general info Flashcards
common condition characterised by the following few symptoms
- low mood
- loss of interest or pleasure in most activities
- range of associated emotional, cognitive, physical and behavioural symptoms (sleep and appetite disturbance, lack of conc, low self-confidence
risk factors for depression
- P/FHx depressive illness
- Hx other mental health conditions
- other chronic comorbids
- female
- recent childbirth
- older age
- psychosocial issues e.g. relationship problems, bereavement, unemployment, poverty or homelessness
M or F - who is more likely to have depression
F
Depression severity depends on …
intensity, freq, and duration of symptoms and their impact on daily functioning
Depression severity can be classified as (4)
LESS SEVERE: sub threshold and mild
MORE SEVERE: moderate and severe
Pt classified as having chronic depressive symptoms include (2)
- for at least 2 years, pt continually meets criteria for diagnosis of a major depressive episode
- for at least 2 years, pt has has persistent sub threshold symptoms, or persistent low mood (with or without concurrent episodes of major depression)
Is depression recurrent
High risk
Increases with each depressive episode
Risk of depression recurrence is high and increases with each depressive episode - true or false
true
Sometimes the symptoms of depression are different and non-specific in elderly. For example, older people may only present with ….
Physical symptoms or deteriorated cognitive functioning
This sleep disturbance is characteristic of depression
early morning wakening
What are the 2 depression identification questions?
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you been bothered by having little interest or pleasure in doing things?
What are some self administered depression questionnaires used in primary care? (aka the patient answers them) And which ones use the DSM-5 criteria?
- 3
- PHQ9
- HADS (does not use DSM5 criteria)
- BDI-II
Management of pt with new episode of less severe depression and does not want treatment, or feels that symptoms are improving (3)
- offer active monitoring with option to consider treatment at any time if needed
- ensure adequate social support and awareness of sources to help if symptoms worsen
- arrange initial review, usually within 2-4 weeks and ensure follow up if pt does not attend
management of pt with new episode of less severe depression & wishes to consider treatment
- match treatment to clinical needs and wishes
- consider offering guided self help first line
- do not routinely offer ADs as 1st line, but if they do wish to start this, 1st line is SSRIs
- arrange initial review usually 2-4 weeks after starting treatment and ensure follow up if pt does not attend
management of patient with new episode of more severe depression
- match treatment to clinical needs and wishes
- offer any treatment as 1st line depending on wishes, previous experiences and local referral pathway and services
- arrange initial review usually 2-4weeks after starting treatment and ensure follow up if pt does not attend
- if they wish to start AD, 1st line is SSRI or SNRI
- do not drive and notify DVLA if significant memory or conc problems, agitation, behavioural disturbance, suicidal thoughts
Arrange regular monitoring and follow up depending on clinical judgement. Consider using a validated depression questionnaire to monitor response to treatment e.g.
PHQ-9
If a pt needs to be admitted to hospital for specialist mental health input, every attempt should be made to persuade them to go voluntarily. If admission necessary and pt declines, compulsory admission can be arranged under sections …. of the Mental Health Act
2,3,4
MHA allows compulsory admission of people who
Have mental disorder of a nature or degree that warrants assessment or treatment in hospital, and
Need to be admitted in the interests of their own health or safety, of for the protection of other people
If patient is at risk of suicide, you would avoid this AD drug class (with the exception of one drug), and you would also avoid this drug
avoid TCAs except lofepramine
avoid venlafaxine (SNRI)
this is due to risk of death from overdose
If the patient has a chronic physical health condition, these 2 SSRIs may be preferred 1st line as lower likelihood of drug interactions
sertraline
citalopram
A patient has been taking sertraline for 3 years says that they have heard antidepressants are addictive and they are worried and want to stop it. Is this true?
They are not addictive but withdrawals can occur if the medication is stopped abruptly, doses missed, or full dose is not taken as directed
A patient has just started antidepressants. You tell them that if the antidepressant is going to work, it will usually start to work within this time frame
within 4 weeks
A patient is about to be started on antidepressants. You counsel them on what to expect. What do you say?
symptoms of anxiety, agitation, hopelessness or suicidal ideas may increase when starting treatment
if it is going to work, it will usually work within 4 weeks
Following remission, how long should antidepressant treatment be continued for?
continue at the same dose for at least 6 months (12 months in elderly, 2 years if recurrent depression)
at least 12 months in patients receiving treatment for generalised anxiety disorder (likelihood of relapse is high)
Following remission, how long will a patient who takes antidepressants for generalised anxiety disorder have to take their meds for?
at least 12 months at the same dose as likelihood of relapse is high
for all patients, response to treatment should be reviewed …… after initiation
and how often do patients need to be reviewed at the start of AD drug treatment
for all pt, response to treatment should be reviewed 2-4 weeks after initiation
patients on AD should usually be reviewed within 2 weeks of initiation
high risk of suicide or 18-25: review after 1 week of starting treatment or increasing dose
How long does treatment with AD need to be continued for before considering whether to switch AD treatment due to lack of efficacy?
at least 4 weeks (6 weeks in elderly)
When should you arrange initial review after starting AD if the patient is 18-25 years old or if there is particular concern for the risk of suicide?
1 week after starting
A patient is about to be commenced on antidepressant therapy. Their current medication list is as follows: naproxen 250mg tabs, take one TDS PRN, omeprazole 20mg OD. What AD would NOT be suitable and why
SSRI and SNRI not suitable due to increased risk of GI bleed
If someone is taking regular NSAID, taking SSRI or SNRI = increased risk of bleeding. If there is no suitable alternative, you can offer gastroprotection. What are some suitable alternatives? (4)
Mirtazapine
Reboxetine
Trazodone
Moclobemide (specialist)
If a patient takes warfarin, do not routinely offer …. (3)
TCA
SSRI
SNRI
A patients current medication list is as follows. Foster 200/6 inhaler, Warfarin 1mg, 3mg,
Propranolol 10mg.
They are to be started on an antidepressant. Choose the most suitable one: trazodone, sertraline, escitalopram, venlafaxine, lofepramine
Trazadone.
Do not routinely offer TCAs, SSRIs and SNRIs in patients taking warfarin due to increased bleeding risk!
If a patient is taking warfarin, do not roundly offer TCAs, SSRIs, SNRIs. Name 3 suitable alternatives
mirtazapine
trazadone
reboxetine
If a patient is on heparin, do not routinely offer these 2 AD classes. Alternative include these 4
Do not routinely offer SSRI or SNRI
Any alternative, e.g. mirtazapine, TCA, trazodone, reboxetine
If someone is on aspirin, what ADs can you give and what should you avoid
SSRIs - use with caution
Do not routinely give SSRIs and SNRIs
If no suitable alternative, offer gastroprotection
Suitable alternatives: mirtazapine, or when aspirin used alone consider mianserin or reboxetine
Effect of AD on seizure threshold
ALL antidepressants LOWER seizure threshold
When initiating AD therapy in patients with epilepsy, what do you do
- All ADs lower seizure threshold - consider seeking specialist advice
- Consider whether depression may be worsened by AED - MHRA advice on all AEDs and risk of suicide/mental health
What are some suitable antidepressant options for patients on AEDs?
all ADs lower seizure threshold
suitable options
SSRIs: escital, cital, sertraline
Not 1st line fluoxetine and fluvoxamine due to increased risk drug interactions
SNRIs: duloxetine preferred
Moclobemide (specialist)
Try to avoid this AD drug class in patients with epilepsy as they lower seizure threshold, but if you do need to use, then this one is preferred
TCAs
if needed, doxepin preferred
Patients taking triptans - what AD to give?
Do not routinely give SSRis
Suitable ones: mirtazapine, trazodone, mianserin, reboxetine
Patients taking MAO-B inhibitors (selegiline, rasagiline). What AD to avoid and what to give
Do not routinely give SSRIs
suitable alternatives: mirtazapine, trazodone, mianserin, reboxetine
Patients taking methadone, tizanidine, clozapine, theophylline - avoid this AD, suitable alternatives
Do not routinely give fluvoxamine
Suitable alternatives sertraline or citalopram
Patients on fleicanide or propafenone - do not routinely give these 2, and is is preferred to give this one, and these may also be used
do not routinely give citalopram, escitalopram
Preferred option sertraline
Mirtazapine or moclomebine (specialist) may also be used
If patient is on atomoxetine, do not give
fluoxetine, paroxetine, citalopram, escitalopram
give other SSRis instead
