Depression/Setrtonin Syndrome

Question 1

Most common classes

Answer 1

1. Major depressive disorder (clinical depression)
   Symptoms: Loss of pleasure in activities/lack of reactivity to pleasurable stimuli 2+weeks, & ≥3 of:
   continuous low mood/sadness, feeling hopeless/ helpless, low self esteem, guilt ridden, irritable, intolerant of others, no motivation/interest in things, difficult to make decisions, no enjoyment, suicidal thoughts and self harm.
2. Atypical Depression: some/all of clinical depression + 1/all: increased appetite/weight gain, increased sleep, heaviness of the arms, sensitivity in the legs.
3. Seasonal affective disorder:
   Relationship between time of year and depression. show at least 2 eps of depressive disturbance in the last 2 years. seasonal eps outnumber non seasonal eps.
   seasonal disorder- more likely to report atypical symptoms like hypersomnia (day time sleepiness) and increased appetite.

Question 2

Treatment

Answer 2

NICE stepped care model:
Step 1 - Depression confirmed: assessment, support, psychoeducation, active monitoring and referral for further investigation

Step 2 - Persistent subthreshold depressive symptoms; Mild/moderate depression:
Low intensity psychosocial/psychological interventions, MEDICATION and referral

Step 3 - inadequate response to step 2 OR moderate - severe depression:
MEDICATION, High intensity psychological interventions, combined treatments, collab care and referral

Step 4 - Severe and complex depression; Risk to life/ Severe self neglect:
MEDICATION, High intensity psychological interventions, Electroconvulsive therapy, crisis service, Combined treatments, Multi-professional and inpatient care

• any referral would = more assessment/interventions

NEW EPISODES
Subthreshold/mild depression:
1st line psychological and psychosocial therapies.
DIAGRAM

More Severe depression:
DIAGRAM

Prevent relapse:
- NICE visual summary 3
Continuing treatment after full or partial remission can stop relapse. MUST BE HIGH RISK
DIAGRAM
* RISK of relapse should be asses at the end of psychological therapy and every 6 months if on meds.

Further line treatment:
- NICE visual summary 4
No response after 4-6 week of treatment asses adherence/other health factors
STILL NO response to:
DIAGRAM

• 2 antidepressant after trying 2nd gen antipsychotic or lithium FAIL ALT Vortioxetine (SSRi/Serotonin modulator [stimulates serotonin])
• When switching drug class or adding drugs refer/get advise from specialist
• ECT, transcranial magnetic stimulation, and implanted vagus nerve stimulation can be utilised

Chronic depression:
- NICE visual summary 5
BNF
- IF patient has symptoms that significantly impair functioning, Treatment options:
- Monotherapy - CBT or Drugs (SSRi, SNRi, or TCA)
- CBT + SSRi or TCA
TCA greater risk of overdose - Lofepramine better safety profile
- Don’t respond to SSRi/SNRi ALT - specialist setting/ advise. ALT = TCAs, moclobemide, irreversible MOAis, or amisulpride

psychotic and with personality disorder check pic

Question 3

Medication choice

Answer 3

Medication choice depends:
Patient safety and tolerability, physician familiarity, history of previous treatment,

All antidepressants are potentially effective.
Takes 2-6 weeks for response. However, most PTs don’t feel the effects until 6-8 weeks after starting - EXAM Q

Alter treatment if no good response within 6-8 weeks.
once good response continue for 4-9 months in person with 1st ep depression. 2 or + eps then longer course

Question 4

Drug choices (SSRI FAIL)

Answer 4

Increase dose/Switch to different SSRi/ Mirtazapine if initial SSRI fail.

2nd line:
Lofepramine [TCA], Moclobemide [MAOi], Reboxetine [SNRi], Venlafaxine [SNRi], Reserved for more severe cases
- MOAi under specialist

3rd line:
+ another antidepressant or Lithium/Antipsychotic

Question 5

Lifestyle and long term monitoring

Answer 5

Dietary restrictions ONLY FOR MAOIs
- Foods high in tyramine, can produce a hypertensive crisis with MAOIs, - AVOID.
Tyramine triggers nerve cells to release NA = increases BP = Throbbing headaches
- Examples: soy sauce, aged chicken/beef liver, raisins, sour cream, beer, wine, yogurt, mature cheese, bean pods, soy beans, Bovril, OXO, marmite (or similar meat/yeast extracts)

• Exercise and activity can help with depression.
• Meds should be re-evaluated every 8-12 weeks
  Non-response to treatment consider ALT diagnosis (e.g., bipolar or dementia).
  Evaluate PTs functional status and wellbeing every visit.
• Suicidal ideation - evaluated each visit and between visits if needed.

Question 6

PRSC notes

Answer 6

1st line - SSRi

TCA similar efficacy to SSRi but more AEs.
- TCA toxicity is problematic
- TCA more sedating, More antimuscarinic/Cardiotoxic AEs.

MAOi
Dangerous with some foods/drugs (tyramine)
- Reserved for specialist
* Review PTs within 2 weeks at start of treatment - suicide risk PTs 1 week with repeated reviews within 4 weeks.
NB: Pt should know drug may takes minimum 4 weeks to work

• Recurrent depression maintenance treat for at least 2 yrs.
• Take at least 6 months after remission
  12 months for generalised anxiety disorder - more risk of relapse

AVOID ALL Antidepressants in manic phase in bipolar - gives them more energy boost

Question 7

Antidepressant and Hyponatraemia (EXAM Q)

Answer 7

Hyponatraemia associated with ALL antidepressants.
- more in SSRi
Signs of Hyponatraemia:
(SALT LOSS)
S- Stupor/coma
A- Anorexia
L- Lethargy
T- Tendon reflexes decreased
L- Limp muscles (weakness)
O- Orthostatic hypotension
S- Seizures/Headaches
S- Stomach cramps

Question 8

Suicide & Antidepressant

Answer 8

They linked with suicidal thoughts and behaviour
younger esp more risk

Monitor PTs for this esp at the start of treatment

Question 9

Serotonin syndrome

Answer 9

When there’s too much serotonin in the body.

uncommon ADR with SSRi/SNRIs.
- Happens normally with SSRi/SNRi with drug that increases serotonin.

symptoms happen at initiation, dose increase, overdose, adding new drug or replacement of 1 drug without proper washout period.
- washout esp. in irreversible MAOis or drug with long half life.
- Symptoms can be mild-life threatening

Severe toxicity normally occur with MAOi and another drug.

SYMPTOMS of Serotonin syndrome
Neuromuscular hyperactivity - tremor, hyperreflexia, rigidity
Autonomic dysfunction - Hyperthermia, shivering, diarrhoea, BP change tachycardia
Alerted mental state: Agitation, confusion, mania

STOP MEDS if these occur.

Question 10

Causes, Pathophysiology and Diagnosis (not that deep)

Answer 10

Depressed mood and/or loss of pleasure in most activities.
Severity = number and severity of symptoms + amount of functional impairment.
ICD-11 = needs 4 out of 10 symptoms, for diagnosis
DSM-IV = needs 5 out of 9 symptoms, for diagnosis
Symptoms prevalent for at least 2 weeks and each symptom should be present enough for every day.
DSM-IV = 1 KEY symptom,
ICD-11 = 2 KEY symptom
Key symptoms = For both: low mood, loss of interest and pleasure,
ICD only : Loss of energy

Most depression have triggering life event. Some don’t

Primary care:
For primary care PHQ-9, GAD7 to do diagnosis.