Depression

Question 1

depression is more common in who?

Answer 1

females 2:1

• age of onset 25 - 29 years
• twins

Question 2

What is the criteria to diagnose major depressive disorder?

Answer 2

5 or more are present most of the time during a 2 week period

CORE SYMPTOMS (at least 1 must be present) 
1- depressed mood 
2- interest/pleasure in activities diminished 

other symptoms 
3- insomnia/hypersomnia 
4- guilt feelings 
5- energy decrease/fatigue 
6- concentration diminished 
7- appetite or weight changes 
8- psychomotor agitation or retardation 
9- suicidal thoughts

Question 3

How can we differentiate depression from sadness?

Answer 3

• significant distress & impairment of function

- no evidence of mania or hypomania (like bipolar)

Question 4

What are the severities of MDD?

Answer 4

• mild: minimum criteria to make diagnosis
• moderate: between mild & severe
• severe: severe dysfunction with or without psychosis
• > common delusional themes
• > hallucination
• > depressive stupor (catatonia)

Question 5

What investigations are done in case of MDD?

Answer 5

to rule out organic conditions & substance abuse

• CBC
• TSH
• Folate & B12 levels

Question 6

What is the acute phase treatment?

Answer 6

• decide on antidepressant

- educate the patient & family about medication

Question 7

What are the anti-depressant agents?

Answer 7

1- SSRIs (first line)

• Setraline
• Escitaloprm (Ciprolex)

2- Serotonin & Noradrenaline Reuptake inhibitors (SNRI)

3- Mirtazapine (noradrenaline & specific serotonin anti depressant)

4- Wellbutrin (DNRI)

5- TCA
- Amitriptyline -> when target symptom is insomnia, migraines, or neuropathies

Question 8

How is a first line antidepressant chosen?

Answer 8

• patient preference
• covered by hospital insurance
• pharmacological profile (side effects)
• evidence of efficacy
• safety profile

Question 9

What is the cause of mania after taking antidepressants?

Answer 9

only if the patient is BIPOLAR

Question 10

How long should the treatment of MDD continue?

Answer 10

• usually 3 - 4 weeks -> if not, alter medication
• Remission takes longer -> 6 weeks minimum but usually 8 - 12 weeks

First episode of depression -> patient needs to stay on treatment for 1 year & then gradually lower the dose then discontinue

Question 11

If a patient does not respond to medication after 4 weeks, what should be done?

Answer 11

CHECK

• accurate diagnosis - presence of co morbidity
• adequate dosage
• check patient compliance/side effects

Question 12

What is the best method for treatment?

Answer 12

anti depressant medications + psychological therapy + support + psychoeducation

Question 13

When is ECT preformed?

Answer 13

• in severe cases unresponsive to medication (psychotic depression)
• in catatonia
• refractory to drug treatment

done twice weekly
70 - 80% improve

Question 14

What is the general guideline for GPs to follow in assessment of MDD?

Answer 14

1- patient may present initially with physical symptoms (as fatigue or pain)
2- further inquiry will reveal the core symptoms
3- ask about the other associated symptoms
4- do proper suicide risk assessment
5- look for psychotic features
6- if patient has HISTORY of manic episodes -> consider bipolar
7- if a patient has responded well to a particular drug in the past use it again