depression

Question 1

Q1: Mrs D is a 63 y.o. woman whose husband died a year ago presents to GP with a hx of feeling tired and unmotivated for several weeks.

her daughter contacted you earlier and had expressed concern that her mother has not been looking after herself properly for a long time.

also stated that her mother had been looking generally unwell.

Mrs D is a smoker, HTN 15 years

(a) you consider Mrs D might be depressed. suggest 2 alternative possible dx that could account for this presentation.

Answer 1

• grief reaction
• dementia
• dysthymia
• organic disorder (e.g. hypothyroidism)
• schizophrenia (-ve sx)
• substance abuse

Question 2

after further examination, you decide she is clinically depressed

(b) list 4 mental state findings that would be sufficient to reach this dx

Answer 2

1. anhedonia
2. anergia
3. persistently low mood
4. nilhilism
5. alexithymia (loss of ability to feel emotion)
6. suicidal thoughts

Question 3

(c) what is the single most important aspect of risk assement to consider first?

Answer 3

suicide risk

Question 4

(d) you decide to prescribe an anti-depressant drug

list 2 factors which would contribute to your choice of drug

Answer 4

1. suicide risk (i.e. no TCAs)
2. co-morbidities
3. drug allergies
4. previous response to anti-depressant therapy (if applicable)
5. existing therapy (if applicable)
6. interactions with current meds

Question 5

(e) which other health care professional would you ask to help with longer follow up?

Answer 5

1. community psychiatric nurse
2. psychologist
3. her GP

Question 6

Q2: 55 y.o. woman presents to psychiatry outpatients with sx of low energy and depression

GP letter explains she is feeling hopeless and has considered killing herself.

(a) hopelessness is the biggest predictor of a single behaviour in depression. what is that behaviour?

Answer 6

attempted suicide

Question 7

(b) on examination, her pulse is slowed and she has possible evidence of a goitre. what single blood test would you undertake and why?

Answer 7

TFTs to exclude/confirm hypothyroidism as the cause of her sxs

Question 8

(c) the blood test comes back within the normal range. other blood tests and physical examination are all normal. after consultation with your senior colleague, you decide to prescribe Fluoxetine, an SSRI.

what advice would you give her about the time it will take for Fluoxetine to begin to work?

Answer 8

SSRIs typically take 2-6 weeks before their effect is felt

Question 9

(d) she responds to this medication.

how long should she continue to take it once she feels better?

Answer 9

6-9 months

Question 10

(e) after 3 months on the medication, her depression worsens. she wishes to continue the fluoxetine.

suggest two medication strategies that can be offered to boost the effectiveness of her tablet.

Answer 10

• increase dosage and check compliance
• add mood stabiliser e.g. lithium
• add 5HT-2 receptor antagonist e.g. mirtazapine (beware serotonin syndrome)

Question 11

(f) in spite of these changes, her depression continues to worsen.

you decide to change her medication to the SNRI, Venlafaxine

how long a washout is recommended in BNF before this can be done?

Answer 11

Current Maudsley guidelines state that there is no need for a withdrawal period and that Venlafaxine can be started immediately after cessation of Fluoxetine.

Question 12

(g) unfortunately, the change is not effective. she becomes acutely suicidal and says she is going to kill herself.

is it necessary to complete a section of the Mental Health Act to prevent her leaving and could you legally detain her in the surgery if this was not completed in time?

Answer 12

yes, under common law nurses in NHS properties may detain someone for 2 hours without completing a form with a further 1 hour given for a Dr to examine the pt

if necessary, an Emergency Detention Certificate (EDC) 72 hours detention form can then be completed

Question 13

Q3: 25 y.o. man complaining feeling stressed at work.

describes feeling useless and incapable and has no interest in usual social activities.

recently moved out of home to live with girlfriend but relationship has just ended.

(a) list 4 potential dx?

Answer 13

1. adjustment disorder
2. organic disorder e.g. hypothyroidism
3. dysthymia
4. depressive illness
5. schizophrenia -ve sx
6. substance abuse

Question 14

(b) list 2 biological (i.e. somatic) symptoms of depression

Answer 14

Reduced CALS:

• concentration
• appetite
• libido
• sleep

Question 15

You think Mr J is suffering from depression and wish to commence him on antidepressants.

(c) What two possible groups of antidepressants could be used and their mechanisms of action

Answer 15

• SSRIs → inhibit 5-HT re-uptake → ↑ 5-HT in synaptic cleft → ↑ receptor binding → ↑ mood
• SNRIs → similar to the above mechanism but also inhibits Noradrenaline re-uptake → ↑ mood
• TCAs → essentially act like SNRIs but also block Ca/Na channels → ↑↑ toxicity in Overdose

Question 16

A review appointment is made for 1/52 but unfortunately Mr J is admitted to hospital with an attempted suicide. His mother finds him unconscious at home. It appears he has taken an overdose of co-
proxamol and has left a suicide note. If his mother had not called by to check on him he may not have been found until the following day. On examination he has pinpoint pupils.

(d) What specific antidote should be given?

Answer 16

N-Acetyl Cysteine

Question 17

(e) What other complication may develop later and should be anticipated?

Answer 17

Liver Failure

Question 18

(f) Give two features that are in favour of this being a serious attempt?

Answer 18

• Left a suicide note
• Attempt made when likely not to be interrupted