Depression

What is depression?

Disorder presenting predominantly with low mood over a period of at least 2 weeks which interferes with normal life

What are the 4 classifications of depression symptoms?

• Emotional

• Cognitive

• Behavioural

• Physical

List 4 depressive symptoms

• Low mood

• Loss of concentration

• Loss of interest

• Decreased energy

What are some diagnostic assessments ?

PHQ-9, BDl-ll, HADS when examining mental state through observation and direct questioning, against the DSM-5 or ICD11 criteria

What is the treatment guidelines for depression in adults?

• “Watchful waiting” GP sets up a follow-up appointment in 2 weeks

• Antidepressants are NOT recommended for initial treatment of

mild depression because the risk-benefit is poor.

• Offer guided self help based on cognitive behavioural therapy

(CBT), problem solving therapy or counselling over 3 months

If an antidepressant has to be prescribed in mild depression what should it be?

SSRI because they are as effective as TCA’s & less likely to be discontinued due to side effects.

What are the non drug therapies for depression ?

• Talking Therapies

• Substance Abuse Rehabilitation

• Self-help

What are the psychological therapies for depression ?

• Cognitive Therapy

• Behaviour Therapy

What is the treatment guidelines for moderate/severe depression in adults?

• A combination of antidepressants + individual CBT

Patients who have had >2 episodes in the recent past & who have experienced significant functional impairment during the episodes should be advised what?

To continue antidepressants for 2 years

What are the 1st generation antidepressant ?

• Monoamine Oxidase Inhibitors (MAOIs)

• Tricycle antidepressants

What are the 2nd generation antidepressant ?

• Selective Serotonin Reuptake Inhibitors (SSRIs)

What are the 3rd generation antidepressant ?

• Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs)

• Noradrenaline-Dopamine Reuptake Inhibitors (NDRIs)

List 2 MAOIs

• Phenelzine

• Tranylcypromine

What is strongly advised avoiding with MAOIs?

Avoiding strong cheese & ephedrine / pseudoephedrine

What are the side effects of MAOIs?

• Postural hypotension

• Dry mouth

• Blurred vision

• Urinary retention (atropine-like)

• Weight gain

• Restlessness

• Insomnia

List me 3 TCA

• Amytryptilline

• Nortryptilline

• Clomipramine

What conditions should you not use TCAs with?

• Epileptic history

What are the side effects of TCAs?

• Dry mouth

• Constipation

• Bladder problems (emptying difficulties for with prostate problems)

• Blurred vision (anticholinergic effects)

• Sexual Dysfunction (↑ synaptic 5HT)

• Dizziness

• Drowsiness (anti-histminergic effects)

• Postural hypotension (anti-adrenergic effects)

List 5 SSRIs

• Citalopram

• Escitalopram

• Fluoxetine

• Paroxetine

• Sertaline

What are the side effects of SSRIs?

• Agitation

• Sexual dysfunction

• Headache

• Nausea

• Nervousness & insomnia

• GI Bleeding

• Weight gain

• Personality Changes

• Impulsivity / hostility

• Emotional blunting

• Suicidality

List me Serotonin & Noradrenaline Reuptake Inhibitors

• Venlafaxeine

• Duloxetine

What should you be cautious with a SNRI?

• Antihypertensive drugs

Give an example of a noradrenaline & specific serotonin antidepressants (NaSSAs)

• Mirtazpine

What are the side effects of NaSSA?

• Weight gain,

• Drowsiness

• Sedation

• Dry mouth

What are the drawbacks of the antidepressants?:

• TCAs

• MAOIs

• SSRIs

• NaSSAs

• Tricyclics: Cardiotoxicity

• MAOI’s: Dietary restrictions: hypertensive crisis

• SSRI’s: Tremor, akathisia, G.I. disturbance, sleep fragmentation, emotional blunting, impulsivity, sexual dysfunction

• NASSA’s: Weight gain & drowsiness

Why are wash-out periods required when changing antidepressant medication?

Wash-out periods allow the original antidepressant to be fully excreted and prevent serotonin syndrome

What wash-out periods are required when switching between MAOIs and SSRIs?

• MAOI → SSRI: 14 days

• SSRI → MAOI: 5 weeks, due to the long half-life of some SSRIs.

What are the key clinical features of serotonin syndrome?

• Hypertension

• Hyperpyrexia

• Agitation

• Neuromuscular seizures

• Delirium

• Coma.

How should patients be monitored when antidepressant (AD) treatment is first prescribed?

Patients should be reviewed every 1–2 weeks after the first prescription.

How long should antidepressant treatment be continued before assessing efficacy, and what if the response is partial?

Treatment should be continued for at least 4–6 weeks before judging efficacy. If there is a partial response, treatment should be continued for a further 2 weeks.

How long should antidepressant treatment be continued after symptom remission or in recurrent depression?

• After symptom remission, continue the same dose for at least 4–6 months.

• In patients with recurrent depression, maintenance treatment should continue for at least 5 years, and in some cases indefinitely.

What is antidepressant discontinuation syndrome and how is it remembered?

A cluster of symptoms that can occur after stopping or reducing antidepressants, remembered using FINISH

What does FINISH stand for?

• Flu-like symptoms

• Insomnia

• Nausea

• Instability (e.g. dizziness)

• Sensory disturbances

• Hyperarousal.

How is postnatal depression monitored by?

Edinburgh postnatal depression scale (EPDS)

What is the guidance on antidepressant use during breastfeeding?

• Manufacturers advise avoiding tricyclic antidepressants during breastfeeding.

• Drugs such as mianserin, trazodone, and doxepinmay cause sedation and respiratory depression in neonates.

How should mild depression be treated in children and young people according to NICE?

Antidepressant medication should not be used as initial treatment in children and young people.

What is the NICE first-line treatment for moderate–severe depression in children, and when can antidepressants be used?

• First-line treatment is a specific psychological therapy (CBT, interpersonal therapy, or family therapy) for at least 3 months.
  

• Antidepressants should only be used in combination with concurrent psychological therapy, with careful monitoringof adverse effects and mental state.

• A psychiatrist must have weekly contact with the child and parents for the first 4 weeks.

• If psychological therapy is declined, medication may still be prescribed, but the GP must closely monitor progress.

How is Seasonal Affective Disorder (SAD) managed?

Management includes getting outdoors and using light (lux) boxes during daytime.

When are ECT or rTMS used in depression and what are their disadvantage?

• ECT/rTMS are used in severe and treatment-resistant depression. They are highly effective and rapid-acting

• Disadvantages include the need for hospital treatment and amnesic effects.

What should be known about St John’s Wort in depression treatment?

• St John’s Wort (Hypericum perforatum) has some efficacy in mild depression

• It must not be taken with prescription antidepressants.

• Adverse effects include GI disturbance and photosensitivity.