GP - Depression Flashcards
What is depression?
Depression is characterised by persistent low mood/ sadness and/or loss of interest or pleasure in doing things and a range of emotional, cognitive, physical and behavioural symptoms
What criteria do you use to diagnose depression?
There are two of them:
DSM-V (used by GP)
ICD-10 (used by GP/ psychiatrist) - soon to be replaced by ICD-11
What is the DSM-V classification?
Depression is diagnosed according to the DSM-5 classification by the presence of 5 out of a possible 9 symptoms, present for at least 2 weeks, of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning:
- Core symptoms:
- Persistent low mood/ sadness
- Loss of interest or pleasure in doing things
- If at least one of the two ‘core’ symptoms have been present most days, most of the time, for at least 2 weeks, ask about:
- Biological symptoms
- Sleep disturbance (insomnia or hypersomnia nearly everyday)
- Changes in weight (weight gain/ loss)/ changes in appetite
- Fatigue/ loss of energy
- Cognitive symptoms
- Agitation or retardation
- Poor memory and concentration, and indecisiveness
- Feelings of worthlessness/ low self-esteem/ low confidence, or excessive or inappropriate guilt
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
- Biological symptoms
Negative perception of self
Negative perception of current/ future situation
Look for triggers or stressors for depression + establish pre-morbid status (“how do you describe yourself before all of this?”
What questions in the Hx will you ask in a patient with depression?
- Persistent low mood/ sadness
- “Can you tell me about the low mood?” “How often have you been feeling low in mood?”
- Loss of interest or pleasure
- “Have you found yourself not being able to enjoy the things you used to enjoy?”
- Sleep disturbance
- “How has you sleeping pattern recently?”
- “Any difficulties falling asleep?”
- “Do you find yourself waking up early, and finding it difficult to get back to sleep?”
- “Do you feel tired and lack of energy during daytime?”
- Changes in weight
- “Have you noticed a change in your weight?”
- Negative perception of self
- “How do you feel about youself?”
- “Do you often criticise yourself?”
- “How confident a person are you on a scale of 1-10, with 1 being the least confident and 10 being the most confident?”
- “How do you see yourself when compared to other people?”
- Negative perception of current/ future situation
- “How do you feel about your current situation?”
- “How do you feel about the future?”
- Poor concentration
- “How are your current levels of concentration?”
- “Can you follow TV programmes/ read the newspaper/ pursue hobby without getting distracted?”
- Poor memory
- “Have you been finding yourself more forgetful?” e.g. forgetting your appointment, or forgetting your submission deadline
- Agitation/ retardation
- “Have you been finding yourself getting more angry and agitated more easily?”
- “Have you noticed yourself being so fidgety or restless that you have been moving around a lot more than usual?”
- “Have you noticed that you have been thinking or doing things slower than usual?”e.g. moving or speaking slowly
What is the ICD-10 classification?
It’s an agreed list of 10 depressive symptoms
Core symptoms:
- Persistant low mood/ sadness
- Loss of interest or pleasure in doing things
- Fatigue or low energy
(At least one of these present for most days, most of the time, for at least 2 weeks)
If any of the above is present, ask about associated symptoms:
- Sleep disturbance
- Poor memory and concentration, and indecisiveness
- Low self-esteem/ confidence
- Changes in appetite or weight
- Suicidal thoughts or acts
- Agitation or retardation
- Guilt or self-blame
The 10 symptoms in ICD-10 define the degree of depression and management is based on the particular degree. How many symptoms (from ICD-10) does patient have to have in order to be diagnosed mild depression?
Mild depression - 4 symptoms
How many symptoms (from ICD-10) does patient have to have in order to be diagnosed moderate depression?
Moderate depression = 5-6 symptoms
How many symptoms (from ICD-10) does patient have to have in order to be diagnosed severe depression?
Severe depression - 7 or more symptoms +/- psychotic symptoms
How many symptoms (from ICD-10) does patient have to have in order to NOT be diagnosed with depression?
Not depressed - < 4 symptoms
When assessing a patient with depression, what must you rule out?
Rule out other psychiatric diagnoses:
- Bipolar disorder
- “Have you ever experienced periods of feeling particularly high, energetic or euphoric?”
- Schizophrenia
- “Sometimes, patients with depression, they may experience seemingly bizarre events like hearing strange noises or seeing things that shouldn’t be there. Have you had any of that?”
- “Have you ever heard voices speaking when there seems to be no one around?”
- If yes, second order or third order auditory hallucinations
- “Do you ever feel that people are discussing you negatively?”
- “Do you fear that people maybe out to get you?”
- “Have you ever felt that something or someone is able to put thoughts into your head, or remove thoughts from your head?”(Thought insertion/ withdrawal)
- “Have you ever felt that something or someone can hear your thoughts?” (Thought broadcasting)
- “Have you ever heard voices speaking when there seems to be no one around?”
- “Sometimes, patients with depression, they may experience seemingly bizarre events like hearing strange noises or seeing things that shouldn’t be there. Have you had any of that?”
- Physical (organic) causes
- Are you taking any drugs - prescriptional or recreational?
- Do you have any health problems? e.g. hypothyroidism, Parkinson’s disease, cancer (can cause hypercalcaemia)
- Note that health problems can make one depressed!
What must you assess if the patient has depression?
Risk of suicide
How would you assess the risk of suicide?
Think about BEFORE, DURING, and AFTER:
Start with an open question - “This might be a bit of a sensitive question to ask, but sometimes patients with depression may feel that life is no longer worth living for. Have you felt that way?” or “Have you thought about ending your life or harming yourself?”
Before
- Was there a trigger or a precipitant?
- e.g. an argument with a spouse
- Was the self-harm planned, or was it impulsive?
- “Have you made any plans for it?”
- “How often do you think about doing it?”
- “Is there anyone else involved in your plan?”
- Did the patient carry out any final acts?
- Writing a suicide node
- Leaving a will
- Terminating contracts e.g. mobile phone, gas, and electricity
- Were there any precautions taken against discovery?
- Closing curtains
- Locking doors
- Wait until everyone in the house has left knowing that they won’t be back for a few hours
- Going somewhere remote
- Was alcohol used?
- Amount and type
- Previous alcohol use
- “Do you drink when you are depressed?” “If so, how much and how often, and do you feel better after?”
During
- Method of self-harm
- Was the patient alone?
- Where were they when they self-harmed?
- What was going through their mind at the time?
- Did they think that self-harm would end their life
- What did they do straight after the self-harm?
After
- Did the patient call anyone? How did they get to A&E? Who were they found by?
- How did they feel when help arrived?
- What is the patient’s current mood?
- Does the patient still feel suicidal?
- If the patient were to go home today, what would they do? (cover the next few days)
- If the patient were to feel like this again, what might they do differently?
- Protective factors:
- “Are there anything that might prevent you from doing this again in the future?”
- “Does the patient feel that there is anything to live for?”
- Will the patient accept treatment?
- “What do you think about the treatment you are currently receiving?” “Are they effective?” “Have you noticed any positive changes in your mood ever since you are started on the medications?” “ Any side effects?”
Previous episodes of self-harm
Employment status
Relationship status
Chronic pain or disability
What questions would you ask about overdose in risk assessment?
- What medication?
- Where did they get the medication from?
- How much of the medication did the patient take?
- What did the patient take the medication with?
- What did the patient think that amount of medication would do?
- What made the patient decide to take the medication/ how long had they been thinking about taking an overdose for?
- What did the patient do after taking the medication?
- How did the patient get to the hospital?
What questions would you ask about cutting in risk assessment?
Where are the cuts?
How many cuts?
What tool?
How deep are the cuts?
How did the patient feel whilst they were cutting?
How did the patient feel when they saw BLOOD?
What was the patient hoping the cutting would do?
What physical/ organic causes must you rule out?
Hypothyroidism
Anaemia
Cancer
Conditions that cause chronic pain
What would you ask in Sx in a patient with depression?
Smoking
Alcohol
Recreational drug use
Gambling (usually in manic patients)
Occupation (has your mood affected your work? have you taken any time off work because of your condition?)
Relationship with friends and family
Live alone?
Support groups? (do you have anyone to go to when you feel depressed?)
Give 5 risk factors for depression
Chronic comorbidities e.g. diabetes, COPD, cardiovascular disease, chronic pain syndromes
Female
Recent childbirth (postnatal depression)
Psychological issues e.g. divorce, unemployment, poverty, homelessness
FHx of depression
Hx of bullying, physical, emotional or sexual abuse
What tool do you use to assess the severity of depression?
- PHQ-9
- It scores each of the nine DSM-5 symptoms as “0” (not at all) to “3” (nearly everyday)
- The questions are bascially asking about each symptom of the DSM-5 criteria
- Depression severity (always in multiples of 4):
- 0-4 no depression
- 5-9 mild depression
- 10-14 moderate depression
- 15-19 moderately severe depression
- 20-27 severe depression
What is another tool that is used in the hospital to assess the severity of depression and anxiety?
HADS
Consists of 14 questions, 7 for depression and 7 for anxiety
Each item is scored 0-3
Disease severity: 0-7 normal, 8-10 mild, 11-14 moderate, 15-21 severe depression
Give 3 differential diagnoses of depression
Adjustment disorder, normal grief reaction
Bipolar disorder
Physical causes e.g. hypoglycaemia, hypothyroidism, anaemia, hyperparathyroidism, dementia, Parkinson’s disease
Schizophrenia
Drugs-induced depression
What are the differences between a grief reaction and depression?
Grief reaction VS. Depression
Mnemonic (Green Hulk Dodged Monsters Prettily SSS)
Guilt. Regret and guilt over specific events. Excessive feelings of guilt
Hope. Episodic and focal loss of hope but the. Persistent hopelessness
person is able to look forward to the
future
Distress. Related to a particular loss Pervasive and affects all
aspects of life
Mood. Sadness and dysphoria Persistent sadness that
lasts a long time
Pleasure. Interests and capacity for pleasure. Markedly diminished
intact interested or pleasure in activities
Suicidal ideation. Passive and fleeting desire. Preoccupied with a desire
to die
Self-worth. Maintained Worthlessness
Symptom fluctuations. Grief comes in waves. Constant
but improves with times
What drugs can cause depression as a side effect?
Carbon monoxide poisoning (tho it’s not really a drug)
Susbtance misuse (alcohol, steroids, cannabis, cocaine)
Methyldopa, propranolol, opioids, CNS depressants (e.g. benzodiazepines)
What investigations would you do in a patient with depression?
Tests are mainly done to exclude organic causes of depression!
- Blood tests - FBC, U&Es, LFTs, TFTs, Ca2+, Mg2+, glucose, CRP, ESR
- FBC to rule out anaemia
- TFTs to rule out hypothyroidism
- Ca2+ to rule out hypercalcaemia
- Mg2+ to rule out hypomagnesaemia
- HIV or syphilis serology
Give 3 complications of depression
Increased risk of substance abuse
Family problems and relationship breakups
Employment problems (e.g. due to loss of productivity, or absenteeism)
How do you manage depression?
For people with mild depression who do not want an intervention, or people with subthreshold depressive symptoms who request an intervention –> active monitoring
For people with persistent subthreshold depressive symptoms or mild-to-moderate depression –> 1st line: low-intensity psychosocial intervention (individual guided self-help, CBT, or a structured group-based physical activity programme); 2nd line: group-based CBT
- Avoid the use of antidepressants, but consider this in people with:
- A Hx of moderate/ severe depression
- Persistent subthreshold depression
- Subthreshold symptoms or mild depression that persist after other interventions
- Mild depression that complicates the care of a chronic physical health problem
- For patients with a chronic physical health problem –> add group-based peer support programme
For people with moderate or severe depression, OR those with persistent subthreshold depression or mild to moderate depression that is unresponsive to initial interventions –> 1st line: antidepressant + high-intensity psychological intervention (individual CBT, interpersonal therapy (IPT), behavioural activation, behavioural couples therapy); 2nd line: Counselling + short-term psychodynamic psychotherapy for mild to moderate depression
- 1st line antidepressant - SSRI (sertraline)
-
Sertraline (+ PPi for gastroprotection) is preferred for a first episode of depression and also for patients with chronic physical health problem
- Note that sertraline can increase the risk of suicide in patients < 30 yrs so they need frequent reviews!
-
Sertraline (+ PPi for gastroprotection) is preferred for a first episode of depression and also for patients with chronic physical health problem
- For patients with a chronic physical health problem –> Add group-based CBT + individual CBT
What is subthreshold depression?
At least 2 but < 5 symptoms of depression
What is persistent subthreshold depression?
If a person has subthreshold depression for > 2 years, which is not the consequence of a partially resolved ‘major depression’
Give 3 side effects of sertraline
Suicidal ideation
SIADH
Anxiety
Arrhythmias
Arthralgia
Constipation/ diarrhoea
Dry mouth
What should you do before you switch from one SSRI to another?
The first SSRI should be withdrawn before the alternative SSRI is started
What should you do if you want to switch from a SSRI to a TCA?
Cross-tapering
(The current drug dose is reduced slowly, while the dose of the new drug is increased slowly)
What should you do if you want to switch SSRI to a SNRI like venlafaxine?
Cross-tapering
Start venlafaxine 37.5 mg daily and increase very slowly
When should you arrange follow-up (reviews)?
For those NOT at risk of suicide:
- Arrange an initial review within 2 weeks
- Review regularly thereafter e.g. every 2-4 weeks for the first 3 months
For those at risk of suicide, or people aged < 30 yrs:
- Arrange an initial review within 1 week
- Weekly follow-up is recommended for the first month until the risk is no longer considered clinically important
What advice do you give to a patient with depression in primary care?
Advice:
- Advice on guided self-help groups and support groups e.g. MIND, Samaritans, Depression Alliance, Depression UK
- Advice about the side effects of antidepressants, if used
- Advice on sleep hygiene for people with sleeping difficulties
- Advice on quitting alcohol and drug misuse
- Advise the person receiving treatment:
- To be vigilant for worsening depressive symptoms and suicidal ideas, particularly when starting and changing medications, and at times of increasing personal stress
- That it usually takes 2-4 weeks for symptoms to improve
- That antidepressants should be continued for at least 6 months after they have recovered, to reduce the risk of relapse
