Depression

Question 1

What is depression?

Answer 1

Low moods associated with a loss of interest and enjoyment in ordinary things

Question 2

What are the symptoms of depression?

Answer 2

Psychological - loss of interest, poor memory, suicidal thoughts

Physical- poor sleep, lack of appetite and lethargy

Emotional - anger, irritable or sadness

Question 3

What are the complications of depression?

Answer 3

Exacerbation of conditions- pain

Risk of substance misuse

Reduced QoL

Increased morbidity

Suicidal thoughts

Question 4

What is the DSM-5 criteria for diagnosing depression?

Answer 4

A consistent state of depressive mood continuously for 2 years in adults

1 year in children and adolescents

Not been without symptoms for more than 2 months

Question 5

How should you treat mild depression?

Answer 5

CBT - low intensity (8 sessions), high = up to 20

Sleep hygiene

Anxiety management

Exercise

No antidepressants poor risk: benefit ratio

Question 6

How should moderate depression be treated?

Answer 6

CBT and antidepressants

More impact on QoL

Question 7

How should severe depression be treated?

Answer 7

Unable to function at all

CBT and antidepressants

Question 8

Which antidepressant increases the risk of suicidal thoughts and what should be done?

Answer 8

SSRIs

Refer patient to a crisis team - mind or samaritans

Only continue treatment after 6 months of remission to prevent relapse

Review the patient

Question 9

What is first line treatment for depression and why?

Answer 9

SSRIs - sertraline, citalopram, fluoxetine

Under 16s - fluoxetine

Sertraline less drug interactions

Question 10

How should SSRIs be taken?

Answer 10

Take in the morning - high serotonin suppresses REM sleep

In elderly, taking NSAIDs or aspirin give a PPI

Question 11

What is second line treatment for depression and why?

Answer 11

SNRI - duloxetine and venlafaxine

Has more side effects but has dual action

Question 12

Which SNRI can be taken at night?

Answer 12

Mirtazapine

It is not an uptake inhibitor but an antagonist of 5HT2, H1and alpha 2

Antihistamine action at low dose

Question 13

Why are monoamine oxidases not used often?

Answer 13

It has strong side effects but is used in dramatic decline

Hepatotoxicity

Interacts with cheese

Seizures

Hypertension

Serotonin syndrome

Question 14

When will antidepressants give an effect?

Answer 14

It takes 4 weeks an effect

Question 15

What is the plan action if antidepressant does not work after 4 weeks?

Answer 15

Switch to another SSRI, SNRI or mirtazapine

Cross tapering- Gradually reduce dose of 1st antidepressant and start the 2nd at a low dose, increase when lowering the first one

Same class can do a direct switch

Question 16

What are symptoms of withdrawal and how should they be managed?

Answer 16

Relapse, restlessness, sweating and poor sleep

Reduce dose by 25% every 4-6 weeks

Withdraw over 6-8 weeks

Question 17

What are the symptoms of serotonin syndrome?

Answer 17

Cardiac

Tremors

Jerky movements

Question 18

Which drugs cause serotonin syndrome?

Answer 18

Triptans

Tramadol

SSRI

SNRI

Question 19

What are the major drug interactions with antidepressants?

Answer 19

NSAIDs - in elderly

Warfarin - increases INR

Triptans

Question 20

What combinations are used in treatment resistant depression?

Answer 20

Fluoxetine and olanzapine or aripiprazole

Antidepressant and second-gen antipsychotic

Side effects can lead to failure

Question 21

When is electro-convulsive therapy used?

Answer 21

When patients want to commit suicide

Severe manic episodes

The pt is on constant anaesthesia

Question 22

What are the issues with tricyclic antidepressants?

Answer 22

Strong side effects - anticholinergic burden and sedating

Weight gain

High BP