depression

Question 1

what are the symptoms of depression that are exhibited?

Answer 1

indecisiveness

disturbed sleep

fatigue

increased appetite

Question 2

what further questions should Amy be asked initially?

Answer 2

persistent sadness/ low mood

loss of interests or pleasure

agitation or slowing of movements

feelings of worthlessness or inappropriate guilt

suicidal thoughts or acts

Question 3

what are the criteria for major depressive disorder/depression?

Answer 3

can be mild, moderate, severe

NICE guidelines use DSM-IV criteria

at least 1 of the key symptoms most days, most of the time for at least 2 weeks:

• persistent sadness or low mood
• marked loss of interests or pleasure

4 or more associated symptoms as well as one key:

• disturbed sleep
• changes in appetite or weight gain
• fatigue/loss of energy

Question 4

what other questions should be asked to determine risk?

Answer 4

thoughts and/or actions related to:

• self-harm (most commonly happens in young females 17-19 yrs)
• suicide (most commonly happens in middle aged males 40-59 yrs)
• harm to others (particularly important in psychosis)

asking about self-harm, suicide etc. does not increase risk of these things happening

Question 5

what 5 things can be considered true when referring to self-harm?

Answer 5

history of self-harm is associated with increased suicide risk

can involve cutting, scratching, burning, hair-pulling - may also take other forms such as punching a wall, banging one’s head against a hard object, getting into fights

self-harm is usually a way of coping with/expressing difficult feelings

suicide is a fatal act of self-harm initiated with the intention of ending one’s own life

Question 6

what is parasuicide?

Answer 6

apparent attempted suicide without the actual intention of killing oneself

Question 7

what are some of the biological factors that contribute to risk of depression?

Answer 7

physical health

metabolic disorders

immune/stress response

neurochemistry

genetic vulnerability

Question 8

what are some of the bio-psycho factors that contribute to risk of depression?

Answer 8

emotions

cognitive factors/IQ

sleep

Question 9

what are some of the psychological factors that contribute to risk of depression?

Answer 9

coping skills

self esteem

attitudes/beliefs

personality/temperament

Question 10

what are some of the bio-social factors that contribute to risk of depression?

Answer 10

diet/lifestyle

drug effects

Question 11

what are some of the social factors that contribute to risk of depression?

Answer 11

culture

financial security

work/school

social support

family circumstances

Question 12

what are some of the psycho-social factors that contribute to risk of depression?

Answer 12

interpersonal relationships

traumatic life events

Question 13

what is ACE?

Answer 13

adverse childhood experiences

experiencing/seeing certain things during childhood can increase risk of certain behaviours/illnesses

Question 14

what high risk behaviours have a strong association with ACE scores?

Answer 14

binge drinking

heavy drinking

smoking

high risk HIV behaviour

depression

disability caused by poor health

use of special equipment because of disability

Question 15

what is bias?

Answer 15

occurs when systematic error is introduced into sampling or testing by selecting or encouraging one outcome or answer over others

can occur at any phase of research
e.g. confirmation bias, selection bias, recall bias

Question 16

what is the difference between clinical and statistical significance?

Answer 16

statistical significance indicates reliability of the study results

clinical significance reflects its impact on clinical practice

“P” value, frequently used to measure statistical significance, is the probability that the study results are due to chance rather than to a real treatment effect

Question 17

what is the monoamine hypothesis?

Answer 17

underlying pathophysiologic basis of depression is depletion in the levels of serotonin, norepinephrine, and/or dopamine (i.e. monoamines) in CNS

Question 18

what are some of the drugs that can result in an anti-depressant effect?

Answer 18

SSRI

post-synaptic serotonin receptor agonist

monoamine oxidase inhibitor

serotonin auto-receptor antagonist

Question 19

what information should be given to people before they start a course of antidepressants?

Answer 19

drugs take several weeks to work

symptoms may worsen initially

need to continue for around 6 months after remission of symptoms

need to wean drugs gradually - if stopped suddenly, may cause side-effects

may interact with several commonly prescribed drugs (tell doctors what medications you are taking?

Question 20

what are the aims of social prescribing?

Answer 20

enable healthcare professionals to refer people to local, non-clinical services - variety of activities typically provided by voluntary or community sector organisations

recognises that health is determined by a range of social, economic and environmental factors - seeks to address needs in a holistic way

aims to support individuals to take greater control of their own health

many different models for social prescribing - most involve link worker/navigator who works with people to access local sources of support

Question 21

how do monoamine oxidase inhibitors work?

Answer 21

monoamine oxidase - breaks down neurotransmitter

inhibition increases amount of neurotransmitter that can be released into the synapse

increases likelihood of neurotransmitter binding to post-synaptic receptor and triggering an action potential

Question 22

how do tricyclic antidepressants work?

Answer 22

increase norepinephrine and serotonin

block re-uptake channels

neurotransmitter stays in synapse for a longer period of time

increases likelihood of neurotransmitter binding to post-synaptic receptor and triggering an action potential

Question 23

how do SSRIs (e.g. Prozac) work?

Answer 23

block very specific serotonin re-uptake channels

neurotransmitter stays in synapse for a longer period of time

increases likelihood of neurotransmitter binding to post-synaptic receptor and triggering an action potential

Question 24

why do monoamine oxidase inhibitors have many side effects?

Answer 24

affect ALL monoamine neurotransmitters (not just in brain, all around the body)

e. g. affects medication metabolism process in liver, need to be careful about drug interactions
e. g. affects digestion of certain foods - fruits, alcohol, dairy etc.

Question 25

what are the side effects of TCAs?

Answer 25

can affect histamines - can lead to fatigue and sluggishness

toxic at higher levels - could cause cardiac arrest if a patient overdoses (intentionally or accidentally)

but usually given for bipolar disorders as other drugs like SSRIs can trigger manic episodes

Question 26

what are the side effects of SSRIs?

Answer 26

sleeping problems

weight gain

sexual dysfunction

(if taken in conjunction with other serotonin inducing medication, can cause serotonin syndrome)

Question 27

what are some newer antidepressants?

Answer 27

selective serotonin and norepinephrine reuptake inhibitor (SSRIs, SNRIs) - work like TCAs

selective norepinephrine and dopamine reuptake inhibitor (NDRIs)

selective norepinephrine and dopamine releasing agents (NDRAs) - inhibit reuptake and stimulate release

Question 28

what is cognitive behavioural therapy (CBT)?

Answer 28

type of talking treatment focussing on how thoughts, beliefs and attitudes affect feelings and behaviour

used for many mental health problems including anxiety, depression, bipolar disorder, OCD, schizophrenia

teaches you coping skills for dealing with different problems.

combines cognitive therapy (examining the things you think) and behaviour therapy (examining the things you do)

Question 29

what is the theory behind CBT?

Answer 29

based on the idea that the way we think about situations can affect the way we feel and behave

interpreting a situation negatively might result in experiencing negative emotions - those might then lead you to behave in a certain way

these patterns might become part of a continuous cycle

CBT works to identify and challenge any negative thinking patterns and behaviour which may be causing you difficulties - in turn this can change the way you feel about situations, and enable you to change your behaviour in future

Question 30

how does negative thinking start?

Answer 30

can start from childhood onwards

e.g. not getting enough attention or praise from your parents or teachers at school - thoughts about worthlessness, uselessness

over time you might come to believe these assumptions, until as an adult these negative thoughts become automatic

this way of thinking might affect how you feel at work, in your general life

Question 31

does social prescribing work?

Answer 31

studies have pointed to improvements in areas such as:

• quality of life
• emotional wellbeing
• mental and general wellbeing
• levels of depression and anxiety

Question 32

what is a practical benefit of social prescribing for the NHS?

Answer 32

reduction in use of NHS services

one study showed reductions in use of A&E attendance, outpatient appointments, inpatient admissions

another showed reduced GP attendance rates

Question 33

what are the isssues with assessing the benefits of social prescribing?

Answer 33

robust and systematic evidence very limited

many studies:

• small scale
• no control group
• focus on progress, not outcomes
• relate to individual interventions rather than social prescribing model

evidence is qualitative and self-reported

difficulty of measuring outcome of complex intervention, making meaningful comparisons between different schemes

hard to determine cost, cost effectiveness and resource implications - contrast between short term and long term

Question 34

how does social prescribing fit in with wider health and care policy?

Answer 34

interest in the model has expanded in the past decade or so although it has been used for longer - more than 100 schemes currently running in the UK (quarter in London)

was highlighted in a 2006 paper as a mechanism for promoting health, independence and access to local services

objectives of social prescribing support the principles set out in NHS policy documents (including the 2014 NHS five year forward view - encourages focus on prevention and wellbeing, patient-centred care, and better integration of services, highlighting role of third sector in delivering services that promote wellbeing)

a 2016 paper emphasised role of voluntary sector organisations (including through social prescribing specifically) in reducing pressure on GP services

social prescribing also contributes to a range of broader government objectives, for example in relation to employment, volunteering and learning.

NICE does not provide guidance on social prescribing specifically, but some of its guidelines relating to mental health include initiatives that could be described as social prescribing activities.

increasing amount of guidance on social prescribing available for commissioners and others in the NHS and local government

new Social Prescribing Network set up to provide support and share practice on social prescribing at a local and national level.

2016 - NHS England appointed a national clinical champion for social prescribing to advocate for schemes and share lessons from successful social prescribing projects