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PY366 Depression, anxiety and schizophrenia > Depression- the disease and treatment > Flashcards

Depression- the disease and treatment Flashcards

1
Q

what is meant by prevalence

A

total number of cases in the population at a given time divided by the number of individuals in the population

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2
Q

what is meant by incidence

A

measures the risk of developing the disease within a specified time frame

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3
Q

describe the epidemiology of depression

A

ranked as the single largest contributor to global disability and major contributor to suicide deaths

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4
Q

what is the estimated annual costs of treating people with depression

A

£1.7 billion

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5
Q

outline the risk factors of developing depression

A
  1. gender- females higher during reproductive years, then trend reverses
  2. age- younger onset, shorter duration, less frequency in elderly
  3. marital status- highest in separated, then widowed, then divorced females
  4. socio-economic factors- higher incidence in social class 3, higher in rented accommodation and highest in street homelessness
  5. ethnicity- highest in asian females
    - no differences in males
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6
Q

what is depression

A

refers to a wide range of mental health problems characterised by the absence of a positive effect, low mood and a range of associated emotional, cognitive, physical and behavioural symptoms

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7
Q

what is meant by anhedonia

A

a loss of interest and enjoyment in ordinary things and experiences

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8
Q

what 3 elements is depression severity composed of

A
  1. symptoms- may vary in frequency and intensity
  2. duration of disorder
  3. impact on personal and social functioning
    - severity of depression is a consequence of all these 3 elements
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9
Q

what is meant by personal functioning

A

when an individual is able to effectively engage in normal activities of everyday living and can react to experiences

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10
Q

what is social functioning

A

ability to interact with other people, develop relationships and to gain from and develop these interactions

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11
Q

what are the 2 episodes of depression

A
  1. less severe depression- encompasses subthreshold and mild depression
    - scoring less than 16 on the PHQ 9 scale
  2. more severe depression- encompasses moderate and severe depression
    - scoring 16 or more on the pHQ 9 scale
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12
Q

outline the classification of depression

A
  1. subthreshold- fewer than 5 symptoms
  2. mild- few, if any, symptoms in excess of the 5 required to make the diagnosis and symptoms result in only minor functional impairment
  3. moderate- symptoms or functional impairment are between mild and severe
  4. severe- most symptoms and the symptoms markedly interfere with functioning
    - can occur with or without psychotic symptoms
    - symptoms must be present for at least 2 weeks
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13
Q

how is depression defined in ICD 11

A

the presence of depressed mood or diminished interest in activities occurring most of the day, nearly every day, for at least 2 weeks, accompanied by other symptoms

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14
Q

what are the symptoms of depression

A
  1. reduced ability to concentrate and sustain attention
  2. beliefs of low self worth or inappropriate guilt
  3. hopelessness about future
  4. recurrent thoughts of death or suicidal ideation
  5. significantly disrupted sleep or excessive sleep
  6. significant changes in appetite or weight
  7. psychomotor agitation or retardation
  8. reduced energy
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15
Q

what does PHQ stand for

A

patient health questionnaire

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16
Q

outline the causes of depression

A
  1. physical- numerous
    - exacerbates/causation
    - consider metabolic and other organic causes
  2. iatrogenic- loss and regret
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17
Q

what needs to be considered for treatment of depression

A
  1. carry out assessment of need and develop treatment plan
  2. take into account physical health problems
  3. take into account any coexisting mental health problems
  4. what factors would make pt most likely to engage with treatment
  5. take into account any previous treatment history
  6. address barriers to delivery of treatments
  7. ensure regular liaison between healthcare professionals and patient
18
Q

what should be included in the management plan for starting treatment of depression

A
  1. reasons for offering medication
  2. choices of medication
  3. the dose, and how the dose may need to be adjusted.
  4. benefits, what improvements the person would like to see in their life and how the medication may help.
  5. harms, possible side effects and withdrawal effects
  6. any concerns they have about taking or stopping the medication
19
Q

how would you counsel a patient who has been prescribed antidepressants

A
  1. how they may be affected when they first start taking it
  2. how long it takes to see an effect (usually 4 weeks)
  3. when 1st review will be- usually 2 weeks to check symptoms are improving and for side effects
  4. importance of following instructions of how to take the medication
  5. why regular monitoring is needed
  6. how they can self monitor symptoms
  7. treatment may need to be taken for at least 6 months after the remission of symptoms
  8. some side effects may persist throughout treatment and withdrawal effects
20
Q

what are the pharmacological treatments of depression

A
  1. An SSRI is first choice
    - As effective as TCAs and less likely to be discontinued because of side effects/ toxicity
  2. If agitation / anxiety / akathisia occurs either change AD or prescribe a benzodiazepine short-term and review in 2 wks.
  3. St John’s wort ~ not recommended by NICE
    - lack of evidence of efficacy in moderate / severe MDD
21
Q

outline the prescribing guidance for St Johns wort

A
  1. don’t prescribe or advise its use in depression
    - uncertainty about appropriate doses, persistence of effect, variation in the nature of preparations and serious interactions with other drugs
  2. advise people with depression of the different potencies of the preparations available and of the serious interactions
22
Q

describe the process of stopping antidepressants

A
  1. Inform pts about possibility of discontinuation symptoms on stopping / reducing or missing doses
  2. Advise pts to take meds as prescribed.
  3. Reduce ADs gradually over a 4-week period.
  4. If pts experience mild withdrawal symptoms, then reassure, if severe then re-introduce and decrement even more gradually
23
Q

what are the key points of step 4 of the matched care model

A
  1. Assess symptoms, suicide risk, treatment history, psychosocial stressors, personality factors and any significant relationship difficulties
  2. Re-introduce previous treatments that were inadequately delivered or adhered to.
  3. High Intensity Psychological therapies
  4. Consider ECT, multi-professional and in-patient care
  5. Crisis resolution teams (CRTs) should be used for pts with severe depression and those presenting with significant risk
24
Q

what are the pharmacological treatments for recurrent depression and relapse prevention

A
  1. Continue ADs for two years for people who have had two or more episodes in the recent past and have suffered functional impairment during these episodes
  2. Re-evaluate pts on maintenance treatment after two yrs taking into account age, co-morbid conditions + other risk factors.
  3. the Maintenance Dose is the dose that achieved remission
25
Q

describe the efficacy of antidepressants

A
  1. Equal efficacy
  2. 70% response rate with all antidepressants
  3. 30% treatment refractory
  4. treatment resistant population of 15%
26
Q

what is the mechanism of action of antidepressants

A
  1. Almost all antidepressants increase either
    serotonin or noradrenaline post synaptically
27
Q

what 3 factors should be considered to prescribe the right drug for the right patient

A
  1. does the drug work- efficacy
  2. can the patient tolerate the drug- safety
  3. how does the drug fit with the lifestyle of the patient
28
Q

what are the side effects of SSRIs and SNRIs

A
  • Nausea,
  • agitation
  • GI upset
  • hyponatraemia
  • sexual dysfunction
  • Panic attacks
  • discontinuation / serotonin syndrome
29
Q

what are the side effects of TCAs

A
  • Anti-cholinergic
  • BP disturbances
  • sedation
  • hyponatramia
  • discontinuation / serotonin syndrome.
30
Q

what are the side effects of reboxetine

A

Dry mouth, constipation, insomnia, sweating, anxiety / agitation

31
Q

what are the side effects of MOAIs

A

main issue is the food and drug interactions resulting in possible hypertensive crisis

32
Q

outline the further options if no or limited response from antidepressant treatment

A
  1. adding a group exercise intervention
  2. switching to a psychological therapy.
  3. continuing antidepressant therapy by increasing the dose or changing the drug.
  4. switching to another medication in the same class, intra-class
  5. switching to a medication of a different class, inter-class
  6. switching to or from an MAOI, or from one MAOI to another, will need to take place in secondary care.
  7. TCAs are dangerous in overdose
    - lofepramine has the best safety profile, dosulepin the worst
  8. changing to a combination of psychological therapy ( CBT, interpersonal psychotherapy) and medication
33
Q

when is treatment refractory depression diagnosed

A

when patients do not respond to two antidepressants, given sequentially.
- 70% will respond to the initial AD
- remaining 30%, half of these patients will respond to the second AD
- This leaves a treatment refractory sub-population of 15%.

34
Q

what is the sequenced treatment alternatives to relieve depression programme for TRD

A
  1. where evidence based interventions are mostly drawn from
  2. a pragmatic effectiveness study which used remission of symptoms as its main outcome
    - pts given citalopram
    - 28% attained remission
    - 47% responded
35
Q

what are the treatment options for treatment refractory depression

A
  1. Add Lithium (aim for plasma level of 0.4-1.0mmol/L)
  2. ECT
  3. Venlafaxine at doses >200mg/day
  4. Add Tri-iodothyronine; 20-50micrograms/day
  5. SSRI + Bupropion
  6. SSRI or Venlafaxine + Mianserin or Mirtazapine
36
Q

what does research on serotonin show

A

A comprehensive review shows there is no convincing evidence that depression is associated with lower serotonin concentrations or activity

37
Q

why is the serotonin theory obsolete

A
  1. Tryptophan depletion does NOT cause depression
  2. Levels of HIAA (the metabolite of 5-HT) do not correlate with depression
  3. Pts with depression do NOT have reduced levels of 5HT in the plasma
  4. The number of post-synaptic 5HT1-a receptors is NOT increased in depressed subjects.
  5. Genetic polymorphism with subjects having variations in SERT molecules has no effect on depression
38
Q

what are the symptoms of antidepressant discontinuation syndrome

A
  • flu like symptoms
  • gastrointestinal
  • anxiety
  • sleep disturbance
  • panic attacks
39
Q

describe the management of antidepressant discontinuation syndrome

A
  1. Gradually reduce antidepressant therapy.
  2. Reassure patient that symptoms will not persist.
  3. Reassure patient that symptoms are not indicative of a relapse
40
Q

why is alcohol not recommended whilst taking antidepressants

A
  1. Alcohol can potentiate the sedative effects of certain antidepressants
  2. Alcohol is a CNS depressant
  3. Alcohol consumption is strongly associated with self harm and suicide.

PY366 Depression, anxiety and schizophrenia (8 decks)

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