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53 Cards in this Set
- Front
- Back
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What are the somatic symptoms of depression? |
Psychomotor retardation Poor sleep with early morning waking Anergia (lethergy) Anorexia Loss of weight Loss of libido Constipation Amenorrhoea Symptoms present for >2weeks |
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How can you assess the level of depression, including potential risk of self-harm? |
2 screening questions can detect up to 95% of cases 1) During the last month, have you often been bothered by feeling down, depressed or hopeless? 2) During the last month, have you often been bothered by having little interest or pleasure in doing things? |
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What is the mechanism of action of ECT? |
Induction of a modified cerebral seizure = 1) Neurotransmitter release: 5HT, NA, Dopamine 2) Hyopthalamic and pituitary hormone secretion 3) Snaptogenesis and neurogenesis 4) Modulation of neurotransmitter receptors 5) Transient increase in blood-brain barrier permeability |
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What are the indications for ECT? |
Severe depressive illness Prolonged or severe episode of mania that has not responded to treatment Catatonia Moderate depression that has not responded |
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What are the side effects of ECT? |
Cognitive impairment Anaesthetic complications Dysrhythmias due to vagal stimulation Post-ictal headache Confusion Retrograde and retrograde amnesia |
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What are the main NICE recommendations for the treatment of depression? |
Screening should be undertaken in primary care and general hospital settings for depression in high-risk groups eg: history of depression, other mental or physical health problems predisposing See treatment plans for rest. |
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How does bipolar affective disorder present? |
Depression - as 'above' Mania - elevation of mood, can be labile with periods of irritability Distractible Poor concentration Flight of ideas Pressure of speech Expansive or grandiose ideas and delusions Increased energy Decreased need for sleep Uninhibited behaviour |
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How does an abnormal grief reaction present? |
Maladaptive thoughts and behaviours related to the death of the deceased (frequent troubling rumination, feeling they let the deceased down, disbelief), continuous emotional dysregulation (shock, anger, bitterness, numbness) about the death, social isolation and suicidal ideation (life is meaningless without them). |
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How are abnormal grief reactions different to normal ones? |
Prolonged grief symptoms for at least one month after six months of bereavement |
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What is the epidemiology of depression in the UK? |
1 in 4 people in the UK will experience a mental health problem each year. 2.6 in 100 people have depression (2009). F>M |
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What is the role of mental health teams in the management of depression? |
Mental health teams have an MDT approach. Comprised of: CPN, key worker, social worker, clinical psychologist, OT, volunteer organisation, GP |
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What is the impact of mental health problems in primary care? |
Up to 95% of mental illness is managed exclusively in primary care Pts often go undetected in primary care as they present with physical symptoms |
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What is the initial management of disturbed or agitated pts? |
Attempt to establish a rapport, offer and negotiate realistic options, avoid threats. Aks open questions and ask about the reason for their anger. Listen carefully and do not patronise |
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What is a basic management plan for an adult pt with mild depression? |
1) Watchful waiting - 2 weeks until further assessment in pts who do not want an intervention or who may recover without one. 2) Guided self-help - based on CBT 3) Short-term psychological treatment - brief CBT and counselling |
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What is a basic management plan for an adult pt with moderate depression? |
1) Short-term psychological treatment - brief CBT and counselling 2) SSRI - as effective as TCA and less side effects |
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What is a basic management plan for an adult pt with severe depression? |
1) Combination of antidepressants and individual CBT. Ensure antidepressant taken as prescribed. 2) Stay on SSRI for at least 6 months or if had 2+ episodes in the recent past should be 2 years on SSRI 3) Switch to different class or different drug in same class 4) Add lithium if severe 5) Switch to MAOI in atypical depression (increased sleep, phobic anxiety) 6) Antipsychotic if psychotic symptoms |
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What is a basic management plan for an adult pt with acute mania? |
Difficult to treat in community, may need to admit under MHA. Antipsychotics, benzodiazepines (in extreme agitation or severe insomnia), lithium may be used acutely, but takes longer to act than antipsychotics |
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What is a basic management plan for an adult pt with bipolar disorder? |
Psychological support and education Look at social - what has precipitated this event. Self-help and support groups, OT for return to work Pts who have had 2+ episodes of mood disorder in 5 years should take prophylactic medication - Lithium effective conc of 0.4-1mmol/L (toxic at 1.5) |
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What is the mechanism of action of Selective noradrenaline reputake inhibitors (SNRIs)? |
Increased CNS levels of NA by selectively inhibiting pre-synaptic reuptake of NA |
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What are the indications for SNRIs? |
Major depression |
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What are the contraindications for SNRIs? |
None direct - caution with bipolar, CVD, epilepsy, urinary retention |
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What are the adverse effects of SNRIs? |
Anorexia, constipation, dry mouth, nausea, chills, dizziness, impotence, insomnia, palpitation, postural hypotension, sweating, tachycardia, urinary retention, vasodilation |
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Give an example of an SNRI and it's dose |
Reboxetine - 4mg BD up to 10mg/24hrs after 3-4 weeks. |
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What is the mechanism of action of presynaptic alpha-2-adrenoceptor blockers? |
Antagonist at alpha-2-auto and hetero- (serotonin-related) receptors. This causes an increase in NA and 5HT release by removing negative feedback in to the presynaptic nerve. |
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What are the indications for presynaptic alpha-2-adrenoceptor blockers? |
Major depression |
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What are the contraindications for presynaptic alpha-2-adrenoceptor blockers? |
None direct. Caution in cardiac disorder, DM, history of seizures, urinary retention, hypotension, psychoses
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What are the adverse effects of presynaptic alpha-2-adrenoceptor blockers? |
Causes H1 blockade = sedation, and therefore agitation and anxiety on withdrawal, confusion, dizziness, dry mouth, fatigue, increased appetite, insomnia, myalgia, postural hypotension
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Give an example of a presynaptic alpha-2-adrenoceptor blocker and it's dose |
Mirtazapine - initially 15-30mg nocte, up to 45mg |
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What is the mechanism of action of Monoamine oxidase inhibitors (MAOIs)? |
Inhibit monoamine oxidase causing an accumulation of amine neurotransmitters in the synapse (dopamine, NA, A, histamine and serotonin) |
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What are the indications for MAOIs? |
Depressive illness, social anxiety |
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What are the contraindications for MOIs? |
Acute confusional states, phaeochromocytoma |
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What are the adverse effects of MAOIs? |
Dizziness, postural hypotension (especially in elderly) |
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Give examples of MAOIs and their doses |
Phenelzine - irreversible. Initially 15mg TDS, up to 30mg TDS in hospital Moclobemide - reversible inhibitor of monoamine oxidase type A (RIMA) - 300mg daily, up to 600mg daily taken after food |
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Describe a MSE for a pt with depression |
A - down-turned eyes, sagging corners of mouth, furrows between eyebrows, poor eye contact. Wt loss and dehydration, unkempt, poor personal hygiene, dirty clothes B - psychomotor retardation S - slow with long delays before answering questions M - low and sad, hopelessness, bleak future. Anxiety, irritability and agitation, reduced energy and drive. Inability to feel enjoyment. Loss of interest in normal activities T - pessimistic. Delusions of poverty or illness. Suicidal thoughts P - mood congruent auditory hallucinations, second person and derogatory C - poor concentration may lead pt to think memory is impaired. Particularly important in elderly pts. |
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What are the top 10 presenting symptoms of pts with depression? |
1) tiredness 2) headache 3) stress 4) low mood 5) backache 6) sleep problems 7) chest pains 8) indigestion 9) dizziness 10) pain |
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What are the medical differentials for depression? |
Hypothyroidism, Drugs (B-blockers, L-DOPA), Dementia, stroke, PD, MS, Infection (flu, glandular fever), carcinoma, Cushing's disease, Addison's disease |
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What are the psychiatric differentials for depression? |
Anxiety, Schizophrenia, Alcohol misuse |
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What investigations would you do if you suspected depression? |
U&Es, FBC, TFTs, LFTs, Illicit drugs screen, Vit B12 and Folate, Syphilitic serology, EEG/CT |
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What are the two forms of bipolar disorder? |
Bipolar I - bipolar disorder with true mania Bipolar II - bipolar disorder with hypomania |
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What are the differentials for mania? |
Intoxication (alcohol, amphetamines, cocaine, cannabis), Prescribed drugs (steroids, DOPA, thyroxine), Thyrotoxicosis, Dementia, MS, epilepsy, Carcinoma |
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What is the management of acutely suicidal patients? |
COMMUNICATION is key, as is hope. Check medications, sometimes could be drug precipitated eg: withdrawal from sedatives or alcohol. Take extra time to reassure the anxious or explain to the suspicious. Treat underlying psychiatric illness Clozapine for schizophrenia, lithium for bipolar, SSRIs for depressed Use family and friends Refer, and admit to hospital |
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Sociocultural issues and Depression |
Black and Asian races present less often to their GP with "depression". Mediterranean people present with "nerves and headaches", Asian people present as "weak, tired". A psychiatric diagnosis with preclude marriage in some cultures. Migration and not speaking the local language are risk factors for suicide. Males tend to present less often due to stigma - masculinity We are affected by our own cultural biases |
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What is the ICD-10 classification of depression? |
Mild - 4 symptoms Severe - 7+ symptoms with or without psychotic symptoms Present for >1 month every day |
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DSM-IV classification of depression |
Mild - 5 core symptoms + minor social/occupational impairment Moderate - 5+ core symptoms + variable degree of social/occupational impairment Severe - 5+ core symptoms + significant social/occupational impairment |
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What is so great about SSRIs? |
Evidence shows that all antidepressants are about as good as each other. 2/3rd of people with depression who take any one type will find they improve. |
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What are some causes of depression? |
Genetic Drugs - steroids, contraceptive pill, digoxin, beta blockers Physical illness - hypothyroidism, heart disease, stroke, cancer, MS Other mental illness - dementia, alcohol excess Life events and social problems - divorce, low social class, unemployment Childbirth - 10% mothers get postnatal depression Lack of sunlight |
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What neurotransmitters and hormones are involved in depression? |
Linked to reduced CNS levels of serotonin and NA |
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What are the ICD-10 "core symptoms" of depression? |
Persistent sadness or low mood Loss of interests or pleasure Fatigue or low energy (at least one of these needed most days for >2 weeks) |
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What are the ICD-10 "associated symptoms" of depression? |
Disturbed sleep, poor concentration or indecisiveness, low self-confidence, poor or increased appetite, suicidal thoughts or acts, agitation or slowing of movements, guilt or self-blame |
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What are the DSM-IV core symptoms of depression? |
Depressed mood or irritable most of the day, nearly every day Decreased interest or pleasure Significant wt change (5%) or change in appetite Change in sleep - in or hypersomnia Change in activity - psychomotor retardation or agitation Fatigue or lethargy Guilt/worthlessness Diminished concentration Suicidality |
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Define counselling |
"The skilled use of the relationship to help the pt develop self-knowledge, self-esteem and the ability to take control of their own life" |
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Define poverty of speech |
General lack of additional, unprompted speech content. AKA alogia |
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Define stigma |
A mark of disgrace associated with a particular circumstance, quality or person. Discreditable - hiding conditions eg: HIV Discrediting - it cannot be hidden eg: acne Felt - sense of fear and shame Enacted - discrimination by others Courtesy - felt by someone with a person open to stigma Cultural stereotyping - impairment and 'learned helplessness' |
