Depression + Primary Care Flashcards
What is the classification for mental illness
ICD-10 = UK
DSM-5
What measurement tools are used in depression
SCAN - ICD-10
SCID - DSM-5
What is depression associated with
F>M FH / 1st degree relative with MDD or BPH = main Unemployed Lower education Financial worries Associated adverse life events PMH Other psychiatric disorders Long term physical health conditions
What are the key symptoms of depression
Persistent low mood Anhedonia (loss of pleasure) Fatigue / low energy At LEAST TWO for TWO weeks No manic episodes In the absence of substance misuse or organic disorder
What is the classification of depression
Dysthymia = <5 symptoms but >2 years of distress
Mild = 2 key + 4 additional symptoms
Moderate = 2 key + 5-6 additional
Severe = All key + additional to make 8 OR
Psychosis / stupor + low mood
What are additional symptoms of depression
Diurnal variation - worse in morning Disturbed sleep Becks triad -ve thoughts about themselves, world and future Poor concentration Low self-confidence / self-esteem Guilt of self blame Lack of motivation Indecisive Suicidal ideation and self harm
What type of sleep disturbance is there
Early morning wakening
Initial insomnia
Broken sleep
What are psychotic symptoms
Hallucinations - often auditory
Delusions - often nihilistic
Thought disorder
Lack of insight
What are other psychological Sx
Ideas of reference Anxiety OCD Panic attacks Apathy Withdrawal Social and occupational decline
What are physical Sx / somatic
Weight loss >5% in 1 months Sleep Headache Palpitation Chest pain Constipation Loss of libido Psychomotor agitation / retardation Stupor Catatonia = suggest psychotic
What do you do if person not E+D
Admit
ECT
Anti-psychotic
Increased appetite medication e.g. mitrazapine
What are the complications of depression
Suicide
Psychosis
Social and occupational dysfunction
What are measurement tools
PHQ-9 - patient health Q
HADS - hospital anxiety and depression
What are screening questions
In the last month
Have you felt down or depressed
Had little interest
What are differential of depression
Consider TFT / urine drug screen / steroid use etc
Normal reaction to life even Seasonal affective disorder - Rx as depression Dysthmia Cyclothymia Bipolar Substance misuse / withdrawal Schizophrenia - -ve Sx can mimic Stroke / tumour / hydrocephalus Dementia Delerium Hypothyroid - Addison Hyper PTH / hypercalcaemia Infection - influenza / HIV / hepatitis Drugs - steroid / retinoid Post concussion syndrome
What are the stages of grief
Denial - numb / pseudohallucination Anger Bargaining Depression Acceptance
What do you not give if SAD
Sleeping tablet
How do you investigate depression
Full Hx inc neuro + systematic Collateral Hx Bloods Drugs ECG CT if neuro / trauma
What bloods
Urine drug screen FBC TFT Glucose U+E + LFT for baseline
When do you do if ECG
Going on anti-psychotic
What do you ask in collateral
Are they always like this Previous Hx FH Any vulnerable people Any period of elevated mood
How do you treat mild depression
Period of active monitoring Manage suicide risk / safe guard Sleep hygiene Guided self help / support group Computer or low intensity / group CBT
What do you do for mod-severe
High intensity psych - CBT / IPT / family / couples
Anti-depressant
When would you give long term anti-depressant
Chronic
Prophylaxis of severe / psychosis / suicide
When would you start anti-depressant straight away
Past history of mod-severe
Dysthymia
Chronic health
Waiting for psychological or don’t respond
What are physical treatment
ECT
Psychosurgery
DBS / VNS
When do you use ECT
Resistant or severe depression
Manic psychosis
Catatonia
Responded in past
What is CI to ECT
Raised ICP
What are SE of ECT
Headache Nausea Retrograde memory Confusion / drowsy Decreased appetite Arrhythmia
What are long term consequences
Apathy
Anhedonia
Decreased cognition
What do you do before and after
Assess memory
One patient recovered what do you do
Keep on same dose for 6-12 months
2 years if PMH
How do you choose drug
Symptoms SE Suicide risk CO-morbid Past drugs Preference
HOW DOES GP FOLLOW UP
2-4 week intervals
3 monthly
Fitness for work
Fitness to drive
What is the difference between grief and depresion
Grief = longing
Can still have +Ve emotion
Sx worse when thinking
Want to be with others
What is prolonged grief
Marked distress >6 months after bereavement or >2 weeks till start grieving
Who is more at risk
Women
Sudden death
Decreased support
How many abnormal grief present
Pseudohallucination
How do you Rx
Counselling
Behaviour / cognitive /exposure therapy
Anti-depressant
Refer if functional impairment
What is insomnia
Chronic inability to sleep >3 months for 3 nights a week
What are secondary causes of insomnia
Anxiety / depression Physical health OSA Excess alcohol or drugs Circardian rhythm disorder
What is parasomina
Sleep walking / terrors
Restless legs
What is sleep hygiene
Avoid stimulation / alcohol / caffeine / exercise / heavy meal Regular day time exercise Sam ebedtime Relaxation Bedroom promotes sleep
What are other measures
Sleep diaries
CBT
Melatonin short term
Hyponotics only if severe and affecting function
How long melatonin
<13 weeks
Used e.g. for jet lag / shift work
What hypnotics do you give
Benzo or Z (Zopiclone)
Zopiclone better
If prescribe benzodiazepine what do you do
Review in 2 weeks
What else will GP deal with
BMI
BP
Smoking
Bloods
What do you do to SSRI before ECT
Reduce dose
