depression and anxiety case Flashcards
what are the risk factors associated depression
- Gender ~ females: higher during reproductive yrs then trend reverses
- Age ~ predicted changes in recent decades – younger onset shorter duration, less frequent in elderly but some increases now coming through.
- Marital status ~ highest in separated, then widowers then divorced females.
- Socio-economic factors ~ social class 3 higher incidence than 1,2. Higher in rented accommodation, highest in street (roofless) homeless
- Ethnicity ~ Females: highest in Asian / South East Asian, then Whites lowest amongst West Indian / African.
- Males: No differences.
what are the 3 classifications
Sub-threshold: Fewer than 5 symptoms
Mild: Few, if any, symptoms in excess of the 5 required to make the diagnosis and symptoms result in only minor functional impairment.
Moderate: Symptoms or functional impairment are between ‘mild’ and ‘severe’
Severe: Most symptoms and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.
Symptoms must be present for two weeks.
what are the key 3 symptoms for depression?
- LOWERED MOOD (also referred to as ‘affect’)
- ANERGIA (Think: what does the prefix ‘a’ or ‘an-’ denote?) lack of energy
- ANHEDONIA (think opposites! What is a hedonist?)- no longer take pleasure of what they used to do
what are the other symptoms associated with depression?
- Weight changes (can go up as well as down)
- Changes in sleep pattern ~ examples? Insomnia, sleeping in excess, disrupted sleep. Lowest level of cortisol leads to more depression. People with asthma will have IV hydro cortisol.
- Agitation / anxiety / somatisation
- Psychomotor retardation
- Psychotic features ~ delusions / hallucinations: note: these will be mood congruent
- Sexual dysfunction (essential to take a sexual history prior to any proposed pharmacological intervention ~ why??) many of antidepressants can induce sexual dysfunctions if they already have existing problems
- Decrease in self-esteem, self-confidence
- Feelings of guilt (often either over-valued /exaggerated or overtly delusional), worthlessness
- Self - harm / suicidal ideation / suicide (number of suicides in England + Wales each year?) 6000
what are some of the causes of depression?
• Physical ~ numerous – exacerbates / causation; consider metabolic and other organic causes (everything from chronic pain to poorly-controlled thyroid dysfunction)
• Iatrogenic ~ ‘Now then, who’s prescribed depression this morning?’
The rest can be summed up by the following three words:
Loss and Regret*
…….Of job, status, relationship, health et cetera
‘Have you ever ignored a bill for a week? Yes? Well, ignore them for a year – I’ll save you a bed in St Pats’ (homeless hostel.) The vast majority of us are 6 failed mortgage re-payments away from homelessness.
* ‘I’d trade all my tomorrows for a single yesterday.’
what are the 4 steps that the NICE guidelines say about depression?
Step One: All known and suspected presentations of depression
Step Two: Treatment of persistent sub-threshold depressive symptoms, mild to moderate depression.
Step Three: Persistent sub-threshold or mild to moderate depression that has failed to respond to initial interventions, moderate or severe depression.
ADs should be offered routinely to all patients, before psychological interventions
Step Four: Severe and complex depression; risk to life; severe self-neglect.
what is step 1 from the NICE guidelines of treating depression?
Step One: All known and suspected presentations of depression
Who to assess? Those designated ‘High risk:’
• People with a past history of depression (relapse: 50-85%)
• Significant physical illness causing disability (DM, CHD
MS et cetera)
• Other mental health problems ~ e.g. dementia
Screening questions:
“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?”
( these questions therefore explore / assess key symptoms, duration et cetera)
what is step 2 from what the NICE guidelines say about treating depression?
Step Two: Treatment of persistent sub-threshold depressive symptoms, mild to moderate depression.
Watchful waiting: (NB this is applicable to mild depression only)
If the patient does not want treatment or may recover without further intervention, re-assess in two weeks time.
• Sleep and anxiety management.
• Exercise:
Advise pts of all ages that structured exercise of 45-60mins duration, three times a week for at least 10 -12 weeks has proven benefits in mild depression.
NICE ~ Treatment of Depression
• Guided self-help
• Computerised Cognitive Behavioural Therapy (CBT)
A useful website: www.rcpsych.ac.uk
Other psychological interventions – menu includes:
• CBT
• Cognitive Analytical Therapy
• Interpersonal therapy
• Psychodynamic (psychoanalytic) psychotherapy
what does NICE guidelines say about antidepressants?
Antidepressants (ADs):
• ADs are NOT recommended for the initial treatment of mild depression because the risk : benefit ratio is poor.
(Adverse effects? Yes. Efficacy? Only Possibly)
• When mild depression persists after other interventions (see before) or is associated with psychological or medical problems consider use of an AD
• If a patient with a history of moderate or severe depression presents with mild depression consider (early) use of an AD. (If it remains appropriate – age? Co-morbidities? - then consider re-prescribing, at the treatment dose, the previously effective AD)
what does step 3 say in the NICE guidelines about the treatment for depression
Step Three: Persistent sub-threshold or mild to moderate depression that has failed to respond to initial interventions, moderate or severe depression.
ADs should be offered routinely to all patients, before psychological interventions
KEY Medication counselling points:
• ‘Addiction’
• Potential side–effects
• Discontinuation symptoms
• Delay in full benefit, length of treatment.
Make available appropriate written information (+?)
Consider referral and collaborative care
what is the monitoring risk for people who have depression?
Monitoring Risk:
• Pts at increased risk of suicide or younger than 30 years; follow up after 1 week.
If high risk of suicide: prescribe a limited number of ADs, consider additional primary support and telephone contact.
• Monitor for (increased) signs of anxiety, agitation and akathisia. If marked or prolonged review use of AD. Consider inter-class ‘switch’ or co-prescription of short-course, low-dose BDZ with frequent review.
what are the drug treatment options for depression?
When a pt fails to respond to the initial AD (SSRI) prescribed then:
Ensure the AD has been taken as prescribed ~ correct dose, frequency, duration etc
• If response at the standard dose is inadequate and side-effects are tolerable consider an increase in dose in line with the SPC.
• If no response after 1 month then consider a switch in AD. If there has been a partial response then postpone decision to switch for 6 weeks.
If an AD is ineffective and / or poorly tolerated and if the decision is made
what are the drug choices for 2nd line antidepressants?
Choices for a second-line antidepressant include: • Another SSRI • SNRI – Venlafaxine, duloxetine • Mirtazapine (NaSSA) • Moclobemide (RIMA) • TCAs ~ avoiding dosulepin
what should be reviewed for people who have severe depression?
Continuing treatment:
Review pts who are not in the high risk grp after 2 weeks then every 2-4 weeks thereafter for first 3/12.
For pts with a moderate or severe depressive episode continue ADs for 6/12 after remission has been attained.
After 6/12 from remission, review need for continued treatment based on: number of previous episodes, age, residual symptoms and concurrent psychosocial difficulties.
what other antidepressants choices are available?
Choice of Antidepressants:
• An SSRI (examples?) should be prescribed as first choice. As effective as TCAs (examples?) and less likely to be discontinued because of side effects/ toxicity (See later)
• If agitation / anxiety / akathisia occurs + persists either change AD or prescribe a benzodiazepine short-term and r/v in 2 wks.
• St John’s wort* ~ not recommended by NICE; there is a lack of evidence of efficacy in moderate / severe MDD. SJW is known to have numerous, clinically significant pharmacokinetic and pharmacodynamic drug-drug interactions.
what does the NICE guidelines say about st john worts?
Although there is evidence that St John’s wort may be of benefit in mild or moderate depression, practitioners should:
• not prescribe or advise its use by people with depression because of uncertainty about appropriate doses, persistence of effect, variation in the nature of preparations and potential serious interactions with other drugs (including oral contraceptives, anticoagulants and anticonvulsants)
• advise people with depression of the different potencies of the preparations available and of the potential serious interactions of St John’s wort with other drugs.
what should a healthcare professional do/advise if a patient decides to stop antidepressants?
Stopping Antidepressants:
• Inform pts about the possibility of discontinuation symptoms on stopping / reducing or missing doses.
• Advise pts to take meds as prescribed.
• Reduce ADs gradually over a 4 week period.
• If pts experience mild withdrawal symptoms then reassure, if severe then re-introduce and decrement even more gradually.
what does step 4 say in the NICE guidelines say for the treatment of depression?
Step Four: Severe and complex depression; risk to life; severe self-neglect.
Key Points:
• Assess symptoms, suicide risk, treatment history, psychosocial stressors, personality factors and any significant relationship difficulties.
• Re-introduce previous treatments that were inadequately delivered or adhered to.
• Consider ECT, multi-professional and in-patient care
• Crisis resolution teams (CRTs) should be used for pts with severe depression and presenting with significant risk.
what is meant by treatment refractory depression?
This diagnosis is made when patients do not respond to two antidepressants, given sequentially.
70% will respond to the initial AD, of the remaining 30% half of these patients (50%) will respond to the second AD. This leaves a treatment refractory sub-population of 15%.
what are the treatment options for Treatment Refractory Depression
Add Lithium (aim for plasma level of 0.4-1.0mmol/L)
(NICE recommended)
ECT (well established, effective. Poor public reputation)
Venlafaxine at doses >200mg/day (NICE recommended, STARD supported)
Add Tri-iodothyronine; 20-50micrograms/day (well tolerated, TFT essential supported by STARD)
SSRI + Bupropion{up to 400mg/day} ( supported by STARD)
SSRI + Buspirone {up to 60mg/day} (supported by STARD, poorly tolerated)
SSRI or Venlafaxine + Mianserin or Mirtazapine (NICE recommended, risk of serotonin syndrome, mianserin-induced blood dyscrasia)
how do AD work
Concisely; ADs work by increasing the amount of certain chemicals that can influence the working of the CNS. This is the monoamine theory of depression ~ so-called because the chemicals involved are monoamine neurotransmitters, namely Serotonin and Noradrenaline
Early anti-hypertensives depleted / decreased levels of these NTs and people uniformly became depressed.
Anti TB drugs boosted these NTs and people who were depressed ‘got happy’
what are the side effects of antidepressants?
SSRI: Nausea, vomiting, insomnia, anxiety/agitation/akathisia, sexual dysfunction, headache, rarely sedation
TCA: Sedation, dry mouth, blurred vision, constipation, sedation, urinary retention, cardiac irregularities (arrhythmias) and rarely increase in blood sugar, seizures
( See later)
what are the symptoms of AD discontinuation syndrome
– “flu” like symptoms – gastrointestinal – anxiety – sleep disturbance – panic attacks
what is the management if decide to discontinue AD?
- Gradually reduce antidepressant therapy.
- Reassure patient that symptoms will not persist.
- Reassure patient that symptoms are not indicative of a relapse.
what is meant by anxiety?
Anxiety disorders are neither minor nor trivial. These cause considerable distress, are disabling and often chronic in nature.
what are the different subtypes of anxiety?
• Specific phobia • Social anxiety disorder • Generalised Anxiety Disorder (GAD) • Panic Disorder • Agoraphobia • Separation anxiety disorder • Selective mutism Please note that both Obsessive Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) are now considered diagnoses distinct from the anxieties clusters
what is meant by specific phobia?
marked fear or anxiety about a specific object or situation. (Duration; 6/12 +)
Social anxiety disorder
Persistent fear or anxiety about 1 or more social or performance situations that is disproportionate (6/12+)
GAD
Excess worry about a number of events or activities and difficulty controlling this (6/12+)
what is meant by seperation anxiety
Excessive fear or anxiety focussed on separation from home or attachment figures (1/12 in children, 6/12 in adults)
Selective mutism
Consistent failure to speak in social situations when there is an expectation to do so (1/12+)
what is meant by panic disorder?
Recurrent unforeseen panic attacks ~ i.e. an abrupt surge of intense fear (An initial panic attack followed by 1/12 of persistent worry about additional attacks)
• Repeated unpredictable attacks of severe anxiety occurring without warning unrelated to a specific situation
• Can peak within 10 minutes with many somatic / physical symptoms
• Can be combined with GAD or phobic disorders
what is meant by Agoraphobia
Marked fear or anxiety about situations where escape might be difficult (6/12 +)
This anxiety typically leads to a pervasive avoidance of a variety of situations ~ examples include: being alone outside the home or being home alone, being in a crowd of people, travelling by car, bus or plane or being on a bridge or in a lift.
what is the stepped-care model:
Step 1: Focus of intervention; all known + suspected presentations of GAD.
Nature of intervention; identification + assessment; education about GAD and treatment options; active monitoring.
Step 2: Diagnosed GAD that has not improved after education and active monitoring in 1 0 care.
Low intensity psychological interventions; Individual non-facilitated self-help, individual guided self-help and psycho-educational groups.
Step 3: GAD with an inadequate response to step 2 interventions or marked functional impairment.
Choice of a high-intensity psychological intervention (CBT / applied relaxation) or a DRUG TREATMENT
Step 4: Complex treatment-refractory GAD and very marked functional impairment ~ e.g. self neglect or high risk of self-harm.
Highly specialist treatment~ complex drug treatment and / or psychological treatment regimens; MDHT input, crisis services, day hospitals or in-patient care.
what are the risk factors associated with anxiety?
- Family History
- Childhood adversity
- Stressful life events
- Specific personality traits – excessive worrying
- Certain Parenting styles* ~ such as being over-protective, lacking emotional warmth or parents ‘modelling’ fear and avoidance
- Younger age
- Being female, unmarried or unemployed
- Poor physical or mental health
what is meant by generalised anxiety disorder?
- A persistent, excessive anxiety, apprehension or worry present for at least 6 months
- Chronic condition with acute episodes ~ peaks and higher peaks
- Often begins in early adulthood
- Twice as common in women than men
what is phobic disorder
- Phobia is an irrational fear out of all proportion to the situation or object
- Recognised as excessive but cannot be reasoned away.
- Sub-divided into agoraphobia, social phobia and simple specific phobia
what are some of the most common type of phobias?
1) Arachnophobia-spiders
2) Ophidiophobia-snakes
3) Acrophobia- heights
4) Agoraphobia (see previous)-
5) Cynophobia-dogs
6) Astraphobia-thunder and lightening
7) Trypanophobia-needle
8) Social phobias
9) Pteromerhanophobia- flying
10) Mysophobia- germs
what is meant by obsessive compulsive disorder?
- A time consuming obsession and compulsion which interferes with a persons day to day functioning, work or relationship
- If compulsion is resisted anxiety levels are increased
- Life time prevalence of 2%
- Males and females equally affected
what is meant by post traumatic stress disorder?
- Intense and prolonged can be delayed response to a particular trauma
- Characterised by emotional numbness, detachment, flashbacks, recurring memories and vivid dreams.
- Do not have to be personally involved can be a bystander or rescue worker
what is meant by Mixed disorders
• Both anxiety and depression present
It is essential therefore to consider the differing signs and symptoms presenting.
Global assessment scales should be used to provide objective measures to confirm diagnosis, assess / assign severity and monitor response to treatment interventions.
A variety of interventions both pharmacological and psychological may need to be initiated, optimised and monitored on an on-going basis.
what is the mechanism of anxiety?
2 brain systems involved in fear and anxiety:
• Defence system- responds to both learned and unlearned threats; can initiate fear, flight, fight or freeze behaviour
• Behavioural inhibition system- Responsible for avoidance behaviour - a neurobehavioral system thought to regulate negative affect and avoidance behaviour in response to threats or punishment. Individuals vary in the sensitivity of the system (refer to work by Kagan et al from 1984.)
what is the general management of anxiety disorder
- Shared decision making between the patient and individual promotes concordance and optimises outcomes
- Appropriate and usable information should be given to patients, carers, family members etc; medication information must be included
- Pts families etc should be informed of all appropriate self-help, support groups etc.
what is the treatment options
Discuss in a full and frank manner with the patient and his/her family / carers etc and give the following menu:
• Self-help
• Psychological therapy
• Pharmacological therapy
what is the pharmacological treatment for anxiety
If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI).
Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication*. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions.
Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the ‘British national formulary’ on the use of a benzodiazepine in this context (see following slide)
Do not offer an antipsychotic for the treatment of GAD in primary care.
Sertraline therapeutic indication
- Major depressive episodes. Prevention of recurrence of major depressive episodes.
- Panic disorder, with or without agoraphobia.
- Obsessive compulsive disorder (OCD) in adults and paediatric patients aged 6-17 years.
- Social anxiety disorder.
- Post traumatic stress disorder (PTSD).
what are the pharmacological treatments options
- Benzodiazepines
- Anti-depressants
- Anxiolytics – Buspirone
- Pregabalin
- Antipsychotics
- Beta-blockers
- Antihistamines
What is the MoA for Benzodiazepines
- Act on postsynaptic GABA-A receptors
- Responsible prescribing with appropriate monitoring ensures maximal benefit from BDZs as therapeutic agents.
- BDZs have been proven to be efficacious in certain situations for selected patients.
- Examples of this would include use as immediately acting agents for severe symptom control while awaiting other treatment to work and to ensure other treatments can be accessed ~ eg: CBT, IPT, ‘flooding’ / exposure etc
what is the benzodiazepine indications?
Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness.
The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.
Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or causing the patient extreme distress.
MoA Selective Serotonin Reuptake Inhibitors (SSRIs)
- Inhibits reuptake of serotonin at post synaptic receptor site
- Increase central serotonergic activity
- ‘Onset of action may not appear for 6 weeks and the full response may take 12 weeks’ ~ discuss.
how does serotonin play a key role in the mode of action of SSRIs, SNRIs and certain TCAs
Serotonin (5-HT) plays a key role in the mode of action of SSRIs, SNRIs and certain TCAs.
5-HT facilitates defensive responses to potential threat (e.g. inhibitory avoidance) related to presentation of anxiety.
This action would be exerted at the forebrain – chiefly the amygdala and medial prefrontal cortex.
Chronic administration of antidepressants suppress panic attacks by increasing the release of 5-HT and enhances the response of 5-HT1A and 5-HT2A receptors in the midbrain (DPAG). The efficacy against generalised anxiety is thought to be due to desensitisation of 5-HT2C & to a lesser extent increased stimulation of 5-HT1A in the forebrain which results in less activation of the amygdala, medial PFC and insula by ‘warning signals.’
(This has been shown using functional neuroimaging in healthy volunteers and pts with anxiety disorders)
other treatments for anxiety
- Beta-Blockers – only treat somatic or physical symptoms (consider tolerability versus efficacy, relative and absolute contra-indications) eg propranolol
- Buspirone – complex mode of action (partial 5HT 1A agonist, acts on both Noradrenergic and Dopaminergic pathways) takes time to work (1/12 minimum) better than placebo, worse than BDZ in terms of efficacy and tolerability (drug interactions with cyp 450 3A4 inducers + inhibitors)
- Sedating Antihistamines ~ e.g. high dose Hydroxyzine (not recommended, following Cochrane systematic review of 2010)
MoA of Pregabalin
Pregabalin binds to an auxiliary subunit (α2-δ protein) of voltage-gated calcium channels in the central nervous system, this causes conformational changes thereby reducing excitatory neurotransmission.
Relatively rapid onset of action, excreted unchanged (P’kinetic drug interactions therefore minimal)
Reduce dose in patients with renal impairment
Use when SSRI / SNRIs not tolerated – could consider as adjunct.
Monitor for misuse (10% of patients prescribed versus neuropathic pain report euphoria; rescheduled to CD3 from April 1st 2019)
what other treatment
• Antipsychotics – specifically used in PTSD and, occasionally in OCD ~ examples include SGAs such as Olanzapine, Risperidone and Quetiapine. NOT for routine use in GAD
• Other treatment options used in Social Anxiety Disorder and PTSD include valproate and carbamazepine.
Evidence base for the above is weak and in all cases the pharmacological treatment options should form part of the overall care package that also incorporates psychological interventions.
what is meant by schizophrenia?
Schizophrenia is a syndrome characterised by a broad range of cognitive, emotional and behavioural problems
what is the ‘first rank’ symptoms
- Auditory Hallucinations:
• Voices repeating the subjects own thoughts
• Two or more hallucinatory voices discussing the subject / arguing in the third person
• Voices giving a running commentary on the subjects thoughts or behaviours.
Hallucinations; perceived in the absence of stimuli. - Thought insertion or withdrawal
- Thought broadcast
- Feelings, impulses or acts being experienced or carried out under external control ~ the patient feels therefore that he has become hypnotised or a robot
- Being a passive & reluctant recipient of bodily sensations imposed by some external agency
- Delusional perception.
Delusions: fixed (certainty) false (impossible, untrue, bizarre) beliefs that no amount of proof to the contrary will alter (incorrigibility)
what are the positive and negative clinical aspects of Schizophrenia
Positive symptoms:
• Hallucinations, delusions.
• Disorganised speech / formal thought disorder.
• Disordered / catatonic behaviour.
Negative symptoms: These relate to the loss of normal functions; • Flattening or blunting of affect • Alogia (reduced production of speech) • Emotional apathy • Social withdrawal • Lack of motivation • Loss of pleasure (anhedonia)
what is the diagnosis summary for Schizophrenia
• Positive symptoms ~ hallucinations, delusions, thought disorders
• Negative symptoms ~ reduced self-care, motivation, anhedonia, alogia, affective blunting
• Reduced social functioning
There should be an absence of mood disorder ~ mania / depression
what are the clinical aspects of Schizophrenia
Aetiology of Schizophrenia:
Clinically, schizophrenia is heterogeneous so the aetiology is likely to be heterogeneous.
Putative causes may include:
• Genetic disorders (consider mono-zygotic twins)
• Neurodevelopment problems (age of onset)
• Neurochemical imbalances (drug misuse)
• Psychosocial stressors (‘S/he was really stressed out’)
more clinical aspects Schizophrenia ~ clinical aspects
The course of the illness is highly variable and is influenced by the psychosocial environment of the individual.
Schizophrenia can follow a relapsing and remitting course or it can be chronic and progressive.
The chronic, progressive course occurs particularly in individuals who have a later onset of the disease.
Prevalence: total number of cases in the population at a given time divided by the number of individuals in the population
Incidence: measures the risk of developing the disease within a specified time frame ~ a month? A year? A lifetime?
what is the prognosis of Schizophrenia
Most common form of presentation is an initial acute episode with florid positive symptoms followed by the emergence + persistence of negative symptoms.
Studies suggest the following:
• 20% of patients with schizophrenia recover fully.
• 70% have relapsing / remitting disease.
• 10% are seriously disabled by the disease.
what is the classification of Schizophrenia?
Paranoid schizophrenia
Catatonic schizophrenia
Simple schizophrenia
Undifferentiated schizophrenia
what is meant by Paranoid schizophrenia:
Paranoid delusions, auditory hallucinations & perceptual disturbances.
