Depression Flashcards by M Njm

The following two questions can be used to screen for depression

‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’

‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’

A ‘yes’ answer to either of the above should prompt a more in depth assessment.

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There are many tools to assess the degree of depression including

Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).

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Hospital Anxiety and Depression (HAD) scale

consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly

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Patient Health Questionnaire (PHQ-9)

asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe

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NICE use the DSM-IV criteria to grade depression:

1-9

Depressed mood most of the day, nearly every day
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished ability to think or concentrate, or indecisiveness nearly every day
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

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Define Subthreshold depressive symptoms

Fewer than 5 symptoms

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Define Mild depression

Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment

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Define Moderate depression

Symptoms or functional impairment are between ‘mild’ and ‘severe’

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Define Severe depression

Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms

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Persistent subthreshold depressive symptoms or mild to moderate depression

General measures

sleep hygiene

active monitoring for people who do want an intervention

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Persistent subthreshold depressive symptoms or mild to moderate depression - drug treatment is first line

false

do not use antidepressants routinely but consider them for specific people

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Persistent subthreshold depressive symptoms or mild to moderate depression - drug treatment indicated in

a past history of moderate or severe depression or

initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or

subthreshold depressive symptoms or mild depression that persist(s) after other interventions

if a patient has a chronic physical health problem and mild depression complicates the care of the physical health problem

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low-intensity psychosocial interventions may be useful in persistent subthreshold depressive symptoms or mild to moderate depression - these include

Individual guided self-help based on CBT principles - (Includes behavioural activation and problem-solving techniques)

Computerised CBT
group-based CBT

A structured group physical activity programme

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Individual guided self-help based on CBT principles should include?

include written materials (or alternative media)
be supported by a trained practitioner who reviews progress
consist of up to 6-8 sessions (face-to-face and by telephone) over 9-12 weeks, including follow-up

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Computerised CBT should include?

explain the CBT model, encourage tasks between sessions, and use thought-
challenging and active monitoring of behaviour, thought patterns and outcomes
be supported by a trained practitioner who reviews progress and outcome typically take place over 9-12 weeks, including follow-up

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A structured group physical activity programme should include?

Interventions should:

typically consist of 3 sessions per week (lasting 45 minutes to 1 hour) over 10-14 weeks

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Group based CBT should include?

be based on a model such as ‘Coping with depression’
be delivered by two trained and competent practitioners
consist of 10-12 meetings of 8-10 participants
typically take place over 12-16 weeks, including follow-up

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For patients with chronic physical health problems NICE also recommend considering a group-based peer support programme:
focus on

focus on sharing experiences and feelings associated with having a chronic physical health problem
consist typically of 1 session per week over 8-12 weeks

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for Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression

The following ‘high-intensity psychological interventions’ may be useful

Individual CBT
Interpersonal therapy (IPT)
Behavioural activation
Behavioural couples therapy

counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression; offer 6-10 sessions over 8-12 weeks
short-term psychodynamic psychotherapy for people with mild to moderate depression; offer 16-20 sessions over 4-6 months

For patients with chronic physical health problems the following should be offered:
group-based CBT
individual CBT

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Describe delivery of Interpersonal therapy (IPT)

typically 16-20 sessions over 3-4 months

for severe depression, consider 2 sessions per week for the first 2-3 weeks

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Describe delivery of Behavioural activation

typically 16-20 sessions over 3-4 months
consider 3-4 follow-up sessions over the next 3-6 months
for moderate or severe depression, consider 2 sessions per week for the first 3-4 weeks

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Describe delivery of Behavioural couples therapy

typically 15-20 sessions over 5-6 months

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Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression

For these patients NICE recommends an antidepressant - normally a ?

selective serotonin reuptake inhibitor, SSRI

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currently the preferred SSRIs

fluoxetine

citalopram

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sertraline is useful

post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants

SSRIs should be used with caution in

children and adolescents

SSRI most common side effect

gastrointestinal symptoms

SSRI there is an increased risk of

gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID

SSRI patients should be counselled

patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI

SSRI higher propensity for drug interactions

fluoxetine and paroxetine

Citalopram should noe be used in

those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval

Citalopram max dosage?

maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

Citalopram QT prolongation is/is not dose dependent

is dose dependent

SSRI drug interactions

``` NSAIDs warfarin / heparin aspirin triptans monoamine oxidase inhibitors (MAOIs) ```

NSAIDs: NICE guidelines advise 'do not normally offer SSRIs

true | but if given co-prescribe a proton pump inhibitor

warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering

mirtazapine

SSRIs & what increase risk of serotonin syndrome

triptans - increased risk of serotonin syndrome | monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after

2 weeks For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week.

If a patient makes a good response to antidepressant therapy they should continue on treatment for at least

6 months after remission as this reduces the risk of relapse.

When stopping a SSRI do what?

dose should be gradually reduced over a 4 week period | (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

SSRI Discontinuation symptoms

``` increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia ```

SSRIs and pregnancy first trimester

gives a small increased risk of congenital heart defects

SSRIs and pregnancy third trimester

can result in persistent pulmonary hypertension of the newborn

Paroxetine has an increased risk of

Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Serotonin and noradrenaline reuptake inhibitor (SNRI's) are

class of relatively new antidepressants. Inhibiting the reuptake increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects.

SNRI examples

venlafaxine and duloxetine.

SNRI used for?

major depressive disorders, generalised anxiety disorder, social anxiety disorder and panic disorder and menopausal symptoms.

Mirtazapine is an antidepressant that works by

blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.

Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in

older people who may be affected more or be taking other medications

side effects of mirtazapine

sedation and an increased appetite

Side effects of mirtazapine can be beneficial in older people

True sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.

mirtazapine generally take when

generally taken in the evening as it can be sedative.

Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose

true

TCA used widely in the treatment of

neuropathic pain, where smaller doses are typically required.

TCA common side effects

``` drowsiness dry mouth blurred vision constipation urinary retention lengthening of QT interval ```

TCAs that are more sedative

Amitriptyline Clomipramine Dosulepin Trazodone

TCAs that are less sedative

Imipramine Lofepramine Nortriptyline

Choice of tricyclic

low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine) lofepramine has a lower incidence of toxicity in overdose amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI

the first SSRI should be withdrawn* before the alternative SSRI is started

Switching from fluoxetine to another SSRI

withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI

Switching from a SSRI to a tricyclic antidepressant (TCA)

cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly) - an exceptions is fluoxetine which should be withdrawn prior to TCAs being started

Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine

cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly

Switching from fluoxetine to venlafaxine

withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly

Electroconvulsive therapy is a useful treatment option for patients with

severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.

ECT cintraindications

The only absolute contraindications is raised intracranial pressure.

ECT short term S/E

``` headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia ```

ECT long term S/E

some patients report impaired memory

The risk stratification of psychiatric patients into 'high', 'medium' or 'low risk' can usefully guide decision making

false review in the BMJ (BMJ 2017;359:j4627) concluded that 'there is no evidence that these assessments can usefully guide decision making' and noted that 50% of suicides occur in patients deemed 'low risk'.

Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide

``` male sex (hazard ratio (HR) approximately 2.0) history of deliberate self-harm (HR 1.7) alcohol or drug misuse (HR 1.6) history of mental illness history of chronic disease advancing age unemployment or social isolation/living alone being unmarried, divorced or widowed ```

schizophrenia: NICE estimates that ?% of people with schizophrenia will complete suicide

10%

If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date:

``` efforts to avoid discovery planning leaving a written note final acts such as sorting out finances violent method ```

factors which reduce the risk of a patient committing suicide. These include

family support having children at home religious belief

SAD should not be treated the same way as depression

false

seasonal affective disorder, you should not give the patient sleeping tablets as this can make the symptoms worse

true

seasonal affective disorder evidence for light therapy is limited

true

SAD mx

mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed

Factors suggesting diagnosis of depression over dementia

short history, rapid onset biological symptoms e.g. weight loss, sleep disturbance patient worried about poor memory reluctant to take tests, disappointed with results mini-mental test score: variable global memory loss (dementia characteristically causes recent memory loss)

Non-selective monoamine oxidase inhibitors examples

tranylcypromine, phenelzine

Non-selective monoamine oxidase inhibitors examples used in

used in the treatment of atypical depression (e.g. hyperphagia) and other psychiatric disorder

Non-selective monoamine oxidase inhibitors not used frequently due to side-effects

true

Adverse effects of non-selective monoamine oxidase inhibitors

hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans anticholinergic effects

serotonin and noradrenaline are metabolised by what in the presynaptic cell

monoamine oxidase

Depression Flashcards

(82 cards)