Down and out Flashcards
What is depression?
Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.
What are the different types of depression?
Clinical depression Depressive episode Recurrent depressive episode Reactive depression Dysthymia Manic depression Psychotic depression Prenatal or postnatal depression Seasonal affective disorder
What increases your risk of developing depression?
Psychosocial factors Genetic factors Personality Failure of adaptive measures to stress Chronic comorbidities A past head injury - inc hypopituitarism
What are the symptoms of depression?
During the last month have you often been bothered by feeling down, depressed, or hopeless? Do you have little interest or pleasure in doing things?
Other symptoms:
Fatigue/loss of energy.
Worthlessness/excessive or inappropriate guilt.
Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts.
Diminished ability to think/concentrate or indecisiveness.
Psychomotor agitation or retardation.
Insomnia/hypersomnia.
Significant appetite and/or weight loss
How should you, as the HCP, treat the patient with depression in your consultations?
Build a trusting relationship and explore treatment options with hope and optimism, explaining the different courses of depression and that recovery is possible.
Be aware of possible stigma and discrimination associated with depression.
Ensure that confidentiality, privacy and dignity are respected.
Provide information about depression and its treatment, and about self-help groups, support groups and other resources.
Ensure that comprehensive written information is available in the appropriate language and in audio format if possible.
Addressing cultural and ethnic differences when developing and implementing treatment plans.
What affects the development, course and severity of the depression?
History of depression and comorbid mental health or physical disorders.
Any past history of mood elevation (bipolar disorder), Response to previous treatments
The quality of interpersonal relationships, Living conditions and social isolation.
Consider if the person has a learning disability or acquired cognitive impairment
What is the treatment for mild-to-moderate depression?
Consider a psychological intervention - one or more low-intensity psychological interventions or group-based CBT for people who decline this intervention.
A group-based peer support programme, either alone or in combination with the above, for people with a chronic physical health problem.
Avoid use of antidepressants unless they have a history of moderate-to-severe or have been depressed for at least 2 years.
What is the treatment for moderate-to-severe depression?
Offer an antidepressant and a high-intensity psychological intervention. The type of intervention offered will depend on the severity of depression and the presence or absence of a chronic health problem.
Antidepressant drugs are effective for treating moderate to severe depression associated with psychomotor and physiological changes such as loss of appetite and sleep disturbance.
What should you take into consideration when choosing an antidepressant?
The person’s preference.
Adverse effect profile — for example, sedation, sexual adverse effects, weight gain.
Toxicity in overdose — avoid tricyclic antidepressants or venlafaxine if there is a history, or likelihood, of overdose.
Current drug treatments that may interact with the antidepressant drugs.
How does the type/incidence of depression affect the type of antidepressant given?
If this is a first episode of depression, consider prescribing a generic selective serotonin reuptake inhibitor (SSRI), such as citalopram, fluoxetine, paroxetine, or sertraline.
If this is a recurrent episode of depression, consider:
Prescribing an antidepressant that the person has had a good response to previously.
Avoiding antidepressants that the person has previously failed to respond to or could not tolerate.
If the person has a chronic physical health problem:
Sertraline may be preferred, because it has a lower risk of drug interactions.
If an SSRI is prescribed, consider gastroprotection in older people who are taking nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin.
How should you prepare patients for antidepressants?
Consider suicide risk and toxicity in overdose.
Explain that symptoms of anxiety may initially worsen.
Explain that antidepressants take time to work.
Explain that antidepressants should be continued for at least 6 months following remission of symptoms, as this greatly reduces the risk of relapse
How should patients be followed up after being given an antidepressant?
For those who are not suicidal:
Arrange an initial review:
Within 1 week for people less than 30 years of age who have been started on an antidepressant.
Within 2 weeks for other people.
Arrange subsequent reviews every 2–4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered
What are the major classes of antidepressant drugs?
SSRI’s (Sertraline, Citalopram, Fluoxetine): better tolerates and safer in overdose, less sedating and fewer antimuscarinic. First-line.
TCA’s (Amitriptyline, Lofepramine (less sedation), Dosulepin): similar efficacy to SSRIs but have toxicity in overdose.
MAOI’s (Moclobemide (reserved for second line treatment), Tranylcypromine (greater stimulant action but likely cause hypertensive crisis), Phenelzine (cause hepatotoxicity) and isocarboxazid). MAOIs have dangerous interactions with some foods and drugs.
What are some of the minor antidepressant drugs?
Tetracyclic antidepressants
Flupentixol - psychosis
Vortioxetine - directly modulate serotonergic receptor activity and inhibit the re-uptake of serotonin, ifor patients who haveresponded inadequately to 2 antidepressants.
Tryptophan is licensed for use in treatment-resistant depression.
St John’s wort is a herbal medicine used to treat mild depression available over the counter.
What is the second-line treatment for depression?
Failure to respond to initial treatment with an SSRI may require an increase in the dose, or switching to a different SSRI or mirtazapine (tetra).
Other second-line choices include lofepramine, moclobemide, and reboxetine.
Other tricyclic antidepressants and venlafaxine should be considered for more severe forms of depression.
MAOIs should only be prescribed by specialists.
Failure to respond to a second antidepressant may require the addition of another antidepressant of a different class, or use of an augmenting agent (such as lithium, and antipsychotic).
Electroconvulsive therapy may be initiated in severe refractory depression.
What are the side-effects of anti-depressants?
Hyponatraemia (considered in all patients who develop drowsiness, confusion, or convulsions while taking an antidepressant). Suicidal behaviour (The use of antidepressants has been linked with suicidal thoughts and behaviour; children, young adults, and patients with a history of suicidal behaviour are particularly at risk. Where necessary patients should be monitored for suicidal behaviour, self-harm, or hostility, particularly at the beginning of treatment or if the dose is changed) Serotonin Syndrome (neuromuscular hyperactivity (such as tremor, hyperreflexia, clonus, myoclonus, rigidity), autonomic dysfunction (tachycardia, blood pressure changes, hyperthermia, diaphoresis, shivering, diarrhoea), and altered mental state (agitation, confusion, mania).
