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Flashcards in Depression Deck (60):
1

Core symptoms of depression

Present most of the day, nearly every day

Low mood

Anergia

Anhedonia

2

Time criterion for depression

Persistent (diurnal variation allowed) for >=2w

3

Biological secondary symptoms of depression

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

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

Diurnal mood variation

reduced libido

Psychomotor agitation/retardation

4

Psychological secondary symptoms of depression

Past: Low self-esteem, guilt, worthlessness

Present: Poor concentration, reduced motivation + interest

Future: Hopelessness + helplessness, suicidal thoughts

 

5

Determining severity of depression

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)

6

Indication for emergency ECT in depression

Depressive stupor due to psychomotor retardation

Risk of death from dehydration

7

Definition of dysthymia

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

8

Lifetime prevalence rate of depression

10-20%

9

M:F ratio for depressive disorders

1:2 for unipolar/dysthymia

1:1 for bipolar

10

Heritability of depressive disorder

40%, overlap with anxiety but not bipolar

two-fold risk in FDRs

11

Risk factors for depression

Female

Chronic/severe physical illness

Major life events

Cumulative childhood disadvantage

Lack of confiding relationship

FHx of anxiety or depression

12

% of suicides with depressiv disorder

>40%

13

Biological aetiological factors of depressive disorder

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

14

Psychological aetiological factors of depressive disorder

Childhood: Parental loss, deprviation, adverse events

Personality: Neurotocism, low self-esteem

Cognition: Negative bias, learned helplessness

15

Social aetiological factors for depression

Unemployment

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

Social isolation

Lower socioeconomic status, education

Substance misuse

16

Whooley questions for screening depression

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?

 

 

17

Screening tools for depression

Primary care: PHQ-9

Secondary care: HADS

Postnatal: EPDS

Baseline: BDI

18

Differntial for depressive symptoms

Physical cause

Depressive episode

Recurrent depressive disorder

Bipolar affective disorder, depressive episode

Dysthymia

Adjustment disorder

Psychoactive substance use (incl alcohol)

Dementia

19

Physical causes of depressive symptoms, categories

Systemic

Neurological

Autoimmune

Endocrine

Iatrogenic

20

Systemic causes of depressive symptoms

Infection: HIV, syphilis, Lyme disease, influenza

Carcinoma (paraneoplastic effects, chemotherapy meds)

Sleep apnoea

21

Neurological causes of depressive symptoms

Head injury

Epilepsy

Huntington's

PD

Dementia

MS

CVA

vCJD

22

Endocrine causes of depressive symptoms

Hyper/hypothyroidism

Addison's, Cushing's

Hyperparathyroidism

Diabetes mellitus (hypoglycaemia)

Prolactinoma

Perimenstrual/menopausal

23

Autoimmune cuases of depressive symptoms

Rheumatoid arthritis

SLE

24

Common meds leading to depression

VVV common, check BNF

Anticonvulsants

PD meds

Benzodiazepines

NSAIDs

Antihypertensives

Anithistamines

Corticosteroids

Combined OCP

 

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)