Depressive disorders Flashcards
What is the DSM-5 criteria for major depression?
5 or more of the following present during the same 2-week period (at least one of the first 2)
- Depressed mood most of the day, nearly every day (irritable in children)
- Anhedonia
- Weight loss (unintentional)
- Insomnia or hypersomnia
- Psychomotor agitation of retardation
- Fatigue or loss of energy
- Feelings of worthlessness or inappropriate guilt
- Problems thinking or concentrating
- Recurrent thoughts of death, suicidal ideation with or without a specific plan.
What is a general description of persistent depressive disorder (dysthymia)?
Less severe, but more prolonged depressive episode
What is a general description of disruptive mood dysregulation disorder?
Chronic, severe, and persistent irritability without overt depressive features.
What is melancholic depression?
‘biological’ depression which is less related to external triggers and is more amenable to pharmacological than psychological treatment.
What is the survey instrument used to identify melancholia in depression?
The Sydney Melancholia Prototypic Index (SMPI)
In the SMPI, which items favour melancholia?
- Very low energy
- Depressed mood prevents deriving pleasure from things (humorous things don’t lift mood)
- Mood and energy levels worse in the morning
- General loss of interest in things they previously enjoyed
- Can’t look forward to anything
- Significant psychomotor retardation
- Significant effects to concentration
- Weight loss
- Depression is far worse than expected for given circumstance
- Early years no more difficult than most people
- Good functioning / relationships when not depressed
- Depressions come out of the blue
What are the defining features of psychotic depression?
Significant psychomotor retardation
Small bursts of agitation
Stereotypic movements
Delusions and (sometimes) hallucinations
What are the two types of delusions in psychotic depression?
Mood congruent (thematically congruent with depressed mood: nihilistic, persecutory)
Mood incongruent (thematically incongruent with depressed mood: TV communicating with them, people spying on them)
What are the key features of non-melancholic depression?
Predisposing personality factors
Precipitating environmental factors
Very responsive to psychological intervention
Respond better to placebo
What personality styles are associated with non-melancholic depression?
High trait anxiety Shy and avoidant Sensitive to judgement Self focussed Highly self critical Perfectionistic
What is the general hierarchy of treatments for major depression?
- Lifestyle (SNAPW +drugs and sleep)
- Social treatments (family psychoeducation, support groups).
- Psychological OR pharmacological treatments
- Psychological AND pharmacological treatments (dosage adjustments, augment with lithium / antipsychotics)
- ECT
What is the first line pharmacological treatment for major depression, according to the RANZCP guidelines?
SSRI (Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline)
NARI (Reboxetine)
Tetracyclic (Mirtazapine, Mianserin)
Melatonergic agonist (Agomelatine)
NDRI (Bupropion)
What is the second line pharmacological treatment for major depression, according to the RANZCP guidelines?
SNRI (Desvenlafaxine, Venlafaxine, Duloxetine, Milnacipran)
TCA (Amitryptyline, Clomipramine, Dothiepin, Imipramine, Nortriptyline, Trimipramine, Doxepin)
Serotonin modulator (Vortioxetine)
What is the Third line pharmacological treatment for major depression, according to the RANZCP guidelines?
MAOI (Phenelzine, Tranylcypromine)
Reversible MAOI (Moclobemide)
What is the pharmacological treatment for major depression according to the RANZCP guidelines?
1st:
SSRI, NARI, TetraCA, MA, NDRI
2nd:
SNRI (greater toxicity), TCA, Serotonin modulator
3rd (MAOI, reversible MAOI)
What are the Indications for ECT relevant to major depressive disorder?
First line: Severe melancholic depression (refusing food // drink) High risk of suicide High level of distress Psychotic depression Catatonia Previous good response Patient's choice
Second line
Not responding to several trials of medications including TCA’s and MAOIs.
What is the Psychological therapy most recommended for major depression?
CBT - formal
Why are SNRI’s classified as second line in the RANZCP guidelines?
Because of greater toxicity in overdose
What are the first line treatments for major depression according to eTG?
(SSRI) Can’t Ever Fucking Fix Sad People. (SNRI) Double Down with Venlafaxine and (OTHER) Mirtazapine
SSRI -
(Citalopram 20mg, Escitalopram 10mg, Fluoxetine 20mg, Fluvoxamine 50mg, Sertraline 50mg, Paroxetine 20mg)
SNRIs-
(Desvenlafaxine 50mg, Duloxetine 60mg, Venlafaxine 75mg)
Other: Mirtazapine (15-30mg)
What are the second line treatments for major depression according to eTG?
Agomelatine (25mg)
Moclobemide (300mg)
Reboxetine (2-4mg)
What are the third line treatments for major depression according to eTG?
TCAs (25-75mg)
Mianserin (30-60mg)
MAOIs
What is the treatment for major depression when other treatments fail, according to eTG?
ECT
Lithium augmentation
Liothyroxine (T3 augmentation)
Atypical antipsychotic augmentation
What alternative medicine should be avoided when receiving pharmacotherapy for depression?
St John’s wart - Can cause serotonin toxicity when taken alongside serotonergic anti-depressants.
