Severe Depression Flashcards
Explain the symptoms and presentation of depression
Depression is a complex heterogenous illness
It involves significant periods of hypothymia, avolition, loss of pleasure/interests, grief, psychomotor problems, worthlessness, hopelessness, guilt and suicidality.
Presentation is based on multiple factors such as psychological, biological, genetic, and social factors.
Depression is catergorised into mild (one or two symptoms, no functional impairment), moderate (three or four symptoms, some degree of functional impairment) and severe (a lot of symptoms and significant functional impairment). Assessed using the DSM and ICD 11.
Brain morphology explainations for depression
Stress - activates cortisol which can affect sleep, appetite and enjoyment
Cushings Disease - high depression rate due to high level of cortisol
Learned helplessness - exposure to so much difficuilty so stops trying to change their circumstances
Neurotransmitters - deviancy in serotonin, dopamine, noradrenaline causes depression
Important considerations for treating depression with medication
Anti-depressants should only be used for moderate to severe depression
May be an interval of 2 weeks before anti-depression works and therapuetic effect takes place
During first few weeks of treatment there is an increased potential for agitation, anxiety and suicidal ideation
Around 10-20% of patients fail to respond due to inadequate dosage; doses should be sufficiently high for effective treatment but not toxic - therapeutic range needs to be explored
Treatment should be continued for atleast 4 weeks before considering to switch due to lack of efficacy
Following remission, anti-depressant treatment should be continued at the same dose for at least 6 months – need to fully explain this to patient
Patients with a history of recurrent depression should receive maintenance treatment for at least 2 years – need to fully explain this to patient – risk of relapse
Explain the role of tricyclic anti-depressants
They block the reuptake of serotonin and norepinephrine in presynaptic terminals, which leads to increased concentration of these neurotransmitters in the synaptic cleft.
- Cardiotoxic
- Sedative properties in amitriptyline
- Less sedative properties in lofepramine & nortriptyline
- Used as a second or third line for treatment resistant depression
Explain the role of monoamine oxidase inhibitors (MAOI)
MAOI’s are an extremely strong class of antidepressants that treat depression by preventing the breakdown of the brain chemicals serotonin, dopamine, and norepinephrine.
Have dangerous interactions with some foods and drugs, and should be reserved for use by specialists
Should be tried in any patient who are refractory to treatment with other anti-depressants as there is occasionally a dramatic response
Response to treatment may be delayed for 3 weeks or more and may take an additional 1 or 2 weeks or more and may take an additional 1 or 2 weeks to become maximal
Mainly used as second or third line for treatment resistant depressant
Examples: tranylcypromine, phenelzine
Explain the role of SSRI’s
SSRI’s block the reuptake of serotonin.
Examples: sertaline, fluxotine, citalopram, paroxetine
Explain what the first line of medication treatment
These medications are less cardiotoxic and more tolerable in overdose.
SSRI - fluxeotine, sertaline, citalopram, paroxetine
SNRI (serotonin and noradrenaline reuptake inhibitors) - duloxetine and venlaflaxine
NASSA’s (noradrenaline and specific serotonergic anti-depressants) - mirtazepine (sedating properties)
Explain the process of an individual failing to respond to medication treatment
may require an increased dosage if SSRI or change to a different SSRI or class
Other second line choices include lofepramine
Tricyclic anti-depressants and venlaflaxine should be considered for more severe forms of depression
May require a second anti-depressant of a different class
Augmentating agent may be considered such as
lithium, aripiprazole [unlicensed], olanzapine [unlicensed], quetiapine or risperidone [unlicensed]).
Electroconvulsive therapy may be initiated in severe refractory
depression
