Mental Health: depression Flashcards
Prevalence of depression
- 8 - 12% of UK population experience depression in any year
- more common in women in most age groups
- common in patients with physical illness
Aetiology of depression
- Multifactorial
- Biochemical
- Neuroendocrine
- Genetic
- Social
- Psychodynamic
Biopsychosocial model:
•Biological
- Psychological
- Social
- Predisposing
- Precipitating
- Perpetuating
Screening for depression
The following two questions can be used to screen for depression
- ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
- ‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
Diagnostic criteria for a depressive episode
- Depression can be mild, moderate or severe
- Diagnostic guidelines are that symptoms should last for at least 2 weeks, there are no symptoms (current or historic) that could indicate bipolar affective disorder and there are no other possible causes (organic / substance misuse)
- At least 2 of the 3 core symptoms must be met, most days for most of the time:
- Low mood
- Loss of interest or pleasure in activities usually interesting or pleasurable (anhedonia)
- Decreased energy levels (anergia)
What are core symptoms of depression?
- Low mood
- Loss of interest or pleasure in activities usually interesting or pleasurable (anhedonia)
- Decreased energy levels (anergia)
number of other symptoms needed to assess the level of depression
Number of core + additional symptoms → determine the level of depression (2 core needed to diagnose depression)
- 2 core + 2 additional symptoms = mild depression
- 2 core and 4 additional symptoms = moderate depression
- 3 core and at least 5 additional symptoms = severe depression
Other (apart from core) symptoms of depression (apart from core symptoms they are needed to describe the severity of depression)
- Loss of confidence / self esteem
- Guilt - feelings of self reproach
- Recurrent thoughts of death, recurrent suicidal ideation
- Diminished ability to think or concentrate, or indecisiveness
- Change in psychomotor activity (agitation or retardation)
- Sleep disturbances (of any type)
- Appetite disturbance, either decreased (anorexia) or increased (leading to hyperphagia)
Symptoms characteristics required for the diagnosis of depression (3)
- Symptoms should be present nearly every day
- The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
- The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism)
Psychosis and depression
- Severe depression may occur with or without psychotic symptoms
- Usually, psychotic symptoms are “mood congruent”, i.e. nihilistic delusions, persecutory hallucinations etc.
Physical symptoms of depression
- Loss of libido
- Physical complaints (i.e. somatic symptoms), e.g. aches, pains, constipation, increased worry about pre-existing medical problems
- Diurnal variation of mood (worst in the morning, improves as the day progresses)
- Irritability
- Anxiety, worry, dread, catastrophising
Thoughts pattern in depression
- Negative about self, world and future
- Helpless, worthless
- Worthless, useless, inadequate
- Burden, others better off without them
What does the severity of the depressive episode depend on?
- Number of symptoms of depression
- Degree of functional impairment
Diagnosis and management of mild depression
- enough symptoms to meet criteria
- a person with a mild depressive episode is probably capable of continuing with the majority of their activities
- Managed in primary care → Non-pharmacological treatment only
Moderate depressive episode
- characteristics
- management
- Between mild and severe
- A person with a moderate depressive episode will probably have difficulties continuing with their ordinary activities
Management:
- May require secondary care
- Combination of treatment (i.e. medication and psychological therapy)
Severe depression
- characteristics
- management
- People with this type of depression have symptoms that are marked and distressing
- Suicidal thoughts and acts are common
- Psychotic symptoms may be present, e.g. hallucinations, delusions, psychomotor retardation or severe stupor (referred to as a severe depressive episode with psychotic symptoms)
Management:
- usually require secondary services
- may require treatment in hospital
- may require detention under Mental Health Act 1983
(3) categories of management of depression
- Biological
- Psychological
- Social
Biological management of depression
Antidepressant medication:
- SSRI
- Dual re-uptake inhibitors (SNRI)
- Tricyclics
- MAO inhibitors
- Others
What we may need to add to antidepressants?
- Antipsychotics (Quetiapine, Risperidone, Aripiprazole)
- Lithium Carbonate
- Addition of a second antidepressant (either SSRI + Mirtazapine or Mirtazapine + Venlafaxine)
How long does treatment with anti-depressants last?
- a single episode of depression should be treated for at least 6 to 9 months after remission
- the risk of recurrence is high and increases with each episode
- multiple episodes may require treatment for years
- the chances of staying well are greatly increased by taking antidepressants
Advantages of anti-depressants
- Effective
- Not addictive
- Not known to loose their efficacy over time
- Not known to cause new long-term side effects
- Need to be continued at treatment dose
Stopping anti-depressants
- Must not be stopped abruptly
- May lead to unpleasant discontinuation effects
- Confers higher risk of relapse
- Antidepressants should be reduced slowly and under supervision of a doctor
- May have discontinuation effects however slowly reduced
Indications for electroconvulsive therapy (ECT)
- only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and / or when the condition is considered to be potentially life-threatening, in individuals with:
- severe depressive illness
- catatonia
Side effects of ECT
Short-term side-effects
- headache
- nausea
- short term memory impairment
- memory loss of events prior to ECT
- cardiac arrhythmia
Long-term side-effects
- some patients report impaired memory
Contraindications for ECT
The only absolute contraindications is raised intracranial pressure
Psychological treatments for depression
- Counselling
- Cognitive Behavioural Therapy (CBT)
- Mindfulness
- Interpersonal Therapy (IPT)
- Groups, such as self-help, self-esteem, self-confidence
- Anxiety management
- Relaxation techniques
Social treatments for depression
- Exercise
- Signposting
- Housing
- Finances
- Social Services
- First-line pharmacological treatment for depression
- name preferred drugs (2)
- what drug to use if post-MI?
Selective serotonin reuptake inhibitors (SSRIs)
- citalopram (careful in QT interval) and fluoxetine are currently the preferred SSRIs
- sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
What antidepressant to use in children and adolescent?
SSRIs should be used with caution in children and adolescents
Fluoxetine is the drug of choice when an antidepressant is indicated
SEs of SSRIs
- Gl symptoms
- there is an increased risk of GI bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
- patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
- fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and QT interval
- citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
- the maximum daily dose is 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
SSRIs interactions with other drugs
- NSAIDs: ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
- warfarin / heparin: recommendation to avoid SSRIs and considering mirtazapine
- aspirin: see above
- triptans - increased risk of serotonin syndrome
- monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
When to review a patient after starting SSRI?
- Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks
- For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week
- If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse
Symptoms of SSRIs discontinuation
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms:
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
- paraesthesia
SSRIs and pregnancy
- to weigh up benefits and risk when deciding whether to use in pregnancy
- use during the first trimester gives a small increased risk of congenital heart defects
- use during the third trimester can result in persistent pulmonary hypertension of the newborn
*Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
