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Psychiatry > Depression > Flashcards

Depression Flashcards

(60 cards)

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1
Q

Core symptoms of depression

A

Present most of the day, nearly every day

Low mood

Anergia

Anhedonia

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2
Q

Time criterion for depression

A

Persistent (diurnal variation allowed) for >=2w

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3
Q

Biological secondary symptoms of depression

A

Change of appetite +/- weight change (usualy low)

disturbed sleep (insomnia, early morning waking >2h)

Diurnal mood variation

reduced libido

Psychomotor agitation/retardation

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4
Q

Psychological secondary symptoms of depression

A

Past: Low self-esteem, guilt, worthlessness

Present: Poor concentration, reduced motivation + interest

Future: Hopelessness + helplessness, suicidal thoughts

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5
Q

Determining severity of depression

A

Mild: 2 core symptoms + 2 secondary symptoms (able to continue w/ most daily activities)

Moderate: 2 core symptoms + 3+ secondary symptoms + great difficulty coping with daily activities

Severe: 3 core symptoms + 4+ secondary symptoms (or psychosis, marker of severity)

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6
Q

Indication for emergency ECT in depression

A

Depressive stupor due to psychomotor retardation

Risk of death from dehydration

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7
Q

Definition of dysthymia

A

Prolonged period of low mood (>2 years) during which no episode fulfills the criteria for mild/moderate/severe depressive episode

May have days/weeks of wellness

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8
Q

Lifetime prevalence rate of depression

A

10-20%

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9
Q

M:F ratio for depressive disorders

A

1: 2 for unipolar/dysthymia
1: 1 for bipolar

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10
Q

Heritability of depressive disorder

A

40%, overlap with anxiety but not bipolar

two-fold risk in FDRs

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11
Q

Risk factors for depression

A

Female

Chronic/severe physical illness

Major life events

Cumulative childhood disadvantage

Lack of confiding relationship

FHx of anxiety or depression

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12
Q

% of suicides with depressiv disorder

A

>40%

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13
Q

Biological aetiological factors of depressive disorder

A

Genetics (Two-fold risk in first degree relatives)

HPA axis dysregulation (raised cortisol)

Monoamine dysregulation

Medical conditions: stroke, IHD, flu, Parkinson’s, endocrine disorders

Medications

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14
Q

Psychological aetiological factors of depressive disorder

A

Childhood: Parental loss, deprviation, adverse events

Personality: Neurotocism, low self-esteem

Cognition: Negative bias, learned helplessness

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15
Q

Social aetiological factors for depression

A

Unemployment

Stressful life events (e.g. disruption of relationships)

Social isolation

Lower socioeconomic status, education

Substance misuse

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16
Q

Whooley questions for screening depression

A

During the past month, how often have you been bothered by:

  1. feeling down, depressed, or hopeless?
  2. Little interest/pleasure in doing things?
  3. Do you want help?
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17
Q

Screening tools for depression

A

Primary care: PHQ-9

Secondary care: HADS

Postnatal: EPDS

Baseline: BDI

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18
Q

Differntial for depressive symptoms

A

Physical cause

Depressive episode

Recurrent depressive disorder

Bipolar affective disorder, depressive episode

Dysthymia

Adjustment disorder

Psychoactive substance use (incl alcohol)

Dementia

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19
Q

Physical causes of depressive symptoms, categories

A

Systemic

Neurological

Autoimmune

Endocrine

Iatrogenic

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20
Q

Systemic causes of depressive symptoms

A

Infection: HIV, syphilis, Lyme disease, influenza

Carcinoma (paraneoplastic effects, chemotherapy meds)

Sleep apnoea

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21
Q

Neurological causes of depressive symptoms

A

Head injury

Epilepsy

Huntington’s

PD

Dementia

MS

CVA

vCJD

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22
Q

Endocrine causes of depressive symptoms

A

Hyper/hypothyroidism

Addison’s, Cushing’s

Hyperparathyroidism

Diabetes mellitus (hypoglycaemia)

Prolactinoma

Perimenstrual/menopausal

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23
Q

Autoimmune cuases of depressive symptoms

A

Rheumatoid arthritis

SLE

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24
Q

Common meds leading to depression

A

VVV common, check BNF

Anticonvulsants

PD meds

Benzodiazepines

NSAIDs

Antihypertensives

Anithistamines

Corticosteroids

Combined OCP

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25
Criteria for use of MHA
Evidence of mental disorder Risk to self/others Refusal of community treatment
26
Management plan categories for depression
**General:** Where, by whom? **Physical:** Exercise, sleep hygiene, drugs (incl alcohol, anxiolytics), ECT **Pharmacological:** Antidepressants **Psychological:** Self-help, online CBT, individual/group CBT, IPT/counselling **Social:** Day hospital, hobbies, employment, support networks
27
Subtypes of depression (ICD-10)
Without somatic symptoms With somatic symptoms With psychotic symptoms Atypical depression
28
Common psychotic symptoms in depression
Mood **congruent** (if incongruent, suspect schizoaffective) **Delusions:** poverty, inadequacy, guilt over misdeeds, responsibility for disasters, nihilism, hypochondriasis **Hallucinations:** Auditory (usually 2nd person, accusatory/defamatory voices, screaming), olfactory (rotting flesh, faeces)
29
Standard Ix for depression (to rule out)
FBC U+Es Calcium LFTs TFTs ESR glucose
30
Special investigations for depressive symptoms (dep on Hx)
Syphilis serology ANA Addison's/Cushing's tests UDS, breath/blood alcohol CT/MRI, EEG
31
Poor prognostic factors for depressive disorder
**Demographic:** Older age, lack of social support, younger age of onset **Personal** Co-morbidity, neuroticism, low-self esteem **Illness:** Insidious onset, residual symptoms, neurotic (cf endogenous/somatic), severe/psychotic symptoms, number of previous episodes
32
Timecourse for depressive disorder, mild-moderate cases
4-30 weeks, most 2-3mo
33
Timecourse for severe depression
Average 6 months
34
Timecourse for recurrent episodes of depressive disorder
Generally shorter, 4-16 weeks
35
Rate of chronicity in depression
10-20% chronic course lasting \>2years
36
Clinical features of atypical depressive episode
Depressed but reactive mood Hypersomnia Hyperphagia + weight gain 'Leaden' limbs Reversed diurnal mood variation
37
Prevalence of dysthymia
3-5%, M:F 1:2
38
Age of onset of dysthymia + atypical depression
Early 20s, median 25
39
Prognosis of dysthymia
25% chronicity 10-20% remission within 1 year
40
Pharmacological management of dysthymia
SSRI (esp citalopram, fluoxetine) May take several months to show benefit
41
Management of mild-moderate depression, first episode
Psychoeducation + advice on sleep hygiene, physical activity, graded return to activity Low intensity psychological intervention: CCBT, group CBT, individual CBT (esp self-help) Follow up within 2-4 weeks (watch out for mania)
42
Indication for antidepressant treatment
Severe depression Hx of moderate-severe depression Subthreshold symptoms \>2 years Subthreshold/mild symptoms persisting after other interventions
43
Indications for hospital admission with depression
Serious risk of suicide, or risk to others (e.g. children) Severe psychotic symptoms Depressive stupor Initiation of ECT Treatment of physical comorbidity Significant self-neglect (esp weight loss) Lack of supportive home environment
44
Drug interactions for SSRIs
NSAIDs Aspirin Warfarin/Heparin Sertraline, citalopram have lower interaction profiles
45
Follow-up frequency following initiation of antidepressant
Every 2-4 weeks for 3mo (suicide risk higher in pts discharged from hospital for 2-4w) Monitor suicidality, response, side effects, ***MANIA***, compliance (main reason for non-response)
46
Interactions of St John's Wort
Induction of cytochrome P450 --\> reduction in drug levels OCP Warfarin Anti-retrovirals Anti-rejection therapies Digoxin Anticonvulsants
47
Prescription of TCAs vs SSRIs
**_TCAs:_** * More sedating * More dangerous in OD (avoid if suicidal) * More SEs, less safe for elderly w/ physical comorbidities * Better evidence for pregnancy safety profile Prescribe SSRIs as first line, similar efficacy for both though
48
Definition of adequate trial of antidepressant
4-6 weeks at maximum tolerated dose, necessary before switching antidepressants
49
Maintenance antidepressant therapy
4-6mo post-recovery for first episode before slow withdrawal (4-week period) **Recurrent episode within 3 years:** Minimum 2, preferable \>5 years therapy
50
Risk of relapse if meds stopped in recurrent depressive disorder
70-90% within 5 years
51
Augmentation strategies for partial responders
Lithium T3
52
Treatment of depression with psychotic symptoms
Admission Low-dose antipsychotic for a few days --\> differentiate from 1ry psychotic disorder + improve compliance (30-50% improve on antipsychotic alone) Initiation of antidepressant Common combination: Olanzapine-fluoxetine Consider ECT if stupor/very severe
53
Approach for treatment-resistant depression
Check compliance Check diagnosis (esp bipolar) Check perpetuating factors Switch class Augment: Li, T3, quetiapine
54
Relapse rate for depression
50% for first episode 70% if 2 episodes 90% if \>2 episodes
55
Change in prevalence of depression from 1ry care to hospital inpatient
**Primary:** 5% **Outpatients:** 10% **Inpatient:** 20%
56
Features of depression in hospital settings
* **Pervasiveness of low mood/anhedonia:** e.g. family visits no pleasure * **Diurnal variation:** Worse in morning * **Hopelessness:** + loss of interest in any potential improvement
57
Management of depression in hospital settings
**Practical:** Clarify prognosis, improve pain, mobility **Psychological:** Liaison psych, theraeutic support by nursing staff **Pharmacological:** Consider antidepressants, but caution in liver/renal impairment
58
Average age of onset for mood disorders
**Depressive episode:** 27 (2nd peak at 60-70) **Dysthymia:** 25 **Bipolar:** 17
59
Prognosis of depressive disorders
**Individual episode:** On treatment, typically 2-3 months **Recurrence:** 60-80% lifetime relapse, 30% at 10y **Suicide:** Up to 10% in severe depression, higher than general population **General morbidity/mortality:** Worse, higher rates of substance abuse, worse respiratory/CV/cancer outcomes
60
Management of moderate-severe depression
Antidepressants (first-line SSRIs) Referral to secondary/specialist care Safety planning High-intensity psychological intervents (e.g. CBT)

Psychiatry (20 decks)

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