unipolar depression clinical Flashcards by kayleigh wootten

what is unipolar depression

psychological and physical symptoms that continue for weeks/months and interferes with daily life

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what are the psychological symptoms of unipolar depression

loss of pleasure
depressed mood
poor memory
sadness
anxiety
suicidal ideation

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what are the physical symptoms of unipolar depression

poor sleep
low appetite
mood swings
fatigue
weight changes
joint pain
sexual dysfunction
headaches

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epidemiology of unipolar depression

1 in 5
W>M

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what are the risk factors of unipolar depression

female
anxiety
genetics
lack of parental care in childhood
social adversity
physical illness
chronic insomnia
vit D deficiency
quitting smoking
drug use

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what are the risk factors for recurrent depression

history of episodes
onset after 60y/o
long duration episodes
family history of affective disorder
poor symptom control
co-morbid anxiety/substance abuse

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what are the risks if unipolar depression is left untreated

alcohol abuse/dependence
cognitive impairment
poor work performance
poor sleep
suicidal ideation

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which drugs can cause unipolar depression

alcohol
steroids
benzos
antipsychotics
anticonvulsants
NSAIDs
CVD drugs
caffeine

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what are the cognitive symptoms of unipolar depression

Difficulty with
○ Attention and concentration
○ Memory
○ Decision making
○ Planning
○ Mental sharpness
○ Word-finding
○ Judgement

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how is unipolar depression diagnosed

key symptoms
- persistent low mood
- marked loss of interest or pleasure
associated
- disturbed sleep
- weight/appetite changes
- poor concentration
- feelings of worthlessness
- suicidal thoughts/acts
DSMIV - one key symptom for at least 2 weeks - minimum 5 symptoms
ICD10 - two key symptoms for at least 2 weeks, minimum 4 symptoms

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what are the NICE categories for unipolar depression

ub-threshold - person has a few symptoms and feels low, but can function
* Mild - enough symptoms for a diagnosis but still functions reasonably well
* Moderate - where the person has a range of symptoms and is not coping well
* Severe - where person has a full set of symptoms, cannot function and may suffer from some psychiatric symptoms too
* Complex - where symptoms have failed to improve with treatment and may have psychosis, other symptoms and problems

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what are the differential diagnosis for unipolar depression

GAD
drug inducesd
schizophrenia
personality disorder
bereavement
physical illness
dementia
panic disorder
SAD
bipolar depression

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what are the co-morbidities with unipolar depression

GAD
psychosis
insomnia
OCD
PTSD
panic disorder

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how is mild to moderate unipolar depression treated

Low intensity psychological or psychosocial interventions
- May suggest medication - not common

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how is moderate to severe unipolar depression treated

Medication
- High intensity or psychological interventions
- Onward referral

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how is severe and complex unipolar depression treated

Medication
- High intensity or psychological interventions
- Combined treatments and collaborative care
- ECT
- Crisis service
- MDT/in-patient care

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what is ECT

electroconvulsive therapy for acute severe depression (life threatening)
Floods the brain with

what are the first line choices for antidepressants

SSRIs - citalopram, escitalopram, fluoxetine, sertraline
duloxetine, mirtazapine, venlafaxine
TCAs- lofepramine
adjunctive - quetiapine

when should each antidepressant be taken

SSRI and SNRI in the morning - no sleep disturbances
- Mirtazapine taken at night

how do you switch from fluoxetine to other antidepressants

Fluoxetine to others - long half life
- Fluoxetine to moclobemide - taper and stop fluoxetine and wait 5-6wks
- From a non-reversible MAOI –> 2 week washout period is required
- 2+ failed antidepressants of adequate dose and duration, suggests the need for review of diagnosis

what is serotonin syndrome

rare cause of serious effects, can occur with combinations of serotonergic drugs

what are the symptoms of serotonin syndrome

restlessness
tremor
myoclonus
rigidity
hyperreflexia
shivering
elevated temperature
arrythmia
cardiac collapse

how are antidepressants stopped

For less than 8 weeks stop over 1-2 weeks
- After 6-8 month treatment - taper over 6-8 weeks
  After long term maintenance decrease by 25% by every 4-6 weeks

what are the withdrawal symptoms from SSRIs

dizziness
sleep disturbances
agitation
volatility
nausea
fatigue
headache

what are the symptoms for withdrawal from SNRIs

same as SSRIs restlessness abdominal distension congestion

what are the central side effects of antidepressants

anxiety - low and slow, split doses seizures confusion - swap meds dizziness - take at night headache - paracetamol insomnia - take in morning nausea - take with food sleepiness suicidal ideation

what are the anticholinergic side effects of antidepressants

blurred vision - usually wears off constipation - fibre and fluid dry mouth urinary retention

what are the other side effects associated with antidepressants

hyponatraemia postural hypotension palpitations sexual dysfunction sweating weight gain

which antidepressants interact with alcohol

Mirtazapine, trazodone, amitriptyline

why do SSRIs interact with NSAIDs

SSRIs double GI bleed risk and is worsened by NSAIDs

which antidepressants interact with warfarin

SSRIs raise INR - fluoxetine and paroxetine are the worst and sertraline/citalopram the best

which antidepressant interacts with tamoxifen

paroxetine may increase breast cancer recurrence

which antidepressant does smoking interact with

decreased duloxetine levels

what does St Johns Wort interact with

Antiretrovirals, ciclosporin, oral contraceptives and digoxin

which antidepressants interact with AEDs

Clozapine - increased by SSRIs Carbamazepine and valproate - increases TCA levels

which antidepressants are suitable for use in children and adolescents

1. fluoxetine - only licenced one if 4-6 sessions of psychological therapies not worked 2. citalopram/sertraline - unlicensed

antidepressants and pregnancy

- Depression risk higher than risk of antidepressant - Avoid paroxetine - Little/no evidence for any detrimental effect on postnatal development

antidepressants and elderly

- No ideal antidepressant - SSRIs better tolerated than TCAs but increased GI bleed risk - Increased hyponatraemia, postural hypotension, haemorrhagic stroke with SSRIs - Low and slow

antidepressants and cardiac disease

SSRIs first choice - may be protective against MI - sertraline no benefit of CBT unless depression present prior to MI - QTc interval prolongation - citalopram and escitalopram C/I in known prolongation

antidepressants and renal impairment

- The greater the renal impairment, the greater the potential for drug accumulation - ADRs such as confusion, postural hypotension and sedation may be more common - Low and slow - Care is needed with anticholinergic drugs which may cause urinary retention and interfere with U and E measurements

antidepressants and hepatic impairment

- Greater the degree of impairment, the greater the impairment of drug metabolism and the greater the risk of toxicity - More sensitivity to S/E - Low and slow - frequent LFTs - In severe liver disease, avoid drugs causing marked sedation and/or constipation ○ Paroxetine is used by some specialist liver units with few apparent problems