Depression (affective disorders)

Question 1

Who does depression affect?

Answer 1

-1 in 4 people in their lifetime
-3rd most common reason for presenting to a GP in the UK

Question 2

What causes depression?

Answer 2

-Can affect anyone
-Having a chronic disease significantly increases the risk
-Women more than men

Question 3

What risk factors are there for depression?

Answer 3

-Female gender (bio-psychosocial factors) - especially during pregnancy and postnatal periods
-Past history of depression / other mental health problems
-Significant chronic / disabling illness
-Psychosocial problems

Question 4

How does depression present?

Answer 4

At least one core symptom most days, most of the time for at least 2 weeks:
-Low mood (can be worst in the morning = diurnal variation)
-Anhedonia
-Anergia
Plus at least 3-4 of associated symptoms:
-Change in appetite / weight loss
-Feelings of worthlessness, guilt
-Diminished concentration
-Insomnia / hypersomnia
-Suicidal ideation

Question 5

What is the classification for mild, moderate and severe depression?

Answer 5

-Subthreshold depressive symptoms = <4 symptoms
-Mild = 4 symptoms, 2 core + 2 other
-Moderate = 5-6 symptoms, 2 core + 3-4 other
-Severe = 7 symptoms, 3 core + 4+ other
NB LEVEL OF FUNCTIONING is key

Question 6

What are the differential diagnoses for depression?

Answer 6

-Bipolar disorder
-Schizophrenia
-Dementia
-Hypoactive delirium
-SAD
-Bereavement
-Organic cause eg hypothyroid
-Adverse drug effects

Question 7

How would you investigate a patient with depression?

Answer 7

-Self-reporting symptom scales eg patient health questionnaire, HAD sclae
-Full H+E, including MSE, enquire directly about thought content / form
-Consider organic causes (FBC, U+Es, LFTs, TFTs, HIV screening)
-RISK ASSESS

Question 8

What treatment would you consider for someone with depression?

Answer 8

STEPPED MANAGEMENT APPROACH
-Mild:
–Consider watchful waiting
–Low-intensity psychosocial interventions guided via IAPT eg self-help CBT, physical activity programmes
–Antidepressants only considered if persistent after other interventions / associated with medical or psychosocial issues, Hx of severe depression - NO EVIDENCE OF EFFICACY IN MD
-Moderate/severe:
–Antidepressants combined with CBT / interpersonal therapy
–Urgent psychiatry referral if instances of suicidal ideation / risk to themselves or others
–ECT

Question 9

What info about antidepressants is good to know?

Answer 9

-2-4 weeks delay in onset of effect
-Increased risk of bleeding so PPIs are often prescribed especially if on blood thinners / NSAIDs
-Review within 2 weeks of commencement (1 week if risk of suicide)
-Consider 1. increasing dose 2. 2nd line SSRI 3. different class of AD if no response after 4 weeks
-Continue for 6+ months after remission, reduce gradually over 4 weeks
-NB they are NOT addictive - no psychological aspect to withdrawal
-Other side effects = dry mouth, headache, sexual dysfunction, tremor

Question 10

What is the first line approach for antidepressant administration?

Answer 10

-1st line = SSRIs - sertraline primarily then fluoxetine, citalopram, paroxetine
-Alternative 1st line = mirtazapine (alpha2-adrenoreceptor antagonist)
-Main reason is because of limited side effects / interactions (sertraline best for this)
-Also less risk of toxicity in overdose