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Depression and suicide risk Flashcards

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1
Q

What is the ICD-10 criteria?

A

Over a 2-week period: Key symptoms (must have at least 2)
3 CORE SYMPTOMS:

  • Persistent low mood
  • Loss of interest or pleasure
  • Fatigue or low energy

If any of above, then ask about:

  • Disturbed sleep
  • Poor concentration or indecisiveness
  • Low self confidence
  • Poor or increased appetite
    Suicidal thoughts or acts
  • Agitation or slowing of movement
  • Guilt or self blame

Episode severity:

4 symptoms = mild
5-6 symptoms = moderate
7+ symptoms = severe (+/- psychotic symptoms)

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2
Q

What is the DSM-5 criteria?

A

Five or mroe of the following over a 2 week period (must have one of *)

  • Depressed mood*
  • Markedly diminished interest or pleasure in all activities*
  • Poor or increased appetite
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness or inappropriate guilt
  • Diminished ability to think or concentrate
  • Recurrent thoughts of death or suicide

Must result in clinically significant distress or impairment of functioning.

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3
Q

What is minor depression, according to DSM-5?

A
  • Sub-threshold depression (minor depression)
    Significant depressive symptoms below the DSM-5 MDD threshold of 5 symptoms, including ICD-10 mild depressive episode with only 4 symptoms
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4
Q

What is a mild-major depressive episode, according to DSM-5?

A
  • Mild-major depressive episode (mild MDE)

Few symptoms beyond the minimum of five and mild functional impairment

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5
Q

What is a moderate MDE, according to DSM-5?

A
  • Moderate MDE

More than the minimum number of symptoms and moderate functional impairment

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6
Q

What is a severe MDE, according to DSM-5?

A
  • Severe MDE

Most symptoms are present and parked or greater functional impairment

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7
Q

What is the grading for episode severity according to ICD-10?

A

At least 2/3 key symptoms

Episode severity:
4 symptoms = mild
5-6 symptoms = moderate
7+ symptoms = severe (+/- psychotic symptoms)

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8
Q

What additional information should you request in a patient history regarding a depressive episode?

A
  • Ask with regards to manic or hypomanic episodes in the past
  • Ask about recent bereavement or loss
  • Many symptoms of depression are normal signs of a bereavement reaction
  • Does the patient suffer from any medical disorders that can cause depression? ex:
    1. Chronic pain
    2. Hypothyroidism
    3. Addison’s disease
    4. Multiple Sclerosis
    5. Diabetes Mellitus
    6. CVD
    7. Drug or substance abuse

Ask about medications - some increase the risk of developing depression:

  • Corticosteroids
  • Beta blockers
  • Statins
  • Oral contraceptives (especially progestogens)
  • Isotretinoin
  • Ask about drug and alcohol abuse, as this can lead to/exacerbate depressive symptoms
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9
Q

Which initial investigations should be performed on a patient with a depressive episode?

A
  • Full history and mental state exam
  • BP and pulse
  • BMI
  • ECG
  • FBC, U&Es, LFTs, TFTs, HbA1c

The above are useful for obtaining a baseline, which will be checked following starting medication.
The bloods will help rule out medical conditions, check for renal or hepatic impairment: increased risk of mood disorders and must be treated
SSRIs and antipsychotics can cause a prolonged QT interval so an ECG is necessary.

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10
Q

What are the common side-effects of sertraline?

A
  • Gastrointestinal upset
  • Dry mouth
  • Drowsiness
  • Mild nausea
  • Decreased sex drive, impotence, or difficulty having an orgasm
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11
Q

What are the less common side-effects of sertraline?

A
  • Urinary incontinence
  • Urinary retention
  • Weight gain
  • Palpitations
  • Tremor
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12
Q

How long should a patient remain on an antidepressant?

A

At a moderately severe level, at least a year, and be regularly reviewed

If a patient still has residual depressive symptoms it would be worth considering a change of treatment in order to resolve the symptoms

Management plans should also include CBT.

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13
Q

How long do antidepressants take to kick in?

A

A delay of 3-6 weeks after a therapeutic dose is achieved before symptoms improve

Continue for at least 6 months after recovery

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14
Q

When should you change antidepressants?

A

If not improvement is seen after a trial of at least 2 months with an adequate dose, switch to another antidepressant or add another agent in.

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15
Q

What are the side effects of tricyclic antidepressants?

A
  • Lower seizure threshold
  • Cardiotoxic (prolongs QTc)
  • Lethal in overdose

Anticholinergic effects

  • Dry mouth
  • Blurred vision
  • Urinary retention
  • Confusion
  • Cognitive/memory problems

Antiadrinergic effects

  • Postural hypotension
  • Sexual dysfunction
  • Tachycardia

Antihistamine effects

  • Sedation
  • Weight gain
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16
Q

What are some examples of tricyclic antidepressants?

A

Imipramine
Clomipramine
Amytriptyline
Doxepin

17
Q

What are some examples of SSRIs?

A 
Fluoxetine
Sertraline
Citalopran
Escitalopram
Paroxetine
18
Q

When are SNRIs given?

A

When a patient does not respond to SSRIs

19
Q

What are some examples of SNRIs?

A

Venlafaxine

Duloxetine

20
Q

How do MAOIs work?

A

They bind to monoamine oxidase and prevent inactivation of norepinephrine, dopamine and serotonin

Lots of side-effects (hypertensive crisis)

21
Q

How do SNRIs work?

A

They inhibit both serotonin and norepinephrine reuptake

22
Q

What is serotonin syndrome?

A
  • Increased, excessive serotonin due to drug interactions leads to autonomic dysfunction, abdo pain, delirium, CV shock, and death
  • Hyperthermia
  • Hypertension
  • Hyperreflexia
  • Tachycardia
  • Termor
  • Agitation
  • Irritability
  • Sweating
  • Diarrhoea
  • Dilated pupils

Treatment:

  • Discontinue medication
  • Benzodiazepines for agitation
  • Cyprogeptadine (serotonin anagonist
  • Active cooling
23
Q

In which suicide presentations should a GP refer to psychiatric services as soon as possible?

A
  • If there is a significant perceived risk of suicide, of harm to others or of severe self-neglect
  • If there are psychotic symptoms
  • If there is a history or clinical suspicion of bipolar disorder
  • In all cases where a child or adolescent is presenting with major depression
24
Q

What should you ask when assessing suicide risk?

A

In any risk assessment it will be important to know the following:

  • What precipitated the attempt?
  • Why did they choose that time and place?
  • Was it planned or impulsive?
  • Did they leave a suicide note?
  • Were they intoxicated (drugs/alcohol)?
  • Did they take any precautions against discovery (e.g. were they expecting their family to be out of the house at that time? Did they tell work in advance that they wouldn’t be in that day?)
  • Have they made previous attempts at suicide or self-harm by any methods?
  • How do they feel about the episode now? (e.g. regrets the attempt? Wish they had succeeded?)
  • Questions to assess his current severity of depression, including ongoing suicidal thoughts. - Completing the PHQ-9 with them may be a helpful first step.
  • If they goes home, what supports – and stresses – will they have there?
  • Do they have thoughts to harm/kill others as well as himself?
  • Are there young children at home?
  • Do they have unsupervised responsibility for them? Are they potentially at risk?
  • What do they think about the future?
25
Q

Which factors are associated with a higher risk of suicide?

A
  • Age 45+
  • Physical illness
  • Unemployed
  • Previous suicide attempts
  • Male
  • Psychiatric illness
  • Divorced, widowed, or single
  • Family history of depression/substance abuse/suicide
26
Q

Which factors are associated with a lower risk of suicide?

A
  • Female
  • Age >45
  • Married or living in a couple
  • Employed
27
Q

What is depression?

A
  • State of low mood
  • Aversion to activity
  • This results in a negative impact upon thoughts, behaviour and feelings
  • Also impacts worldview and physical health
  • Low/depressed mood can be normal or expected:
    1. Response to life events
    2. Symptom of medical conditions
    3. Side-effect of drugs

Clinical depression:

  • In the absence of the above causes
  • Symptoms lasting at least 2 weeks
  • Includes other characteristic symptoms
28
Q

What are the most common symptoms of depression?

A
  • Anhedonia
  • Low mood
  • Early fatigue

Also:

  • Reduced concentration/attention
  • Reduced self-esteem/confidence
  • Sense of guilt/worthlessness
  • Pessimistic views of the future
  • Suicidal ideation
  • Disturbed sleep
  • Diminished appetite

Early morning waking is a symptom to look out for.

29
Q

When should we use the PHQ-9 questionnaire, and what does it do?

A

We should use the PHQ-9 when assessing a patient with a suspected depressive episode.

It covers the aspects of the DSM-5, and grades the severity of symptoms and their effects on quality of life.

30
Q

What is the NICE initial management for depression?

A
  • Assess suicide risk
  • Consider additional factors:
    Past history of mental health disorder
    Mania/hypomania
    Response to treatment
    Quality of relationships
    Family histry
    Living conditions and social isolation
    History of abuse
    Employment and immigration status
    Social support
  • Be aware of learning disabilities and cognitive impairment
  • Identify safeguarding concerns for either the patient or those vulnerable and close
  • Assess for comorbid conditions associated with depression
  • Alcohol/substance abuse or anxiety etc)
  • Consider using a validated measure to inform and evaluate treatment
    (PHQ-9)
31
Q

What is considered at a review with a patient with depression?

A

Reassess:

  • Suicide risk
  • Safeguarding concerns
  • Depressive symptoms and response to treatment

Factors which can affect course and severity of depression:

  • Quality of relationships
  • Living conditions and social isolation
  • Employment and immigration status
  • Social support availability
32
Q

What ongoing management is used, according to NICE guidance?

A
  • Manage suicide risk
  • Manage ongoing safeguarding concerns

If previous poor response to treatment:

For patients with subtheshold depressive symptoms/mild-moderate depression, consider:

  • Low-intensity psychosocial intervention
  • If already taking an antidepressant, check adherence and adverse effects, consider increasing dose/changing drugs

For patients with moderate or severe depression who have not responded to initial treatment

  • Consider combination therapy with an antidepressant and high-intensity psychosocial intervention
  • If depression is complex/severe, refer to specialist services

If patient has chronic physical health problem, consider referral to psychiatry and other appropriate specialty

Offer sleep hygiene advice
Arrange regular follow-up

33
Q

How should high risk patients be managed?

A

In high risk patients (5+ lifetime depressive episodes, and/or 2+ episodes within 2 years), maintain at least 2 years of an antidepressant at the therapeutic dose, and maintain long-term

34
Q

What is the most effective management of a moderate-severe episode of depression?

A

An antidepressant plus high intensity CBT

35
Q

Which questions should be asked following a suicide attempt?

A
  • Was the patient intoxicated?
  • What did they want to achieve?
  • Was it planned or impulsive?
  • What precipitated the attempt?

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