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.