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43 Cards in this Set
- Front
- Back
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According to DSM-5 how is depression diagnosed? |
> or = to 5 symptoms present during the same 2 week period, at least 1 symptom is: 1) depressed mood - most of the day, nearly every day, OR 2) anhedonia - loss of interest or pleasure in all or almost all activities most of the day Symptoms cause significant distress/impairment |
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What are the symptoms of depression used by the DSM to diagnose depression? |
Sleep - increased/decreased Interest decreased Guilt - feelings of worthlessness Energy - decreased, fatigue Concentration - decreased, indecisiveness Appetite - increased/decreased, weight change Psychomotor - agitation/retardation Suicidal ideation, recurrent suicidal thoughts SIGECAPS |
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What is the 12 month prevalence of major depression in Australia? What is the lifetime risk of depression? |
5% (Murtaghs) OR 4.1% (eTG) 12/12 prevalence 15% lifetime risk Present in 17% patients who present to GPs Leading cause of disability for all conditions among both sexes, both in Aus + worldwide. |
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What is the mean age of onset for depression? |
Mean onset = 27 yrs 40% sufferers present by 20yrs Average duration of episodes = 3-4/12 40% relapse within 12/12 period |
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What is the cause of depression? |
Multifactorial - biological, psychological, social factors. Strong familial tendency. Stress-vulnerability model - genetically determined vulnerability, if enough stress endured = mood disorder may result. Stress - neuronal death - decreased activity in prefrontal cortex, increased activity in limbic system, loss of volume of hippocampus - stress/depression = bad for the brain. |
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What are the subtypes of depression? |
Major depressive disorder (MDD) - mild, moderate, severe (uncommon <5% presenting with depression), psychotic depression (even rarer). Dysthymic disorder - enduring, fluctuating low mood (>2yrs), doesn't meet criteria MD. Adjustment disorder with depressed and/or anxious mood - a period of distress and emotional disturbance post stressful life event. |
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What are some of the depression scales that can be used by the GP to screen for depression, and monitor the patient over time? |
K10 - distress score DASS 21 or 42 - for depression and anxiety symptoms |
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When taking a history from a patient presenting with depression what is important to ask about? |
Suicide/self harm risk Psychosocial hx - any stressors Premorbid personality Medications Bipolar disorder - any manic episodes Co-morbid anxiety Co-morbid substance abuse Any physical conditions - thyroid, anaemia |
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What is the lifetime risk of suicide in patients diagnosed with depression? How much is the risk reduced if the depression is treated? |
6% Treatment halves this risk - 3% |
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What are some of the risk factors for suicide? |
Psychiatric disorder, current psychosis Fam hx of suicide Ready access to means with high lethality Definite plan for attempt Hx of dangerous behaviour on impulse Low chance attempt being detected Social isolation Feeling of hopelessness Recent major loss, chronic medical condition |
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Initially what is the most important considerations in the management of a patient presenting with a major depressive disorder. |
Establish patients safety: Suicide risk Need for inpatient assessment Need for referral to a psychiatrist |
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What questions are important in establishing suicide risk? Once risk is established what is the recommended management of the patient at high/med/low suicide risk? |
Ask about - suicidal thoughts, plan, lethality, means, past history, suicide family/friend. High risk - continual thoughts/intent/plan - ensure safe/secure environment, organise reassessment in 24hrs + f/u outcome. Med risk - no current plan, thoughts/intent - make a safety plan, reassess in 1/52, discuss support and treatment options. Low risk - fleeting thoughts, no plan - discuss support/treatment options, f/u consultation. |
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Most depression is managed in outpatient setting, when is inpatient management recommended? |
Depression with psychosis (delusions/hallucinations) Significant risk of suicide or homicide Inadequate support at home Seriously physically unwell Complicated and treatment resistant depression * NOTE can use involuntary inpatient treatment under the mental health act - if at significant risk |
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Once safety is established, what is the recommended treatment for the different types (mild/mod/severe) of major depression? |
Mild - psychological therapies Mod - psychological therapies OR antidepressant, which is better suited to the patient Severe - antidepressant + psychological therapy (if able to participate in this) Psychosis present - add antipsychotic, specialist review +/- ECT (also severe melancholic depression). |
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What does psychological therapy include? |
Basic psychological treatments: Lifestyle changes Problem solving Guided self help Structured supervised exercise Supportive counselling Referral for - CBT, IPT or other psychological techniques |
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What psychological treatment can the GP offer their patient? |
Structured problem solving or stress management - by assessing stressors, encouraging effective coping styles, utilising social supports. Referral to psychologist - for CBT, IPT, short-term dynamic therapy. Web based CBT - through mindhealthconnect - does NOT replace role of therapist relationship. Provide resources - lifeline, apps, websites. |
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When choosing an antidepressant what factors need to be taken into account? |
Antidepressant adverse effect profile Patient response/lack to previous treatments Adverse effects of previous treatments Family history of response to treatments Risk of drug interaction with medications Antidepressant safety in overdose Patient comorbidities |
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In general how long do antidepressants take to have an effect and how long should they be continued for if beneficial? |
Onset of response = >1-2 wks Full benefit = > 4-6 wks If there is a favourable response, continue antidepressants for 6-12/12, after a single episode of major depression as there is a high risk of relapse initially. If there is a history of recurrence, longer-term prophylactic treatment is recommended. |
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Which antidepressant classes and drugs are the first line recommendations for treatment of major depression? |
1. SSRIs - citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline. 2. SNRIs - venlafaxine, desvenlafaxine, duloxetine 3. Others - mirtazapine Similar efficacy, wide safety margin, but differing adverse effect profiles. |
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How do we go about starting a patient on an antidepressant? |
Use any 1st line antidepressant - 50% respond Assess response after 2-4 wks of treatment: - Responds well = continue initial dose - No response = increase dose, if no response at 2-4wks post this, switch antidepressant. - Partial response = increase dose, reassess 2-4wks, if still partial increase dose again if able, or switch if no higher dose possible. |
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If switching antidepressant do you switch to one in the same class or another class? |
Either the same class or another class - no evidence to suggest cannot change to a different SSRI for example if failed to respond to first SSRI prescribed. If there are severe or unacceptable SEs - switch to an antidepressant with different SE profile. |
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Give an example of some specific medications/doses that would be commonly prescribed as first line treatment in major depression. |
Citalopram 20mg mane (max 40mg) if <65yrs Escitalopram 10mg mane (max 20mg) Fluoxetine 20mg mane (max 80mg) Desvenlafaxine CR 50mg mane (max 200mg) Mirtazapine 15-30mg nocte (max 60mg) |
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What are the second line treatment options in major depression? |
Agomelatine - melatonin receptor agonist, serotonin antagonist Moclobemide - monoamine oxidase inhibitor Reboxetine - noradrenaline reuptake inhibitor |
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What is the role for TCA in the management of major depression? |
Due to adverse effect profiles, TCAs, mianserin and irreversible nonselective MOI would generally only be used after unsuccessful trials >2 1st line treatments (either drug or psychological). TCAs should, be considered 1st line for those who responded well to them previously. Some patients respond only to these therapies. Referral to a psychiatrist is advisable. |
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What are some of the adverse effects of TCAs? |
Anticholinergic effects - dry mouth, blurred vision, constipation, urinary retention. Orthostatic hypotension Sexual dysfunction Weight gain Sedation Lethal in overdose - prolong QT interval, QRS complex, arrhythmia. |
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What are the main TCAs, and what dose of a TCA would be used in treatment of major depression? |
Amitriptyline, clomipramine, dothiepin, doxepin, imipramine, nortriptyline and trimipramine. Dose = TCA 25-75 mg nocte, increasing by 25 to 50 mg every 2 to 3 days (depending on adverse effects) to 75 to 150 mg at night by the 7th day. Maximum daily dose is 150 mg for nortriptyline and 200-300 mg for all other TCAs. |
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What should a GP do if a patient fails to respond to antidepressants? |
Reassess diagnosis and management Refer to a psychiatrist, who would consider: * ECT * Combination antidepressant medications * Lithium augmentation * Liothyronine (T3) augmentation * 2nd generation antipsychotic augmentation |
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What are the common adverse effects of SSRIs and SNRIs? |
GIT upset - nausea, anorexia, diarrhoea, abdominal discomfort. Insomnia or sedation Sexual dysfunction - decreased libido, anorgasmia, ejaculatory disturbance. Less common: Agitation Weight gain Orthostatic hypotension/dizziness |
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What are the common adverse effects of mirtazapine? |
Most common: Sedation - effect decreases with increased dose Weight gain Less common: Sexual dysfunction Orthostatic hypotension/dizziness GIT upset Insomnia |
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What should the GP do if a patient experiences an adverse effect? |
Review the dose, timing of the dose, potential drug interactions, give practical advice on management of the side effect (e.g. for nausea take the mediation after food), or if unbearable, switch antidepressant medication. |
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What are some serious but rare adverse effects of antidepressants? |
GIT bleeding - SSRIs increase the risk by block uptake serotonin into platelets. Hyponatraemia - TCAs, SSRIs, SNRIs, MAOI, measure at 3-4/52 if at high risk (old age, polypharm) Psychomotor impairment/sedation - start low. Serotonin toxicity - rapidly progressive hyperthermia and muscle rigidity, progresses to multi-organ failure, medical emergency, increase risk if on combination serotonergic drugs (e.g. St Johns wart + antidepressant). |
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Is it safe to drink alcohol while taking antidepressant medications? |
Avoid in depression as alcohol is powerfully depressogenic, can affect treatment concordance. Warn that effects of alcohol and other CNS depressant drugs, can be potentiated if they are taken in conjunction with sedating antidepressants. Ideally, alcohol should be avoided during treatment with sedating antidepressant drugs. |
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Is co-prescription with an anxiolytic or hypnotic medication recommended?
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Co-prescription is generally not necessary, as these symptoms will resolve with effective treatment of the depression. Antidepressants also have anxiolytic activity. SSRI- and SNRI-induced insomnia and anxiety during the initial stages of therapy often settle within 1 week. Any prescription of an anxiolytic/hypnotic must be short term. |
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What about the use of St Johns wart in depression? |
Short-term studies = more effective than placebo for treatment mild-mod depression. 2008 Cochrane review = St John's wort MAY have equivalent efficacy to antidepressants in major depression, but +results from Germany. m Mode of action unknown, may involve increasing serotonin. Reports of serotonin toxicity with concurrent use St John's wort + antidepressants. |
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How do we go about safely changing from one antidepressant to another? |
An appropriate antidepressant free interval is recommended, the time is based on the drugs pharmacokinetics. E.g. changing mirtazapine to fluoxetine, 2-4 days drug free. Table in eTG. In general higher doses of antidepressant must 1st be tapered to avoid a discontinuation syndrome, start the new drug at a low dose. |
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What happens if an antidepressant is stopped abruptly? |
Discontinuation symptoms may arise, include insomnia, nausea, postural imbalance, sensory disturbances, hyperarousal and flu-like symptoms. Usually, these symptoms are mild, last 1-2/52 and are rapidly extinguished with reinstitution of the antidepressant. Exceptionally, delirium may occur. |
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How should antidepressants be stopped? |
As a general rule, the dose should be halved every week until the daily dose is half of the lowest unit strength available, in which case the antidepressant can be stopped after 1 week on this dose. If antidepressant therapy is being ceased completely, rather than switching, tapering may need to be slower to prevent relapse. |
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What can we do to minimise recurrent major depression episodes? |
Address vulnerability factors (e.g. relationships or employment) during remission. Assist the patient to identify early warning signs of relapse, and have a plan for early intervention. Continue treatment for >6-12/12 after resolution symptoms following single episode depression. Consider long-term prophylactic treatment if recurrent depression. |
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When exactly should long term prophylactic treatment be used? |
If >/= 2 depressive episodes within 5yrs OR 3 previous episodes, although a single severe episode of psychotic depression or a serious suicide attempt may also warrant this. Long-term treatment should be continued for >3-5yrs, and then the need for further management should be reviewed. Some require lifelong antidepressant therapy. |
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Is there any additional treatment option for patients who continue to suffer major depressive episodes while on prophylactic antidepressants? |
1st line prophylaxis = antidepressants Lithium should be considered for patients who continue to suffer recurrence on antidepressants. There is some evidence to support combining antidepressant + lithium for long-term prophylaxis if an antidepressant alone is inadequate. |
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How common is depression in the elderly and how does it normally present? |
Antidepressant prescriptions >80yrs higher than for any other age group. Often under diagnosed. Can have bizarre features, and be misdiagnosed as dementia or psychosis. Agitated depression most common in elderly. Histrionic behaviour, delusions and disordered thinking. Often atypical and less expressive. |
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Why do we need to be careful when prescribing antidepressants to the elderly? |
More serious side effects - nausea, dizziness, falls, hyponatraemia. Also only a modest response to antidepressants. Low initial dose, slow increase. Psychological therapies can be useful, but tend to be underused. |
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How do children with depression generally present? How do diagnose depression in children? |
Feelings of helplessness, worthlessness, despair. Can be diagnosed using the same criteria as for adults, however in children irritability may be more prominent than sadness or low mood. Somatic complaints commonly present. Association family instability, poor motor skills. Anti-social behaviour or separation anxiety can also occur. |
