Depression Flashcards
How is severity graded in ICD-10 definition of depression?
4 symptoms = mild
5-6 symptoms = moderate
7+ = severe (+/- psychotic symptoms)
How is severity graded in DSM-IV definition of depression?
Sub-threshold depression (minor depression) = < 5 symptoms from DSM-IV criteria, including ICD-10 mild depressive episodes with only 4 symptoms
Mild MDE = few symptoms, more than the minimum of 5 and mild functional impairment
Moderate MDE = more than minimum of 5 symptoms and moderate functional impairment
Severe MDE = most symptoms are present and marked or greater functional impairment
Which criteria for depression does the PHQ-9 questionnaire base it’s symptoms on?
DSM-IV criteria
What treatment is given to patients with mild depression?
Low-intensity psychosocial intervention:
Individual guided self-help based on CBT principles
Computerised CBT
A structured group physical activity programme
Group-based CBT
Don’t routinely use antidepressants in these patients unless they have:
A past history of moderate or severe depression
Presenting with mild depression for a long time
Symptoms that persist after other interventions
A chronic physical health problem and mild depression complicates care of physical health problem
What treatment should be given in moderate - severe depression?
Antidepressants
High-intensity psychological intervention:
Interpersonal therapy (IPT)
Behavioural activation
Behavioural couples therapy
What antidepressant medications are given to patients with depression?
1st line = SSRIs SNRI (if not responding to SSRI) MAO inhibitors Tricyclic antidepressants Atypical antidepressants Lithium - for suicidal thoughts Electroconvulsive treatment (ECT) - used in severe depression patients that are resistant to multiple antidepressants
What adverse effects are associated with SSRIs?
GI symptoms (most common)
Increased risk of bleeding:
Don’t give if on warfarin (Give mirtazapine instead of SSRI if on warfarin)
If taking NSAIDs, co-prescribe PPI
Anxiety, restlessness, nervousness, insomnia, fatigue, sedation, dizziness
Citalopram and escitalopram increase risk of prolonged QT intervals (don’t give to patients with preexisting QT prolongation or in combination with medications that also prolong QT interval)
Avoid SSRIs if on triptans (used for migraines)
When switching to a different SSRI, how long is the withdrawal period to gradually reduce the dose?
4 weeks
This withdrawal is not necessary with fluoxetine
What is the risk of switching SSRI by withdrawal?
Discontinuation syndrome: Flu-like symptoms Increased mood change Restlessness Difficulty sleeping Unsteadiness Sweating GI problems - pain, cramps, diarrhoea, vomiting Parasthesia
Paroxetine has a higher incidence of discontinuation syndrome
What is the risk of taking too much SSRI or taking medications that interact with SSRI?
Serotonin syndrome: Autonomic dysfunction (hyperthermia, hypertension, tachycardia, tremor, hyperreflexia, agitation, sweating, diarrhoea) Abdo pain Myoclonus Delirium
How do you treat serotonin syndrome?
Stop SSRI
Benzodiazepine for agitation
In severe cases - give cyproheptadine
Active cooling
What side effect of venlafaxine is important to consider?
Prolongation of QT interval
What side effects can occur with MAO inhibitors?
Postural hypotension Weight gain Dry mouth Sedation Sleep disturbance Sexual dysfunction
Hypertensive crisis:
Can occur if MAO-inhibitor taken with tyramine rich foods (e.g. cheese, poultry, alcohol)
What side effects can occur with TCAs?
Lethal in overdose
Lower seizure threshold
Cardiotoxic - prolonged QT
Anticholinergic effects:
Dry mouth, blurred vision, constipation, urinary retention, confusion, cognitive/memory problems
Antiadrenergic effects:
Postural hypotension, tachycardia and sexual dysfunction
Antihistaminic effects:
Sedation and weight gain
What factors can increase the risk of suicide?
Male Hx of self-harm Alcohol or drug misuse Hx of mental illness e.g. depression, schizophrenia, Hx of chronic disease Advancing age Unemployment or social isolation/living alone Being unmarried, divorced or widowed
