Depression Flashcards
(40 cards)
What are the indications for ECT?
Treatment-resistant depression
Life-threatening severe depression
Treatment-resistant mania
Catatonia
What are the core symptoms of depression?
- low mood
- reduced energy/ fatigue (anergia) - universal symptom
- Loss of interest and enjoyment (anhedonia)
Usually expect them to last for at least 2w to merit a diagnosis
What are additional symptoms of depression?
Reduced concentration, slowing of thinking and speech.
Reduced confidence and self-esteem
Ideas of guilt and unworthiness
Pessimism about the future
Ideas/acts of self-harm/suicide
Disturbed sleep- usually patient wakes early in AM but is ok getting to sleep. Can also see difficulty falling asleep.
Changes in appetite- mostly appetite loss and associated weight loss
What is the somatic syndrome?
The biological symptoms of depression:
(1) marked loss of interest or pleasure in activities that are normally pleasurable (anhedonia)
(2) lack of emotional reactivity
(3) waking in the morning 2 hours or more before the usual time;
(4) depression worse in the morning;
(5) objective evidence of marked psychomotor retardation or agitation
(6) marked loss of appetite;
(7) weight loss (5% or more of body weight in the past month);
(8) marked loss of libido
Describe depression with psychosis.
Delusions: Tend to be mood congruent. e.g. Worthlessness, guilt- that they have committed awful sin/ crime, hypochondriacal - ill health, poverty, imminent disaster
Nihilistic delusions - belief in the absence of something vitally important- that the self, part of the self, part of the body, other people, or the whole world has ceased to exist/ is dead/ not working. “my body is empty, my organs are dead”
Persecutory delusions can also occur - belief that others are trying to harm/ persecute patient.
Think of Mary
Depressive delusion: belief that you are to blame for catastrophes/ accidents etc that you clearly have no link with.
Hallucinations
2nd person auditory - often accusatory or defamatory
Olfactory - e.g. filth, or rotting/decomposing flesh
What are some of the risk factors for suicide?
Depression, self-harm, feelings of hopelessness, anxiety + depression / agitated depression high risk.
5-15% depressed patients commit suicide.
Define mild depression
At least two of the three core symptoms: anhedonia, anergia, low mood
Plus additional symptoms, giving a total of at least four
With or without the somatic syndrome
Define moderate depression
At least two of the three core symptoms
Plus additional symptoms, giving a total of at least six
With or without the somatic syndrome
Define severe depression
All three core symptoms
Plus additional symptoms, giving a total of at least eight
Define severe depression with psychotic symptoms
All three core symptoms
Plus additional symptoms, giving a total of at least eight
Plus delusions, hallucinations or depressive stupor
What are the organic differentials for depression?
- Neurological: Multiple sclerosis, Parkinson’s disease, Huntington’s disease. spinal cord injury, CVA, head injury, cerebral tumours
- Endocrine: Thyroid and parathyroid disorders (especially hypothyroidism), Cushing’s/Addison’s disease
- Infections: HIV/AIDS, syphilis, typhoid, brucellosis, infectious mononucleosis, herpes simplex
- Iatrogenic: Secondary to prescription of opiates, L-dopa, steroids
- Others: Malignancies (especially pancreatic), SLE, rheumatoid arthritis, renal failure, porphyria
What are the psych ddx for depression?
Depression can occur as a consequence of another illness, such as schizophrenia, an anxiety disorder, an eating disorder, dementia, and so on.
Epidemiology of Depression
M:F 1:2
10-20% lifetime risk of developing depression. Point prevalence (in pop at any given pt in time) of major depressive illness 5%.
Aetiology of Depression?
Biological: genetics, hormonal changes, substance misuse, serious illness
Psychological: negative thoughts, learned helplessness, psychodynamic defence mechanisms
Social: life events, social isolation, bereavement, loss, childhood abuse, social adversity
Prognosis and Relapse in Depression.
Prognosis:
50-60% recover within 1 year. 10-25% suffer for more than two years, “chronic”
5-15% will die by suicide
Relapse: 25% will have had a further episode after 1 year, After 10 years, 75% will have had a further episode. Therefore NICE recommends continuing anti-depressants for 6m post depressive episode remission, and 2 years after remission of recurrent depression.
What is the NICE recommendation for treating known and suspected depression? (i.e. STEP 1)
Assessment, active monitoring, computerised CBT, psychoeducation e.g. sleep hygiene, guided self-help,
info on depression, referral for further assessment + intervention
What is the NICE recommendation for treating moderate/severe depression or mild- moderate depression that is not responding to tx? STEP 3
Primary care:
Medication
High-intensity psychological interventions
Consider secondary care referral
What is the NICE recommendation for treating severe complex depression/ life threatening presentation/ severe self-neglect? STEP 4
Secondary Care:
Medication - here, other meds might be considered, including:
venlafaxine, an SNRI
mirtazapine, a NASSA
TCAs, like imipramine
MAOIs, like phenelzine
adjunctive medications, such as antipsychotics (augment response to SSRI) or lithium (mood stabilizer)
High-intensity psychological interventions
ECT
Crisis Resolution and Home Treatment (CRHT)
Multidisciplinary (MDT) approach
Inpatient care
What is the NICE recommendation for treating mild/moderate depression? STEP 2
Primary Care:
Low-intensity psychological interventions
If moderate depression, + Medication - First line treatment would usually be an SSRI, such as citalopram, sertraline, fluoxetine or paroxetine
What is cyclothymia?
A persistent instability of mood with a number of periods of mild depressive symptoms or mild elation, where no episode meets the threshold for a depressive or a manic episode
What is dysthymia?
mild depression for 2y or longer where the person is able to function. Usually it is not recognized until “Double Depression” occurs in which a depressive episode occurs on a background of dysthymia and on taking the history, low mood has been a persistent feature for the individual for some time prior to this event. They respond well to antidepressants.
What is double depression?
“Double Depression” occurs when a depressive episode occurs on a background of dysthymia and on taking the history, low mood has been a persistent feature for the individual for some time prior to this event.
What are the indications for antidepressants? What NT are primarily targetted by antidepressants? What are their general MOA?
- Depressive illness (more effective in moderate and severe depression)
- Anxiety disorders (for initial 2w use with Benzodiazepine cover to reduce initial risk of increased anxiety associated w/ SSRIs)
- Neuropathic pain
- PTSD
- Insomnia
- Bulimia nervosa
- Impulsivity
- Migraines
- Chronic fatigue syndrome
- Irritable bowel syndrome
- Narcolepsy (suddenly fall asleep)
5HT (Raphe Nuclei), NA (Locus Coeruleus), DA
Inhibition of reuptake usually of Serotonin from synaptic cleft increasing [ ] in the cleft and 5HT transmission but rarely totally specific therefore also affects NA/ DA
Describe the SE of SSRIs. Name some SSRIs.
Fluoxetine, paroxetine, citalopram, sertraline, Fluvoxamine
SE: sexual dysfunction (++++), insomnia, headache, nausea, apathy and fatigue, agitation - initially i.e. first 2w, increased suicide ideation + anxiety- initially, diarrhoea/ GI pain and fullness- initially, dizziness, sweating, akathesia (restlessness). Weight gain is not a SE of SSRIs.
Caution Paroxetine: cardiac defects if exposure in Trimester 1
MOA: Selective serotonin reuptake inhibitors (inhibiting transporters on presynaptic neurone)
