Depression Flashcards
The following two questions can be used to screen for depression
‘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?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
There are many tools to assess the degree of depression including
Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
Hospital Anxiety and Depression (HAD) scale
consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Patient Health Questionnaire (PHQ-9)
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
NICE use the DSM-IV criteria to grade depression:
1-9
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Define Subthreshold depressive symptoms
Fewer than 5 symptoms
Define Mild depression
Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
Define Moderate depression
Symptoms or functional impairment are between ‘mild’ and ‘severe’
Define Severe depression
Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms
Persistent subthreshold depressive symptoms or mild to moderate depression
General measures
sleep hygiene
active monitoring for people who do want an intervention
Persistent subthreshold depressive symptoms or mild to moderate depression - drug treatment is first line
false
do not use antidepressants routinely but consider them for specific people
Persistent subthreshold depressive symptoms or mild to moderate depression - drug treatment indicated in
a past history of moderate or severe depression or
initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or
subthreshold depressive symptoms or mild depression that persist(s) after other interventions
if a patient has a chronic physical health problem and mild depression complicates the care of the physical health problem
low-intensity psychosocial interventions may be useful in persistent subthreshold depressive symptoms or mild to moderate depression - these include
Individual guided self-help based on CBT principles - (Includes behavioural activation and problem-solving techniques)
Computerised CBT
group-based CBT
A structured group physical activity programme
Individual guided self-help based on CBT principles should include?
include written materials (or alternative media)
be supported by a trained practitioner who reviews progress
consist of up to 6-8 sessions (face-to-face and by telephone) over 9-12 weeks, including follow-up
Computerised CBT should include?
explain the CBT model, encourage tasks between sessions, and use thought-
challenging and active monitoring of behaviour, thought patterns and outcomes
be supported by a trained practitioner who reviews progress and outcome typically take place over 9-12 weeks, including follow-up
A structured group physical activity programme should include?
Interventions should:
typically consist of 3 sessions per week (lasting 45 minutes to 1 hour) over 10-14 weeks
Group based CBT should include?
be based on a model such as ‘Coping with depression’
be delivered by two trained and competent practitioners
consist of 10-12 meetings of 8-10 participants
typically take place over 12-16 weeks, including follow-up
For patients with chronic physical health problems NICE also recommend considering a group-based peer support programme:
focus on
focus on sharing experiences and feelings associated with having a chronic physical health problem
consist typically of 1 session per week over 8-12 weeks
for Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
The following ‘high-intensity psychological interventions’ may be useful
Individual CBT
Interpersonal therapy (IPT)
Behavioural activation
Behavioural couples therapy
counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression; offer 6-10 sessions over 8-12 weeks
short-term psychodynamic psychotherapy for people with mild to moderate depression; offer 16-20 sessions over 4-6 months
For patients with chronic physical health problems the following should be offered:
group-based CBT
individual CBT
Describe delivery of Interpersonal therapy (IPT)
typically 16-20 sessions over 3-4 months
for severe depression, consider 2 sessions per week for the first 2-3 weeks
Describe delivery of Behavioural activation
typically 16-20 sessions over 3-4 months
consider 3-4 follow-up sessions over the next 3-6 months
for moderate or severe depression, consider 2 sessions per week for the first 3-4 weeks
Describe delivery of Behavioural couples therapy
typically 15-20 sessions over 5-6 months
Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
For these patients NICE recommends an antidepressant - normally a ?
selective serotonin reuptake inhibitor, SSRI
currently the preferred SSRIs
fluoxetine
citalopram
sertraline is useful
post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
SSRIs should be used with caution in
children and adolescents
SSRI most common side effect
gastrointestinal symptoms
SSRI there is an increased risk of
gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
SSRI patients should be counselled
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
SSRI higher propensity for drug interactions
fluoxetine and paroxetine
Citalopram should noe be used in
those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
Citalopram max dosage?
maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
Citalopram QT prolongation is/is not dose dependent
is dose dependent
SSRI drug interactions
NSAIDs warfarin / heparin aspirin triptans monoamine oxidase inhibitors (MAOIs)
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs
true
but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering
mirtazapine
SSRIs & what increase risk of serotonin syndrome
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after
2 weeks
For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.
If a patient makes a good response to antidepressant therapy they should continue on treatment for at least
6 months after remission as this reduces the risk of relapse.
When stopping a SSRI do what?
dose should be gradually reduced over a 4 week period
(this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
SSRI Discontinuation symptoms
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
SSRIs and pregnancy first trimester
gives a small increased risk of congenital heart defects
SSRIs and pregnancy third trimester
can result in persistent pulmonary hypertension of the newborn
Paroxetine has an increased risk of
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
Serotonin and noradrenaline reuptake inhibitor (SNRI’s) are
class of relatively new antidepressants. Inhibiting the reuptake increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects.
SNRI examples
venlafaxine and duloxetine.
SNRI used for?
major depressive disorders, generalised anxiety disorder, social anxiety disorder and panic disorder and menopausal symptoms.
Mirtazapine is an antidepressant that works by
blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.
Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in
older people who may be affected more or be taking other medications
side effects of mirtazapine
sedation and an increased appetite
Side effects of mirtazapine can be beneficial in older people
True
sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.
mirtazapine generally take when
generally taken in the evening as it can be sedative.
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose
true
TCA used widely in the treatment of
neuropathic pain, where smaller doses are typically required.
TCA common side effects
drowsiness dry mouth blurred vision constipation urinary retention lengthening of QT interval
TCAs that are more sedative
Amitriptyline
Clomipramine
Dosulepin
Trazodone
TCAs that are less sedative
Imipramine
Lofepramine
Nortriptyline
Choice of tricyclic
low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
lofepramine has a lower incidence of toxicity in overdose
amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first SSRI should be withdrawn* before the alternative SSRI is started
Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exceptions is fluoxetine which should be withdrawn prior to TCAs being started
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly
Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
Electroconvulsive therapy is a useful treatment option for patients with
severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.
ECT cintraindications
The only absolute contraindications is raised intracranial pressure.
ECT short term S/E
headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia
ECT long term S/E
some patients report impaired memory
The risk stratification of psychiatric patients into ‘high’, ‘medium’ or ‘low risk’ can usefully guide decision making
false
review in the BMJ (BMJ 2017;359:j4627) concluded that ‘there is no evidence that these assessments can usefully guide decision making’ and noted that 50% of suicides occur in patients deemed ‘low risk’.
Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide
male sex (hazard ratio (HR) approximately 2.0) history of deliberate self-harm (HR 1.7) alcohol or drug misuse (HR 1.6) history of mental illness history of chronic disease advancing age unemployment or social isolation/living alone being unmarried, divorced or widowed
schizophrenia: NICE estimates that ?% of people with schizophrenia will complete suicide
10%
If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date:
efforts to avoid discovery planning leaving a written note final acts such as sorting out finances violent method
factors which reduce the risk of a patient committing suicide. These include
family support
having children at home
religious belief
SAD should not be treated the same way as depression
false
seasonal affective disorder, you should not give the patient sleeping tablets as this can make the symptoms worse
true
seasonal affective disorder evidence for light therapy is limited
true
SAD mx
mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed
Factors suggesting diagnosis of depression over dementia
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
Non-selective monoamine oxidase inhibitors examples
tranylcypromine, phenelzine
Non-selective monoamine oxidase inhibitors examples used in
used in the treatment of atypical depression (e.g. hyperphagia) and other psychiatric disorder
Non-selective monoamine oxidase inhibitors not used frequently due to side-effects
true
Adverse effects of non-selective monoamine oxidase inhibitors
hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
anticholinergic effects
serotonin and noradrenaline are metabolised by what in the presynaptic cell
monoamine oxidase
