Depression

Question 1

Definition

Answer 1

Serious mental health mood disorder: Abnormalities in dopamine signalling result in poor concentration and motivation, whereas noradrenaline may play a role in fatigue, and together with serotonin contribute to physical symptoms.

Question 2

Epidemiology

Answer 2

• Age > 65 years
• Female
• Postpartum: 20% of women have a depressive episode in the first 3 months after delivery
• Family history: having a first-degree relative increases the lifetime risk by two-fold
• Co-morbidities: long term health conditions e.g. chronic pain, heart failure
• Medications: e.g. corticosteroids, COCP
• Abuse: childhood, physical, sexual, psychological, or drug abuse

Question 3

Core Symptoms

Answer 3

Low mood
Anhedonia: diminished interest or pleasure activities

Question 4

Associated symptoms

Answer 4

• Functional impairment: in social and/or occupational function
• Weight change: weight loss or gain, with decreased or increased appetite
• Sleep disturbance: insomnia or hypersomnia
• Psychomotor agitation or retardation
• Feeling of worthlessness or guilt
• Suicidal ideation
• Poor concentration
• Low energy or fatigue

Question 5

Screening questions
CLUE: CORE SX

Answer 5

During the last month have you often been bothered by feeling down, depressed, or hopeless?
Do you have little interest or pleasure in doing things?

Question 6

Diagnostic criteria

Answer 6

DSM-IV
ICD-10

Question 7

Validated questionairres

Answer 7

• Patient Health Questionnaire (PHQ-9) : a 9 item questionnaire reflecting the DSM criteria
• Beck depression inventory-II (BDI-II): a 21 item questionnaire reflecting the DSM criteria
• Hospital Anxiety and Depression (HAD) scale : a 14 item questionnaire consisting of questions on anxiety and depression

-Edinburgh Postnatal Depression Scale: If postpartum depression is suspected, the may be used 4-6 weeks after delivery

Question 7

Diagnosis

Answer 7

Clinical diagnosis
Consider:
- Bloods
- Validated questionnaire

Question 8

Treatment

Answer 8

Mild to moderate: PHQ < 16
- FIRST LINE: Self guided help,
- Low-intensity psychosocial interventions : computerised CBT
- Antidepressants: usually an SSRI e.g. citalopram
Moderate to severe: PHQ > 16
- Combination of individual CBT and an antidepressant
Severe:
- Electroconvulsive therapy

Question 9

What medication is preferred in Children

Answer 9

First line SSRI - Fluoxetine

Question 10

In which patients should SSRI’s be avoided

Answer 10

Patients on warfarin
- Mirtazapine = alternative

Question 11

Mirtazapine side ffects

Answer 11

Drowsiness and increased appetite; it is good in elderly patients with insomnia and reduced appetite; to be taken in the evening

Question 12

SSRI side effects

Answer 12

• Increased risk of upper GI bleed = Co-prescribe omeprazole
• Hyponatraemia
• Patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
• fluoxetine and paroxetine have a higher propensity for drug interactions
• citalopram = Prolonged QT interval

Question 13

Which SSRI is preferred for post MI

Answer 13

Sertraline

Question 14

Switching antidepressants

Answer 14

• Switching from citalopram, escitalopram, sertraline or paroxetine to another SSRI: direct switch possible
• Switching from fluoxetine to another SSRI: withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI
• Switching from SSRI to TCA: Cross tapering recommended