Depression

Question 1

Define depression

Answer 1

• Feelings of sadness, loss of interest/pleasure, feelings of guilt or low self-worth, disturbed sleep and appetite
• Persists for > 2 weeks
• Feelings interfere with life

Question 2

What is the epidemiology of depression?

Answer 2

• 1 : 6 in UK

- Incident rate of 3-6% of adults

Question 3

What are the risk factors of depression?

Answer 3

Female:Male = 2:1

• More willing to come forward
• Pregnancy and postpartum depression

Middle aged men

PHx/FHx Mental illness/chronic illness

Refugee/asylum seeker

Question 4

MSE: Appearance & Behaviour of depressed patient

Answer 4

Possibly unkempt
Lack of interest in looks and hygiene

Tearful
Minimal eye contact
Hard to engage

Question 5

MSE: Speech of depressed patient

Answer 5

speech rate = reduced
volume = soft
tonality = monotonous
quantity = minimal
ease of conversation = possibly hard

Question 6

MSE: Mood of depressed patient

Answer 6

Subjective - how patient feels
Objective - how patient seems

Low mood = Dysphoric

Question 7

MSE: Thoughts of depressed patient

Answer 7

Form

• Maybe preoccupation of thought
• Delusion - obsessive thoughts

Content

• Feelings of low self worth
• Feelings of guilt
• Feelings of self harm/suicide
• Lack of future plans

Question 8

MSE: Perceptions of depressed patient

Answer 8

Should not be any unless deteriorated into acute psychoses

Question 9

MSE: Cognition

Answer 9

• Should be intact

- Can orientate to time, place, person

Question 10

MSE: Insight of depressed patient

Answer 10

?Acknowledgement of condition

Awareness of pathological events - suicidal impulses

Question 11

What are the 2 useful screening questions for depression?

Answer 11

1. In the last month have you often been bothered felt down, depressed or hopeless?
2. In the last month have you often been bothered by having little interest or pleasure in doing things?

YES TO EITHER = FURTHER ASSESSMENT

Question 12

What further assessments can be used for depression?

Answer 12

1. HOSPITAL ANXIETY AND DEPRESSION SCORE (HAD)
   - 7 Qs for depression + 7 Qs for anxiety
   - Produces score out of 21 for both depression and anxiety
   - Severity: 0-7 = normal, 8-10 = borderline, 11 + = positive conditions
2. PATIENT HEALTH QUESTIONNAIRE
   - 9 items inc. self-harm assessment
   - Severity: 0-4 = none, 5-9=mild, 10-14 = moderate, 15-19 = moderately severe, 20-27 = severe

Question 13

How does the ICD-10 rank depressive episodes?

Answer 13

Has 2 categories for symptoms

1) MAIN
- Depressed mood
- Anadonyia (loss of interest)
- Reduced energy and activity

2) ACCESSORY
- Reduced concentration
- Reduced self-esteem
- Ideas of guilt and self-worth
- Pessimistic thoughts
- Disturbed sleep
- Diminshed appetite
- Ideas of harm

F32.0 Mild episode
-2 or 3 symptoms but can continue activities

F32.1 Moderate episode
>+4 symptoms - difficulty in activities

F32.2 Severe depression w/o psychosis
-Several symptoms, debilitating, suicidial thoughts and acts common

F32.3 Severe depression w/ psychosis

F33 Recurrent depression

Question 14

What other subtypes of depression can occur?

Answer 14

Atypical depression
Psotnatal depression
Seasonal affective disorder
Premenstrual dysphoric disorder

Question 15

How is depression diffierentially diagnosed from dementia?

Answer 15

• Short Hx & rapid onset
• Biological symptoms e.g. weight loss, sleep disturbances
• Pt worried about memory loss (rather than no insight into memory loss)
• Reluctance to take tests, disappointed with results
• Mini mental test score variable
• Global memory loss

Question 16

What are the various treatment options for depression?

Answer 16

GENERAL
-sleep hygiene, remain physically healthy, active monitoring

PSCYHOLOGICAL INTERVENTIONS
-CBT (One on one, computerised, group)

MEDICAL

• SSRI
• SNRI
• TCAs
• MAOis
• Noradrenergic & specific serotenergic antidepressants

Question 17

What is the drug profile for SSRIs

Answer 17

SELECTIVE SEROTONIN UPTAKE INHIBITORS
e.g. fluoxetine, citalopram, sertraline (1st line)

MOA: Increase extracellular serotonin by limiting reabsorption

SE: sexual dysfunction, withdrawal, insomnia, hyponatraemia

CONTRA: warfarin (use mirtazapine instead)

Question 18

How should taking SSRIs be communicated?

Answer 18

• 1 tablet everyday
• Will take 4-6 weeks before feeling the effects
• Reports of anxiety in first 2 weeks so keep people around you
• standard course 3-6 months AFTER FEELING BETTER
• Must taper dose so if feel better need guidance to reduce otherwise withdrawal

Question 19

What is the drug profile of SNRIs?

Answer 19

SEROTONIN NORADRENALINE REUPTAKE INHIBITORS
E.g. duloxetine, venaflexaine

MOA: Increases extracellular serotonin and noradrenaline by limiting reabsorption

SE: sexual dysfunction, withdrawal, insomnia, hyponatraemia, may increase BP

Question 20

What is the drug profile for TCAs?

Answer 20

TRICYCLIC ANTIDEPRESSANTS
e.g. amitriptyline

MOA: Blocks serotonin and Na+ transporters resulting in elevation in their synaptic connections

SE: Anti-muscarinic (dry mouth, constipation, blurred vision, urinary retention), hyponatraemia

Notes: dangerous in overdose

Question 21

What is the drug profile for MOAs?

Answer 21

MONOAMINE OXIDASE INHIBITORS
e.g. moclobemide, phenelzine, selegine

MOA: Inhibits monoamine oxidase (enzyme) the breaks down monoamines

SE: HTN (hypertensive crisis esp. when eating cheese), hepatocellular jaundice, hyperthermia

Question 22

What is the drug profile for NaSSAs?

Answer 22

Noradrenergic & specific seroternergic antidepressants
e.g. Mitazapine

• GI Problems
• Can be sedating but good for sleep