Depressive disorders

Question 1

What is the DSM-5 criteria for major depression?

Answer 1

5 or more of the following present during the same 2-week period (at least one of the first 2)

1. Depressed mood most of the day, nearly every day (irritable in children)
2. Anhedonia
3. Weight loss (unintentional)
4. Insomnia or hypersomnia
5. Psychomotor agitation of retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or inappropriate guilt
8. Problems thinking or concentrating
9. Recurrent thoughts of death, suicidal ideation with or without a specific plan.

Question 2

What is a general description of persistent depressive disorder (dysthymia)?

Answer 2

Less severe, but more prolonged depressive episode

Question 3

What is a general description of disruptive mood dysregulation disorder?

Answer 3

Chronic, severe, and persistent irritability without overt depressive features.

Question 4

What is melancholic depression?

Answer 4

‘biological’ depression which is less related to external triggers and is more amenable to pharmacological than psychological treatment.

Question 5

What is the survey instrument used to identify melancholia in depression?

Answer 5

The Sydney Melancholia Prototypic Index (SMPI)

Question 6

In the SMPI, which items favour melancholia?

Answer 6

• 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

Question 7

What are the defining features of psychotic depression?

Answer 7

Significant psychomotor retardation

Small bursts of agitation

Stereotypic movements

Delusions and (sometimes) hallucinations

Question 8

What are the two types of delusions in psychotic depression?

Answer 8

Mood congruent (thematically congruent with depressed mood: nihilistic, persecutory)

Mood incongruent (thematically incongruent with depressed mood: TV communicating with them, people spying on them)

Question 9

What are the key features of non-melancholic depression?

Answer 9

Predisposing personality factors

Precipitating environmental factors

Very responsive to psychological intervention

Respond better to placebo

Question 10

What personality styles are associated with non-melancholic depression?

Answer 10

High trait anxiety
Shy and avoidant
Sensitive to judgement
Self focussed
Highly self critical
Perfectionistic

Question 11

What is the general hierarchy of treatments for major depression?

Answer 11

1. Lifestyle (SNAPW +drugs and sleep)
2. Social treatments (family psychoeducation, support groups).
3. Psychological OR pharmacological treatments
4. Psychological AND pharmacological treatments (dosage adjustments, augment with lithium / antipsychotics)
5. ECT

Question 12

What is the first line pharmacological treatment for major depression, according to the RANZCP guidelines?

Answer 12

SSRI (Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline)

NARI (Reboxetine)

Tetracyclic (Mirtazapine, Mianserin)

Melatonergic agonist (Agomelatine)

NDRI (Bupropion)

Question 13

What is the second line pharmacological treatment for major depression, according to the RANZCP guidelines?

Answer 13

SNRI (Desvenlafaxine, Venlafaxine, Duloxetine, Milnacipran)

TCA (Amitryptyline, Clomipramine, Dothiepin, Imipramine, Nortriptyline, Trimipramine, Doxepin)

Serotonin modulator (Vortioxetine)

Question 14

What is the Third line pharmacological treatment for major depression, according to the RANZCP guidelines?

Answer 14

MAOI (Phenelzine, Tranylcypromine)

Reversible MAOI (Moclobemide)

Question 15

What is the pharmacological treatment for major depression according to the RANZCP guidelines?

Answer 15

1st:
SSRI, NARI, TetraCA, MA, NDRI

2nd:
SNRI (greater toxicity), TCA, Serotonin modulator

3rd (MAOI, reversible MAOI)

Question 16

What are the Indications for ECT relevant to major depressive disorder?

Answer 16

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.

Question 17

What is the Psychological therapy most recommended for major depression?

Answer 17

CBT - formal

Question 18

Why are SNRI’s classified as second line in the RANZCP guidelines?

Answer 18

Because of greater toxicity in overdose

Question 19

What are the first line treatments for major depression according to eTG?

Answer 19

(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)

Question 20

What are the second line treatments for major depression according to eTG?

Answer 20

Agomelatine (25mg)
Moclobemide (300mg)
Reboxetine (2-4mg)

Question 21

What are the third line treatments for major depression according to eTG?

Answer 21

TCAs (25-75mg)

Mianserin (30-60mg)

MAOIs

Question 22

What is the treatment for major depression when other treatments fail, according to eTG?

Answer 22

ECT
Lithium augmentation
Liothyroxine (T3 augmentation)
Atypical antipsychotic augmentation

Question 23

What alternative medicine should be avoided when receiving pharmacotherapy for depression?

Answer 23

St John’s wart - Can cause serotonin toxicity when taken alongside serotonergic anti-depressants.