ic11 depression Flashcards
what is the risk factors for depression
“poor, elderly, lonely, man with physical or mental comorbs and prev attempts”
how is suicide risk assessed
through thorough risk assessment which involves
- build rapport, active listening, empathy, direct qns
- collateral info (with pt’s consent)
- conduct suicide inquiry (ideation, suicide plan, intent, explore ambivalence of reasons to die vs reasons to live)
- consultation w specialist whenever in doubt
how is suicide risk managed
- identifying and managing underlying disorders if any (tx w adherence, referrals)
- identifying risk factors (prior attempts, past or current psychiatric disorder, key sx incl anhedonia, hopelessness, anxiety, impulsivity, aggression, delusions, family hx of suicide or child maltreatment, stressors like triggering events, access to meds/ firearms/ pesticides/ other lethal means)
- identifying protective factors (or lack thereof) (family/ community support, problem solving skills)
- removing the means
- activating support system
what kind of questions might be asked in assessing suicide risk
- have you wished you were dead or wished you could go to sleep and not wake up
- have you had any actual thoughts of killing yourself
- have you been thinking about (how) you might do this
- have you had these thoughts and had some intention of acting on them
- have you started to work out or worked out the details of how to kill yourself
- have you done anything, started to do anything, or prepared to do anything to end your life?
- if yes, ask was this within the past 3m
what kind of helplines or referrals are available
for mental well being: IMH mental helpline 6389 2222, samaritans of SG 1800-221-4444, tinkle friend www.tinklefriend.sg, community health assessment team www.chat.mentalhealth.sg
for counseling: TOUCHline, TOUCH Care Line, online (mindline.sg, thinkle friend, community health assessment team)
what is the etiology and pathophysiology of MDD (general classification)
- biological (hormonal influences incl incr secretion of cortisol which is a major stress hormone, monoamine theory of reduction in NT - dopamine, 5HT, NE, glutamate)
- psychological (loss, negative self-evaluation)
- psychosocial (isolation, lack of social support)
- genetics (first degree relative, second degree relative, monozygotic twin, dizygotic twin, polymorphism in 5HTT gene)
- secondary to medical disorders
- pharmacological aka drug-induced
explain the impact on risk of depression depending on the polymorphism of a gene
polymorphism in 5HTT gene
individuals with S allele of the promoter region of SERT gene are more vulnerable to the depressive effects of early life stress
S/S genotype most vulnerable to depression while L/L genotype more immune to depressive effects of early life trauma (protective effect)
what are the secondary causes of depression
- medical disorders: [endocrine] hypothyroidism, T2DM in women [deficiency] anemia, wenicke’s encephalopathy [infections] CNS, STD/HIV, TB [metabolic] electrolyte imbalance (K, Na), hepatic encephalopathy [CV] CAD, CHF, MI [neurological] alzheimer’s, epilepsy, pain, parkinson’s, post-stroke [malignancy]
- psychiatric disorders: alcoholism, anxiety disorders, eating disorders, schizophrenia
- drug induced: lipid soluble BB, psychotropics (CNS depressants like benzodiazepines, opioids, barbiturates), anticonvulsants, withdrawal from alcohol and stimulants, corticosteroids, isotretinoin, interferon beta-1-a for HepA
what is the clinical presentation and diagnostic criteria for MDD
(A) at least 5 sx present during the same 2w period and represent a change from prev func
relate to acronym In SAD CAGES
Interest: decr interest and pleasure in normal activities
Sleep: insomnia or hypersomnia
Appetite: decr appetite, weight loss
Depressed: depressed mood or irritable mood (in children)
Concentration: impaired conc and decision making
Activity: psychomotor retardation or agitation
Guilt: feelings of guilt or worthlessness
Energy: decr energy or fatigue
Suicidal: thoughts or attempts
(B) sx cause significant distress or impairment in social, occupational, or impt areas of func
(C) sx are not caused by underlying medical condition or substance
what are the types of depressive disorders (classification based on DSM-5)
- MDD (at least 5 sx for 2w incl depressed mood or loss of interest)
- persistent depressive disorder (dysthymia) (depressed mood with 2 or more sx for two years but do not fulfil MDD criteria)
- disruptive mood dysregulation disorder (for children up to age 18yo)
- premenstrual dysphoric disorder
- substance/ medication induced depressive disorder
- depressive disorder due to another medical condition
- other specified depressive disorder
- unspecified depressive disorder
what does it mean by MDD “with mixed features”
co existence within a major depressive episode of at least 3 manic sx (but unable to satisfy criteria for a manic or hypomanic episode)
manic sx incl
what are the differential diagnoses for depression
- adjustment disorder (w anxiety and/or depressed mood) - sx occur within 3m from onset of stressor but once stressor removed, the sx do not persist for additional 6m
- acute stress disorder - sx occur within 1m from a traumatic event lasting 3d-1m; sx incl horror, fear, helplessness, dissociations, re-experiencing, avoidance, incr arousal
- seasonal affective disorder
- substance induced mood disorder
what are the general assessments to help with diagnosing depression
- hx of presenting illness
- psychiatric hx
- substance use hx
- complete medical hx and medication hx
- family, forensic, developmental, social, occupational hx
- physical and neurological exam
- mental state exam
- labs and other investigations
how to differentiate between depression, delirium, dementia, withdrawal/ intoxication
differentiate using comparators onset, consciousness, memory
depression: cyclical onset, generally unimpaired consciousness, intact memory
delirium: acute onset, impaired consciousness, poor memory
dementia: insidious/ step wise change onset, consciousness remains clear until later stages, poor short and long term memory
withdrawal/ intoxication: acute onset, continuum of unimpaired to impaired consciousness, intact memory
what are the psychiatric rating scales used for assessment (clinician used and self rated)
clinician used rating scales incl:
1. hamilton rating scale for depression (HAM-D) - remission if score 7 or less (therapy goal is to be sx free)
2. clinical global impression - severity scale (CGI-S)
3. montgomery-asberg depression rating scale (MADRS)
self rated scales incl:
1. screening tool use patient health questionnaire (PHQ-2)
2. assessment tool use PHQ-9 - score 1-4 indicates minimal sx (in remission), 5-9 indicates mild depression, 10-14 indicates moderate depression, 15-19 indicates moderately-severe depression, 20 and above indicates severe depression
3. quick inventory for depressive sx (IDS) -SR
4. beck depression inventory (BDI)
5. geriatric depression scale (GDS) - 15-item short form, 30-item long form
based on the PHQ9 assessment tool, which score is indicated for tx with antidepressants
score 1-4: minimal sx (in remission)
score 5-9: mild depression
score 10-14: moderate depression
score 15-19: moderately-severe depression
score 20 and above: severe depression
classification of moderate depression or worse means indicated for tx
what are the qns asked in screening tool PHQ-2 and when would PHQ-9 be administered to a pt
PHQ-2 qns: over the past 2 weeks how often have you been bothered by any of the following problems? (i) little interest or pleasure in doing things (ii) feeling down, depressed or hopeless
-> if pt has a positive resp to either qn, consider administering PHQ-9
-> if pt has a negative resp to both qns, it is a neg result for depression screening
outline the types of non pharmacotx for depression
- sleep hygiene - to improve sleep habits
- psychotherapy - not suitable for monotx in moderate to severe depression, typically adjunct with antidepressants
- neurostimulation - electroconvulsive therapy (ECT) for severe refractory cases, repetitive transcranial magnetic stimulation (rTMS)
- light therapy - for seasonal affective disorder
outline the types of pharmacotx for depression (when is pharmacotx indicated and what are the considerations before deciding on agent and what is first line)
pharmacotx indicated for moderate to severe depression
antidepressants w/wo adjunctive meds
consider target sx (eg. bupropion for if pt has low energy, mirtazapine for if pt has loss of appetite and insomnia), comorbids, ddi, prior response, preferences
first line is mirtazapine, SSRI, SNRI or bupropion
what are the tx phases for tx of depression
- acute phase: adequate trial = 4-8w at adequate dose
- continuation phase: continue for at least another 4m after acute phase (at least 6-12m total)
