Mood disorders (Depression) Flashcards
Decribe the biopsychoscial model of depression [+]
NICE recommend referral to CAMHS for children with moderate to severe depression. CAMHS can then initiate what treatment plan [5]?
Psychological therapy as the first line treatment with cognitive behavioural therapy, non-directive supportive therapy, interpersonal therapy and family therapy
Pharmacological treatment:
- Fluoxetine is the first line antidepressant in children, starting at 10mg and increasing to a maximum of 20mg
- Sertraline and citalopram are second line antidepressants
- When the child responds to medical treatment, it should continue 6 months after remission is achieved
When they do not respond to medical treatment they may require intensive psychological therapy
Describe the clinical features of depression [+]
Persistent low mood
Anhedonia, or the loss of interest or pleasure in almost all activities once enjoyed, is another key feature
- Individuals may show noticeably diminished interest in hobbies, social interactions, sexual activity and other sources of potential enjoyment.
Another common symptom is decreased energy levels or increased fatigue.
Cognitive changes
- Difficulties in concentration and decision-making are frequently reported.
- Patients may also exhibit negative patterns of thinking such as excessive guilt or feelings of worthlessness.
Insomnia
Appetite changes
- +/- appetitie
Suicidal ideation
Lecture:
- What how would you classifiy someone as having mild, moderate or severe depression? [3]
Mild
* 2 core + 2 symptoms
Moderate
* 2 core + 3 symptoms
Severe
* 2 core + 4 or more symptoms
Both core symptoms need to present most of the time for at least two weeks and represent a change from normal
Also:
- can’t be secondary to. substance misuse, medication or medical disorders
- Need to cause signficant distress + impairment of social/occupation/ general life
Which medical conditions do you need to exclude prior to treating depression? [2]
Hypothyroidism
Anaemia
NICE updated its depression guidelines in 2022. It now favours a simple classification of depression severity.
Describe these classifications [2]
‘less severe’ depression:
- encompasses what was previously termed subthreshold and mild depression
- a PHQ-9 score of < 16
‘more severe’ depression:
- encompasses what was previously termed moderate and severe depression
- a PHQ-9 score of ≥ 16
Describe the clinical assessment you would perform for ?depression [4]
- Psychiatric history and mental state examination
- PHQ-9 screening tool
- Risk assessment (focus on suicide ideation, somatic symptoms, and psychotic symptoms)
- Focused investigations to exclude anaemia and hypothyroidism
Management of less severe depression:
- NICE lists a large number of interventions that may be used first-line.
- It encourages us to discuss treatment options with patients to reach a shared decision.
- Describe these treatment options [+]
They recommend considering ‘the least intrusive and least resource intensive treatment first’. It also recommends not routinely offering ‘antidepressant medication as first-line treatment for less severe depression, unless that is the person’s preference’.
Treatment options, listed in order of preference by NICE
* guided self-help
* group cognitive behavioural therapy (CBT)
* group behavioural activation (BA)
* individual CBT
* individual BA
* group exercise
* group mindfulness and meditation
* interpersonal psychotherapy (IPT)
* selective serotonin reuptake inhibitors (SSRIs)
* counselling
* short-term psychodynamic psychotherapy (STPP)
Management of more severe depression? [+]
Treatment options, listed in order of preference by NICE
* a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
* individual CBT
* individual behavioural activation (BA)
* antidepressant medication
* selective serotonin reuptake inhibitor (SSRI), or
* serotonin-norepinephrine reuptake inhibitor (SNRI), or
* another antidepressant if indicated based on previous clinical and treatment history
* individual problem-solving
* counselling
* short-term psychodynamic psychotherapy (STPP)
* interpersonal psychotherapy (IPT)
* guided self-help
* group exercise
How do you dx depression?
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
* Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
* Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
* Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
* Insomnia or hypersomnia nearly every day.
* Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
* Fatigue or loss of energy nearly every day.
* Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
* Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
* Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Which two questions can be used to screen for depression? [2]
- ‘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.
Which factors suggest depression over dementia? [6]
Factors suggesting diagnosis of depression over dementia
* short history, rapid onset
* biological symptoms e.g. weight loss, sleep disturbance
* patient worried about poor memory
* reluctant to take tests, disappointed with results
* mini-mental test score: variable
* global memory loss (dementia characteristically causes recent memory loss)
Describe the drug class treatment ladder for depression [5]
1st line SSRI.
2nd line different SSRI.
3rd line SNRI.
4th line NSSA (e.g. mirtazapine) or earlier if insomnia a big feature.
5th line mood stabiliser e.g. lithium.
When switching antidepressants:
- which drugs can you perform a direct switch? [4]
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
direct switch is possible
When switching antidepressants:
- which drug needs a gap of 4-7 days before starting another low dose SSRI? [1]
Switching from fluoxetine to another SSRI
When switching antidepressants:
- How do you advise switching from an SSRI to TCA? [1]
- Which exception is there to this? [1]
cross-tapering is recommended (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly
- an exception is fluoxetine which should be withdrawn, the leave a gap of 4-7 days prior to TCAs being started at a low dose
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine - how do you do this? [1]
direct switch is possible (caution if paroxetine used)
Describe the biopsychosocial model of depression [3+]
What are different types of mood disorders? [+]
Unipolar depression / Major Depressive Disorder (MDD)
Bipolar affective disorder (manic depression)
Psychotic depression
Postnatal depression
Premenstrual dysphoric disorder
Mania
Hypomania
Dysthymia
Seasonal affective disorder
Substance-induced mood disorders
Prolonged grief reaction
A patient presents with depression. Based off their symptoms you determine them to have severe depression.
What PHQ score would this mean they have above? [1]
What would this mean with regards to their initial treatment plan? [1]
PHQ score of over 15 / 16 indicating ‘more severe’ depression
- NICE most strongly recommend a combination of individual cognitive behavioural therapy and an antidepressant as this has been found to be the most clinical and cost-effective treatment for ‘more severe’ depression
- Sertraline is first line unless under 18, in which it is flouxetine
What is the prognosis of depression like? [2]
What would indicate a good/poor outcome with regards to depression? [2]
Good outcome: Mild episode, no psychotic sx, comorbid PD, acute onset, good social support
Poor outcomes: developing gradually, neuroticis(alcohol misuse, PD), lack of social support
How long should you warn someone that antidepressants take to work? [1]
2-6 weeks
What are withdrawal symptoms like for antidepressants? [3]
Flu-like symptoms, dizziness and mood changes
You prescribe a patient an SSRI.
What information would you give them about potential side effects? [5]
Risk of GI upset, changes in appetite and weight (loss or gain)
Confusion and reduced conciousness (due to hyponatraemia)
Suicidal thoughts and behaviour
Lower seizure threshold
Citalopram: prolongs QT interval
In combination with other serotnergic drugs - serotonin syndrome (autonomic hyperactivity, altered mental state and neuromuscular excitation)
What is the triad of serotonin syndrome? [3]
serotonin syndrome: autonomic hyperactivity, altered mental state and neuromuscular excitation
Which drugs should patients on SSRIs not be given with? [3]
- Explain why [+]
MOA inhibitors and other serotonergic drugs (e.g. tramadol) due to risk of SS
Bleeding has increased risk with NSAIDs, aspirin, anticoagulants
Drugs that prolong QT interval (e.g. antipsychotics)
How long do you withdraw SSRIs for? [1]
Except which drug and how long is this for? [1]
4 weeks except fluoxetine, which is 2 weeks
You prescribe a patient an SNRI.
What information would you give them about potential side effects? [5]
GI upset
Dry mouth
Neurological effects (headache, abnormal dreams, insomnia, confusion, convulsions)
Suicidal thoughts and behaviour
Hypertension
Which side effect is mirtazepine particularly associated with? [1]
Bone marrow suppression
Which population should venlafaxine be avoided / used in caution with? [1]
People at risk of arrythmia - due to ischaemic heart disease
