Psych - Depression and ECT Flashcards
What are the core symptoms of depression?
- Low mood
- Anhedonia
- Decreased energy (or increased fatiguability)
What tools are available to assess someone’s depression?
Hospital Anxiety and depression scale (HAD)
- 7 questions for anxiety and 7 for depression.
- Produces a score out of 21 for both anxiety and depression, anything >11 is indicative of anxiety or depression
Patient Health Questionaire (PHQ-9)
- Asks patients how they have been feeling in last 2 weeks
- The closest to 27, the more severe the depression
How would you quantify the severity of someone’s depression?
- Mild depression: few, if any of the 5 sx required o make a diagnosis. Sx result in only minor functional impairment
- Moderate depression: sx or functional impairment between ‘milk’ and ‘severe’
- Severe depression: has most sx and these markedly interfere with functioning. Can occur with or without psychotic sx
What are other sx of depression?
- Reduced concentration and attention
- Reduced self esteem and self confidence
- Ideas of guilt and worthlessness
- Feeling of hopelessness regarding the future
- Thoughts of self harm
- Decreased sleep and/or appetite
Describe some clinical features of depression
-Thought content: negative, pessimistic thoughts
-Biological symptoms: reduced sleep, appetite and libido, sleep pattern of waking up hours before you are supposed to
• Motor activity: altered - psychomotor agitation or retardation or both
• Cognition: reduced attention, concentration and decisiveness
• Ahnedonia can be accompanied by loss of motivation and emotional reactivity
• Psychotic features
What type of psychotic features can be present in depression?
- Psychotic features are usually mood-congruent
- Delusions are nihilistic, delusional or hypochondriacal (illness or death)
- Hallucinations: auditory, 2nd person and accusing, condemning or urging patient to commit suicide
What is atypical depression?
-Initial anxiety related insomnia, subsequent oversleeping, increased appetite and relatively bright and reactive mood. Common in adolescence
What is the differential diagnosis for depression?
- Normal sadness (eg bereavement) or severe physical illness. Predominant negative, guilty or suicidal thoughts favour depression
- Psychotic depression vs schizophrenia: differentiate based on through the content (mood-congruent psychotic features) and temporal sequence in which the sx developed
- Alcohol/drug withdrawal can mimic depression
- Depressive retardation vs flat (unreactive) affect of chronic schizophrenia
What else should you screen for when taking a history for depression?
- Hypomania and mania (if someone is low, ask if they ever feel high)
- Anxiety sx
- Psychotic sx
What is the management of depression? When should you make referrals to psych?
- Most depressive illnesses can be managed in primary care
- Make a referral to psych if suicide risk is high, depression is severe, unresponsive to initial treatment, bipolar or recurrent
- Mild depression: self help, CBT, structured physical activity
- Moderate depression: psychological therapy, antidepressants (SSRIs are 1st line, try 2 SSRIs and then switch to SNRIs)
- Resustant depression: can augment with lithium
- ECT in treatment resistant depression
Prescribing antidepressants: What should you do if you are switching from citalopram, escitalopram, sertraline or paroxtine to another SSRI?
-First SSRI should be withdrawn (with dose reduction before stopping) before an alternative SSRI is started
Prescribing antidepressants: what should you do if switching from fluoxetine to another SSRI?
-Withdraw fluoxetine and then leave a gap of 4-7 days (has a long T1/2) before starting a low0dose of the alternative SSRI
Prescribing antidepressants: What should you do when switching from a SSRI to a TCA?
- Cross-tapering is recommended: reduce current drug dosage whilst slowly increasing the dosage of the new drug
- Apart from fluoxetine, which should be withdrawn before starting a TCA
What does ECT involve? What are the indicators for ECT?
-Involves the induction of a modified cerebral seizure
Indications:
- Moderate depression that has not responded to multiple drug and psychological treatment
- Severe depressive illness
- Prolonged or severe episode of mania that has not responded to treatment
- Catatonia
Name some contra-indications of ECT
- Raised ICP
- Recent stroke
- Recent MI
- Crescendo Angina
