Depression

Question 1

Associated symptoms of depression

Answer 1

Disturbed sleep
Decreased/increased appetite/weight 
Fatigue 
Poor concentration 
Feelings of worthlessness 
Suicidal thoughts

Question 2

When is seasonal affective disorder diagnosed

Answer 2

If the person has episodes of depression which recur annually at the same time each year with remission in between

Question 3

Which factors may affect the development, course and severity of depression

Answer 3

Hx of mental illness 
Past history of mood elevation 
Living conditions and social isolation 
Family history 
Domestic violence/sexual abuse 
Employment and immigration status

Question 4

Co-morbid conditions associated with depression

Answer 4

Alcohol or substance abuse 
Anxiety 
Eating disorders 
Psychotic symptoms 
Dementia

Question 5

Which questions are important to ask when assessing the risk of suicide

Answer 5

Any thoughts about death or suicide?
Do you feel life is not worth living?
Have you made a previous suicide attempt?
Is there a family history of suicide?

Question 6

What questions should be asked if an individual has said yes to any of the initial suicide assessment questions

Answer 6

Have you considered a method?

Do you have access to the materials?

Have you made any preparations?

Question 7

Risk factors which increase the risk of suicide

Answer 7

Previous suicide attempts 
Active mental illness 
Family history of mental disorder 
Male gender 
Being unemployed 
Physical health problems 
Drug/alcohol abuse

Question 8

Recommended questionnaires for detecting depression and assessing severity

Answer 8

PHQ-9
HADS
BDI-II

Question 9

Interpretation of PHQ-9

Answer 9

Max score of 27
Scores of 5, 10, 15 and 20 represent cut off points for mild, moderate, moderately severe and severe depression, respectively

Question 10

General management of depression in primary care

Answer 10

Manage suicide risk
Manage safeguarding concerns
Manage any co-morbid condition associated with depression

Question 11

Useful contact for managing suicide risk in primary care

Answer 11

Crisis Resolution and Home Treatment(CRHT) team for urgent assessment

Question 12

When should antidepressants be considered for mild-to-moderate depression

Answer 12

Avoid routine use
Consider in:
History of moderate or severe depression
Subthreshold depressive symptoms that have persists for a long period
Mild depression that is complicating the care of a chronic physical health problem

Question 13

Management of mild-to-moderate depression in primary care

Answer 13

Low-intensity psychosocial intervention

CBT

Question 14

What should be evaluated before starting an antidepressant

Answer 14

Suicide risk and toxicity in overdose
Risk of anxiety worsening
Explain that antidepressants take time to work and should be continued for at least 6 months following remission of symptoms to reduce risk of relapse

Question 15

Who does the mental health act allow compulsory admission for

Answer 15

People who:

Have a mental disorder of a nature or degree that warrants assessment or treatment in hospital, and

Need to be admitted in the interests of their own health or safety, or for the protection of other people

Question 16

How long does section 2 allow compulsory admission for

Answer 16

Up to 28 days for assessment

Question 17

How long does section 3 allow compulsory admission for

Answer 17

Up to 6 months for treatment

Question 18

Who does section 2 and 3 of the mental health act require approval from

Answer 18

Approved mental health professional, or the person’s nearest relative

Written recommendations from two doctors; one of whom is section 12 approved(psychiatrist) and one who has previous acquaintance with the individual(usually GP)

Question 19

When is section 4 of the mental health act used and how long does it allow for compulsory admission for?

Answer 19

Used in exceptional cases to permit compulsory admission for up to 72 hours if there is urgent necessity, and undesirable delay

Question 20

Who does section 4 require approval from

Answer 20

Requires application from an AMHP(or person’s nearest relative) and just one medical recommendation

Question 21

Who can use section 136 of the mental health act

Answer 21

Used by the police to take people from a public place to a place of safety so they can be assessed

Question 22

Can young people who have capacity to consent be admitted on the basis of their parents’ consent

Answer 22

Young people aged 16 or 17 who have capacity to consent, but refuse to do so, cannot be admitted or kept in hospital for treatment on the basis of parents’ consent

They will need to be formally detained under MHA

Question 23

Examples of low-intensity psychosocial interventions

Answer 23

Individual guided self-help, based on the principles of CBT

Computerised CBT

Structured group-based physical activity programme

Question 24

Examples of high-intensity psychological interventions

Answer 24

Individual CBT
Interpersonal therapy
Behavioural activation
Couples therapy

Question 25

First line antidepressant for the first episode of depression

Answer 25

SSRI such as citalopram, fluoxetine, paroxetine or sertraline

Question 26

Which SSRI may be preferred if a person has a chronic physical health problem alongside depression

Answer 26

Sertraline due to lower risk of drug interactions

Question 27

Which SSRI should be avoided in patients already taking medications that can prolong QT interval

Answer 27

Citalopram or escitalopram

Question 28

Organisations that can help with depression

Answer 28

MIND | Depression Alliance

Question 29

General advice for an individual receiving SSRIs for treatment

Answer 29

To be vigilant for worsening depressive symptoms and suicidal ideas especially when starting and changing meds Usually takes 2-4 weeks to improve Not addictive May experience discontinuation symptoms if they stop taking antidepressants abruptly

Question 30

When should you review someone with depression if they are not considered to be at an increased risk of suicide

Answer 30

Arrange an initial review within 2 weeks Review regularly thereafter - for example, every 2-4 weeks for the first 3 months and if the response to treatment is good, longer review intervals can be considered

Question 31

When should you review someone with depression if they are at an increased risk of suicide, or people aged under 30 years

Answer 31

Arrange an initial review within 1 week Review frequently thereafter until the risk is no longer considered clinically important

Question 32

Next step of treatment if low-intensity psychosocial intervention has not worked for depression

Answer 32

High-intensity psychological intervention or an antidepressant Next step is combination therapy

Question 33

Advice regarding use of St john's wort in depression

Answer 33

Advise to avoid

Question 34

Adverse effects of antidepressants that should be monitored for

Answer 34

Suicidal thoughts and suicide attempts Anxiety, agitation, or insomnia Hyponatraemia Sexual dysfunction

Question 35

Symptoms of hyponatraemia

Answer 35

``` Dizziness Drowsiness Confusion Nausea Muscle cramps Seizures ```

Question 36

Management of hyponatraemia in individuals taking antidepressants

Answer 36

Stop the antidepressant Manage according to severity and duration of symptoms, and state of hydration After serum sodium levels have normalised, choose another appropriate antidepressant

Question 37

Risk factors for hyponatraemia in individuals taking antidepressants

Answer 37

``` Older age Female gender Major surgery History of hyponatraemia Co-therapy with diuretics, NSAIDs etc Reduced renal function Low body weight Medical comorbidity ```

Question 38

Management of sexual dysfunction in depression

Answer 38

Watchful waiting Reducing dose of antidepressant Drug holidays(missing doses prior to planned sexual activity) Adjunctive treatment with sildenafil

Question 39

Features of serotonin syndrome

Answer 39

``` Confusion Delirium Shivering Sweating Changes in blood pressure Myoclonus ```

Question 40

How should antidepressants be stopped

Answer 40

Reduce the dose or frequency gradually over a 4-week period

Question 41

Discontinuation symptoms of antidepressants

Answer 41

``` Restlessness Problems sleeping Unsteadiness Sweating Abdominal symptoms Altered sensations(Paraesthesia) Irritability Anxiety ```

Question 42

What should be co-prescribed if a patient is taking an NSAID along with an SSRI

Answer 42

PPI

Question 43

SSRIs in pregnancy

Answer 43

Use during the first trimester gives a small increased risk of congenital heart defects - Use during the third trimester can result in persistent pulmonary hypertension of the newborn - Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Question 44

What type of antidepressant is rasagiline

Answer 44

MAOI

Question 45

Which SSRI has a longer half-life and therefore has a lower risk of inducing withdrawal symptoms

Answer 45

Fluoxetine

Question 46

Definition of treatment-resistant depression

Answer 46

Persistent depressive symptoms not responsive to two antidepressants for a minimum of 4-6 weeks at therapeutic dose

Question 47

Management of treatment-resistant depression

Answer 47

- Mirtazapine(NaSSA) and venlafaxine(SNRI), or other combinations - Augment with an antipsychotic - Lithium - ECT

Question 48

First line treatment of diabetic neuropathy

Answer 48

Duloxetine

Question 49

Side effects of SNRIs

Answer 49

Risk of cardiac dysfunction with SNRIs such as venlafaxine + greater risk of toxicity in overdose than SSRIs + seizures

Question 50

Section 5(2) of MHA

Answer 50

Detention of a patient already in hospital for up to 72 hours (A&E does not count) Can be put on by the ward doctor or an Approved Clinician

Question 51

Section 5(4) of MHA

Answer 51

Any authorised psychiatric nurse may use force to detain a voluntary 'mental' patient who is taking their own discharge against medical advice, if such a discharge would be likely to involve serious harm to the patient (eg, suicide) or to others. During the 6 hours, the nurse must find the necessary personnel to sign a Section 5(2) application or allow the patient's discharge.

Question 52

Section 2 of MHA

Answer 52

The period of assessment (and treatment) lasts for up to 28 days and is not renewable. Patients' appeals must be sent within 14 days to the mental health tribunal (composed of a doctor, lay person and lawyer). An AMHP or the NR makes the application on the recommendation of two doctors, one of whom is 'approved' under Section 12(2) of the Act (in practice a consultant psychiatrist or a specialist registrar of sufficient experience). The second medical recommendation is given by a doctor who knows the patient personally in a professional capacity.

Question 53

Section 3 of MHA

Answer 53

Detention for treatment for 6 months. The exact mental disorder must be stated. Detention is renewable for a further six months (annually thereafter). Two doctors must sign the appropriate forms and know why treatment in the community is contra-indicated. They must have seen the patient within 24 hours and there may not be more than five clear days between the time the first doctor saw the patient and the time when the second doctor saw them. They must state that treatment is likely to benefit the patient, or prevent deterioration; or, that it is necessary for the health or safety of the patient or the protection of others. The AMHP has 14 days after the second doctor has signed their recommendation in which to make an application to hospital.

Question 54

Section 136 of MHA

Answer 54

For up to 72 hours Allows police to arrest a person 'in a place to which the public has access' and who is believed to be suffering from a mental disorder. The patient must be conveyed to a 'place of safety' (usually a designated A&E department) for assessment by a doctor (usually a psychiatrist) and an approved social worker. The patient must be discharged after assessment or detained under Section 2 or 3. The patient may also accept the offer of a voluntary admission into hospital.

Question 55

SSRI discontinuation symptoms

Answer 55

``` increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia ```

Question 56

How should SSRIs be reduced

Answer 56

Over 4 week period