depression_management_flashcards
What should be considered when assessing the severity of depression?
Number of symptoms, degree of functional impairment and/or disability, and duration of the episode.
What aspects of a patient’s history should be explored?
Previous episodes of depression and mood elevation (BPAD), comorbid physical illnesses, responses to previous treatments, and the quality of interpersonal relationships.
What important question should always be asked to assess suicide risk?
“Have you had thoughts of harming yourself or ending your life?” - if significant risk to self, refer to specialist MH services urgently.
What interventions are included in Step 1 of the Stepped Care Model?
Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions.
What interventions are included in Step 2 of the Stepped Care Model?
Low-intensity psychological interventions, psychological interventions, medication, referral for further assessment and interventions.
What interventions are included in Step 3 of the Stepped Care Model?
Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions.
What interventions are included in Step 4 of the Stepped Care Model?
Medication, high-intensity psychological interventions, ECT, crisis service, combined treatments, multi-professional, and inpatient care.
What advice should be given to patients when starting treatment?
Symptoms may get worse soon after starting treatment; provide clear advice on how to seek help, e.g., local crisis lines, Samaritans, A&E.
What should be the management for mild to moderate depression?
Sleep hygiene advice, further assessment within 2 weeks, low-intensity psychosocial interventions such as individual-guided self-help based on the principles of CBT, computerised CBT, and structured group physical activity programmes.
When should medication be considered for mild to moderate depression?
Past history of moderate or severe depression, symptoms present for a long time (>2 years), symptoms persist after other interventions.
What is the first-line medication for moderate to severe depression?
SSRI (e.g., sertraline).
What are the risks associated with SSRIs?
Bleeding, especially in the elderly, gastric ulcers, hyponatremia, and potential drug interactions.
Drug Interaction: fluoxetine, fluvoxamine, paroxetine
Discontinuation Symptoms: paroxetine
Death from Overdose: venlafaxine
Overdose: TCAs (except lofepramine)
Stopping due to side effects: venlafaxine, duloxetine, TCAs
Blood Pressure Monitoring Needed: venlafaxine
Worsening Hypertension: venlafaxine, duloxetine
Postural Hypotension and Arrhythmia: TCA
What should be included in the review after starting antidepressant medication?
Review after 2 weeks (if low suicide risk), then every 2-4 weeks thereafter for 3 months.
What should be done for patients 18-25 years old or at increased risk of suicide?
Follow-up after 1 week.
What high-intensity psychological interventions are recommended for moderate to severe depression?
Individual CBT and Interpersonal Therapy, consisting of 16-20 sessions over 3-4 months.
What should be considered for severe and complex depression?
Use crisis resolution and home treatment teams, develop a crisis plan, consider inpatient treatment, and consider ECT if necessary.
What are the caution points when switching antidepressants?
Be cautious when switching from fluoxetine to other antidepressants, from fluoxetine or paroxetine to a TCA, to a new serotoninergic antidepressant or MAOI, and from non-reversible MAOI.
What is the management for persistent subthreshold depressive symptoms or mild to moderate depression?
Consider psychological intervention, avoid routine use of antidepressants unless certain conditions apply.
What is the management for moderate or severe depression?
Offer an antidepressant and a high-intensity psychological intervention.
What should be considered for the first episode of depression?
Consider an SSRI (e.g., citalopram, sertraline).
What should be considered for a recurrent episode of depression?
Consider an antidepressant that the patient has previously had a good response to, avoid antidepressants that have previously failed.
What should be done if the patient has a co-existing chronic physical health problem?
Sertraline is preferred due to a lower risk of drug interactions.
What should be done if the patient develops psychosis?
Add the antipsychotic earlier on (whenever the psychosis comes on).
What is the process for stopping antidepressants?
The dose should be tapered down over a period of 2-4 weeks.
What should be explained to patients about depression?
Explain that depression is a condition with persistently low mood that impacts day-to-day functioning, it is common, and involves treatment options such as psychological therapy and medication.
