Affective disorders - Depression Flashcards
(86 cards)
1
Q
Are mood disorders primary or secondary?
A
Can be both, occur randomly or in resposne to a problem
2
Q
What changes in mood occur in depression?
A
- Depression
- Anxiety
- Perplexity
- Anhedonia
3
Q
What changes occur in thought content in depression?
A
- Guilt
- Hopelessness
- Worthlessness
- Neuroses - Hypochondriasis, agarophobia
- Ideas of reference
4
Q
What changes in beliefs and perceptions can occur in a depressed individual?
A
- Delusions
- Hallucination
5
Q
What changes in bodily function occur in a depressed individual?
A
- FATIGUE
- SLEEP DISTURBANCE - most commonly early wakening
- APPETITE - weight loss
- LIBIDO
- CONSTIPATION
- PAIN
6
Q
What psychomotor changes can occur in depression?
A
- Agitation
- Retardation
7
Q
What social changes can occur in someone with depression?
A
- LOSS OF INTERESTS/APATHY
- IRRITABILITY
- WITHDRAWAL/LOSS OF CONFIDENCE
8
Q
When classifying depression, what criteria does it have to meet (besides the actual symptomatology)?
A
- Last for at least 2 weeks
- No hypomania or manic episodes
- Not 2o to drug/alcohol misuse, medications, medical disorder, or bereavement
- Cause significant functional limitation
9
Q
What are the core symptoms of depression as defined by ICD-10?
A
- Low mood - most of the day, everyday, for at least 2 weeks
- Anhedonia - loss of pleasure/interest
- Low/decreased energy
10
Q
What are typical symptoms of depression which are additional to the 3 core symptoms as defined by the ICD-10?
A
Remember GLASS SAC
- Unreasonable feeling of Guilt
- Decreased Libido
- Change in Appetite
- Sleep disturbance of any sort
- Low Self esteem
- Suicide thoughts/behaviour
- Agitation or retardation
- Decreased Concentration
11
Q
What are the criteria for the diagnosis of mild depression?
A
At least 2 core symptoms + 2 additional = 4 symptoms
12
Q
What are the criteria for the diagnosis of moderate depression?
A
At least 2 core symptoms + 3-4 additional symptoms = 5-6 symptoms
13
Q
What are the criteria for the diagnosis of severe depression as per ICD-10?
A
All 3 core symptoms + at least 4 additional symptoms = 7 or more symptoms
or
Mild/moderate + psychosis/stupor
14
Q
The presence of what symptom(s) immediately classes depression as being severe?
A
- Psychosis
- Stupor
15
Q
How would you diagnose psychomotor retardation?
A
Objective measurement
16
Q
What are aetiological factors which can increase the risk of the development of depression?
A
- Biological - FH
- Psychological - Neuroticism, low self-esteem, childhood experience
- Social - adverse life event, stress, lower social class
17
Q
If someone presented with symptoms of depression, what would be your differential diagnosis?
A
- Normal reaction to life event
- Psychiatric - Bipolar, schizophrenia, anxiety, anorexia
- Dysthymia/Cyclothymia
- Substance misuse
- Stroke, tumour, dementia
- Infection
- Medications
- Endocrine - Hypothyroidism, Addison’s, hyperparathyroidism
18
Q
If someone presented to you with low mood, what endocrine disorders would you think of?
A
- Hypothyroid
- Addison’s
- Hyperparathyoroidism
19
Q
If someone presented with low mood, what psychiatric problems would you consider as part of your differential diagnosis?
A
- Bipolar
- Schizophrenia
- Anxiety
- Anorexia nervosa
20
Q
If someone presented with low mood, what neurological problems would you consider?
A
- Stroke
- Dementia
- Tumour
21
Q
What investigations would you do in someone with low mood/apparent depression?
A
- Assessment - measurement tools
Beyond this, based on excluding treatable causes:
- Consider Bloods - FBC, ESR, B12/folate, TFTs, LFTs, glucose, Ca2+
- Consider Toxicology screen
- Medication reconcilliation/drug history
22
Q
How would you manage someone with mild depression?
A
Psychological intervention
- Improved sleep hygeine
- Anxiety management
- CBT
No pharmacological intervetion unless symptoms extend beyond 8 weeks
23
Q
How would you manage moderate depression?
A
- High intensity psychological intervention
- Antidepressant - SSRI is first line
24
Q
How would you manage someone with severe depression?
A
Consider contacting mental health services if high risk of self harm
25
What medications are used to treat depression?
Antidepressants
* **SSRI's**
* **TCA's**
* **Monoamine oxidase inhibitors**
* **SNRI's**
26
What is the mechanism of action of Tricyclic antidepressants?
Monoamine (serotonin and noradrenaline) reuptake is blocked by the TCAs which antagonise the amine transporter, resulting in a greater monoamine concentration in the synapse
27
What are examples of TCAs?
* **Amitriptyline**
* **Clomipramine**
* **Nortriptyline**
28
When are TCA's indicated for use?
* **Depression**
* **Anxiety disorder**
* **Neuropathy**
29
What are common side effects of TCA's?
* **Anti-cholinergic effects** - dry mouth, blurred vision, constuipation, hypotension, urinary retention
* **Arrhythmias/Heart block**
* **Hyponatraemia** **-** due to SIADH
30
What is the mechanism of action of monoamine oxidase inhibitors?
## Footnote
Amine neurotransmitters (e.g. 5HT, catecholamines, dopamine) are broken down to inactive metabolites by the enzyme monoamine oxidase (MAO), of which two isoforms exist, in nerve terminals:
* **MAOA** - found principally in the gut and liver
* **MAOB** - found in the brain
MAO inhibitors prevent breakdown of amine neurotransmitters by irreversibly binding with the enzyme
31
When are monoamine oxidase inhibitors used?
* **Resistant depression**
* **Parkinson's Disease**
32
What are side effects of MAOI's?
* **Orthostatic hypotension**
* **Weight gain**
* **Dry mouth**
* **3 S's** - Sedation, Sexual dysfunction, Sleep disturbance
33
What is the mechanism of action of SSRI's?
Serotonin is a monoamine neurotransmitter with a role in regulation of mood. SSRIs selectively inhibit the reuptake of the monoamine serotonin (5-HT) within the synapse. The prolongation of the presence of serotonin in the synapse causes an upregulation of its effects on the postsynaptic neuron.
34
What are examples of SSRI's?
* **Citalopram**
* **Fluoxetine**
* **Paroxetine**
* **Sertraline**
35
What is a specific adverse reaction that can occur with MAOI's?
**Tyramine (cheese) reaction** - Tyramine in foodstuffs is not broken down by bound MAOA and enters circulation causing dangerous hypertension due to its sympathomimetic effect
36
When are SSRI's indicated for use?
* **Depressive illness**
* **Panic disorder**
* **Obsessive compulsive disorder**
* **Anxiety disorders**
37
What problem can occur when MAOI's are taken in combination with medications which increase serotonin?
**Serotonin syndrome**
38
What is serotonin syndrome?
A group of symptoms that may occur following use of certain serotonergic medications or drugs:
* Abdo pain/diarrhoea
* Sweats
* Tachycardia
* HTN
* Myoclonus
* Irritability
* Delerium
Can lead to hyperpyrexia, CVS shock and death
39
When starting someone on SSRI's, what do you have to warn them about?
**Activation and discontinuation syndromes**
40
What symptoms occur in activation syndrome that is caused by SSRI's?
* **Nausea**
* **Increased anxiety, panic and agitation**
41
How long does activation syndrome last in patients who have been started on SSRI's?
2-10 days
42
What are the symptoms associated with discontinuation syndrome with SSRI use?
* **Agitation**
* **Nausea**
* **Disequilibrium**
* **Dysphoria**
More common with drugs with shorter half-life
43
What are the most common side effects associated with SSRI's?
* **GI upset**
* **Sexual dysfunction**
* **Anxiety**
* **Restlessness**
* **Nervousness**
* **Insomnia**
* **Fatigue**
* **Sedation**
* **Dizziness**
44
What can occur when SSRI's are used in combination with other drugs that increase seratonin levels?
Seratonin syndrome
45
What drugs of abuse can in increase the risk of serotonin syndrome developing if used with SSRI's?
* **Amphetamines**
* **Cocaine**
* **LSD**
46
Why does fluoxetine have a lower risk of discontinuation syndrome than other SSRI's?
Longer half-life
47
What is the mechanism of action of serotonin/noradrenaline reuptake inhibitors?
Inhibit both serotonin and noradrenergic reuptake like the TCAS but without the antihistamine, antiadrenergic or anticholinergic side effects
48
What are the indications for SNRI use?
* **Depression**
* **Anxiety**
* **Sometimes neuropathic pain**
49
What is Mirtazapine?
**Novel antidepressant**
Can be used to augment SSRI action due to different mechanism of action
50
What would be a first line anti-depressant?
**SSRI** - fluoxetine, citalopram, sertaline
51
When using SSRI's, what do you have to keep and eye on?
* **FBC** - anaemia
* **U+E's** - hypernatraemia
* **ECG** - citalopram causes QT elongation
52
What delusions are often seen in depression?
* **Usually negative/guilty**
* **Nihilistic**
53
What Hallucinations are seen in depressed patients?
**Auditory** - second person - telling them they are worthless
Can also be visual, tactile, olfactory, gustatory
54
When asking about medical history in a patient with depression, what is important to ask about?
* **Thyroid disorders** - hypo can mimic depression
* **Chronic illness/pain**
55
When asking about medications in a patient with suspected depression, what medications are you looking out for?
Beta-blockers
56
How would someone with depression appear?
* Poor self-care
* Reduced range of facial expressions
57
What might you notice when assessing a depressed persons behaviour?
* Psychomotor retardation/agitation
* Reduced eye contact
58
When assessing speech of someone who is depressed, what might you see?
* **Slow**
* **Quiet**
* **Monotonous**
59
When assessing mood and affect in a person with suspected depression, what might you see?
* Subjectively and objectively depressed mood
* Reduced range and intensity of affects
60
When assesing thought in someone who you suspect to be depressed, what might you notice?
**Form**
* Thoughts may be slowed
**Content**
* Negative, guilty or suicidal thoughts
* Depressive delusions if psychotic
61
When assessing perceptions in someone who you suspect to be depressed, what might you find?
Possible auditory hallucinations if psychotic
62
When assessing cognition in someone with depression, what might you find?
Normal cognition
63
When assessing insight in someone with depression, what might you find?
Usually present
64
What psychological interventions can be used to treat depression?
* **CBT**
* **Interpersonal therapy**
* **Individual dynamic psychotherapy**
65
What physical therapies can be used in depression?
[https://www.youtube.com/watch?v=W8Ypt-vKI2U](https://www.youtube.com/watch?v=W8Ypt-vKI2U)
**Electro-convulsive therapy**
66
When is ECT used?
* **Severe intractable depression**
* **Prolonged, severe mania**
* **Catatonia**
67
What is the proposed mechanism of action of ECT?
It interrupts the hyperconnectivity between the various areas of the brain that maintain depression
68
What are side effects to ECT?
* **Memory loss** - Short term retrograde amnesia
* **Confusion**
* **Headaches**
* **Clumsiness**
69
How long would you trial someone on an antidepressant medication?
6 weeks
70
If the dose of an antidepressant medication is found to be effective, how long should you continue it for for first episode of depression?
6-12 months
71
If the dose of an antidepressant medication is found to be effective, how long should you continue it for for second episode of depression?
2 years
72
If the dose of an antidepressant medication is found to be effective, how long should you continue it for a third episode of depression?
Lifelong
73
What can happen if depression is left untreated?
## Footnote
Untreated, depression usually lasts ***_six to twelve months_***
However it can become chronic
Even if it resolves without treatment, the patient may be left with some symptoms e.g. insomnia
74
What are "complications" of depression?
* **Suicide**
* **Psychosis**
* **Social and Occupational dysfunction**
* Unemployment or problems at work
* Family and relationship problems
* Socially isolation
75
What delusions can be experienced in depression?
* **Poverty**
* **Personal inadequacy**
* **Guilt over presumed misdeeds**
* **Responsibility for events**
* **Deserving of punishment**
* **Nihilistic delusions**
76
What auditory hallucinations can be experienced in depression?
* **Defamatory**
* **Accusatory**
* **Cries for help**
77
What olfactory hallucinations can be experienced in depression?
Bad smells
* **Rotting food**
* **Faeces**
* **Decomposing flesh**
78
What visual hallucinations can occur in depression?
* **Tormentors**
* **The Devil/Demons**
* **Dead bodies/Scenes of death or torture**
79
What are the somatic symptoms of depression?
* **Loss of emotional reactivity**
* **Diurnal mood variation**
* **Anhedonia**
* **Early morning wakening**
* **Psychomotor agitation/retardation**
* **Loss of appetite/weight**
* **Loss of libido**
80
What is important to remember in terms of suicide risk with the use of antidepressants?
Risk increases in the early stages of treatment
81
When choosing which antidepressant to use, what factors should you take into consideration?
* **Patient** - age, sex, comrobidities
* **Tolerability**
* **Symptomatology**
82
In terms of treating someone with depression who was suffering from sleep disturbance, what sort of agent would you potentially use?
More sedative agent
83
In terms of treating someone with depression who was suffering from lack of energy/hypersomnia, what sort of agent would you potentially use?
Adrenergic/stimulatory agent
84
In terms of treating someone with depression who was suffering from OCD symptoms, what sort of agent would you potentially use?
Clomiparmine/SSRI
85
What is seasonal affective disorder?
Seasonally dictated recurrent depressive episodes
86
What is dysthymia?
The presence of chronic, low-grade depressive symptoms. Possible to have superimposed depressive episodes
Can be regarded as a baseline rather than being euthymic
