unipolar depression clinical Flashcards
what is unipolar depression
psychological and physical symptoms that continue for weeks/months and interferes with daily life
what are the psychological symptoms of unipolar depression
loss of pleasure
depressed mood
poor memory
sadness
anxiety
suicidal ideation
what are the physical symptoms of unipolar depression
poor sleep
low appetite
mood swings
fatigue
weight changes
joint pain
sexual dysfunction
headaches
epidemiology of unipolar depression
1 in 5
W>M
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
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
what are the risks if unipolar depression is left untreated
alcohol abuse/dependence
cognitive impairment
poor work performance
poor sleep
suicidal ideation
which drugs can cause unipolar depression
alcohol
steroids
benzos
antipsychotics
anticonvulsants
NSAIDs
CVD drugs
caffeine
what are the cognitive symptoms of unipolar depression
- Difficulty with
○ Attention and concentration
○ Memory
○ Decision making
○ Planning
○ Mental sharpness
○ Word-finding
○ Judgement
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
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
what are the differential diagnosis for unipolar depression
GAD
drug inducesd
schizophrenia
personality disorder
bereavement
physical illness
dementia
panic disorder
SAD
bipolar depression
what are the co-morbidities with unipolar depression
GAD
psychosis
insomnia
OCD
PTSD
panic disorder
how is mild to moderate unipolar depression treated
- Low intensity psychological or psychosocial interventions
- May suggest medication - not common
how is moderate to severe unipolar depression treated
- Medication
- High intensity or psychological interventions
- Onward referral
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
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
- After 6-8 month treatment - taper over 6-8 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
- fluoxetine - only licenced one if 4-6 sessions of psychological therapies not worked
- 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
