initiating antibiotic?

Answer 7

S/Es
Time till efficacy
duration
withdrawal effects and time of follow up
consider adding benzodiazepine if anxiety increase SSRIs

Question 8

Choice of antidepressant in underlying CVD

Answer 8

SSRI, mirtazapine

Question 9

Choice of antidepressant - Suicide risk

Answer 9

fluoxetine, sertraline, mirtazapine (avoid TCAs, venlafaxine)

Question 10

Choice of antidepressant - Seizures risk

Answer 10

sertraline - with monitoring

AVOID fluoxetine

Question 11

Choice of antidepressant in pregnancy

Answer 11

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/

Question 12

Choice of antidepressant in breastfeeding

Answer 12

Case by case

AVOID lithium and fluoxetine

Question 13

At risk of anticholinergic side effects

Answer 13

SSRI, mirtazapine, venlafaxine

particularly elderly at risk

Question 14

Choice of antidepressant in those requiring sedation

Answer 14

without cardiac risk:TCA, mirtazapine

cardiac history, suicide risk: mirtazapine

Question 15

Choice of antidepressant in those with sexual dysfunction

Answer 15

mirtazapine

AVOID SSRIs

Question 16

SSRIs pros + cons

Answer 16

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

Question 17

TCAs pros + cons

Answer 17

Sedation useful for sleep problems

cons
toxicity in OD
CV S/Es - arrhythmias, postural hypotension, tachycardia C/I heart block
Anticholinergic side effects

Question 18

Mirtazapine pros + cons

Answer 18

Pros

• sexual dysfunction less common
• less likely to be fatal in overdose
• sedating

Cons

• Increased appetite and weight gain
• may rarely cause blood dyscrasias

Question 19

SNRI pros + cons

Answer 19

pros
useful for depression accompanied with anxiety

cons
CI in uncontrolled hypertension and in those with ventricular arrhythmias

Question 20

Symptoms of serotonin syndrome - descending in severity

Answer 20

Restlessness
excessive sweating
tremor
shivering
myoclonus
confusion
convulsions
death

Question 21

Discontinuation symptoms

Answer 21

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

Question 22

Higher risk antidepressants for discontinuation symptoms

Answer 22

paroxetine, venlafaxine

Question 23

Counselling points SEs

Answer 23

akasthisia (restless feeling) suicidal ideas, agitation and anxiety