Depression

Question 1

Outline the DSM-5 criteria for depression

Answer 1

• 5+ symptoms (must have one of bold), for ≥2/52
  
  • Depressed mood
  • Anhedonia
  • Significant weight change or appetite disturbance
  • Sleep disturbance
  • Psychomotor agitation/retardation
  • Fatigue; lethargy
  • Feelings of worthlessness
  • Diminished ability to think/concentrate; indecisiveness
  • Recurrent thoughts of death; suicidal ideation/attempt
• Causing significant distress/impairment
• Not attributable to substance use; another medical condition
• Not better explained by psychotic disorders
• No PMH of (hypo)mania

Question 2

Outline the severity of depression

Answer 2

• Subthreshold: Persistent if >2yrs
  
  • <5 symptoms of depression
• Mild:
  
  • Few, if any, symptoms in excess of 5 required
  • Minor functional impairment
• Moderate:
  
  • Symptoms or impairment between mild/severe
• Severe:
  
  • Most symptoms
  • Marked functional impairment ± psychosis

Question 3

Name four risk factors for depression

Answer 3

• Chronic co-morbidites: esp chronic pain syndromes
• Drugs: ^eg. steroids
• Female
• Older age
• Recent childbirth
• Psychosocial issues: ^eg. divorce; unemployment; poverty
• PMH of depression
• FHx of depression
• Adverse childhood experiences
• Personality factors
• Head injury

Question 4

Name three complications of depression

Answer 4

• Exacerbation of pain; disability; distress
• Reduced QoL
• Increased morbidity and mortality
  
  • IHD; DM
  • Suicide
• Impaired ability to function normally
  
  • ADLs; employment; neglect; social problems
• Antidepressant complications

Question 5

Name three complications associated with taking antidepressants

Answer 5

• Risk of self-injurious behaviour
  
  • Transient increase amongst children/young adults
• Sexual adverse effects
• Weight gain
• Hyponatraemia
• Agitation
• Risk of suicide

Question 6

Name one problem associated with stopping antidepressants

Answer 6

• Antidepressant (SSRI/SNRI) discontinuation syndrome
  
  • Restlessness
  • Insomnia
  • Nausea; vertigo
  • Altered sensations: ^eg. electric shocks in head
  • Altered feelings: ^eg. irritable; anxiety; confusion
• Mania

Question 7

Ask two questions for assessing the ‘core’ symptoms of depression

Answer 7

• 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 8

Give two organic causes of depression

Answer 8

• Neurological
  
  • Dementia
  • Parkinson’s disease
  • MS
• Substance use; CO poisoning
• Hypothyroidism
• Obstructive sleep apnoea syndrome

Question 9

Name one depression questionnaire

Answer 9

PHQ-9

Question 10

Outline the management of depression

Answer 10

Safety net and manage suicide risk; safeguarding; comorbidites

Stepped-care model, including:

1. All: Psychoeducation; sleep hygiene; active monitoring
2. Mild-moderate: Self-guided/group CBT
3. Moderate-severe: CBT/IPT or antidepressant
4. Severe; complex; risk to life: CBT/IPT and antidepressant
   
   • Consider ECT if acutely life-threatening or refractory

Question 11

How can the risk of relapse in depression be reduced?

Answer 11

• Continue any antidepressant for 6+/12 after remission
• Review need for continued treatment beyond 6/12
  
  • Advise 2+ years if at risk of relapse
• Significant risk of relapse or residual symptoms
  
  • Individual CBT
  • Mindfulness-based cognitive therapy

Question 12

How is the choice of antidepressant determined?

Answer 12

• Patient choice using information on
  
  • Adverse effects inc. discontinuation syndrome
  • Efficacy/tolerability perceptions of past antidepressants
• Toxicity in overdose if significant risk of suicide ^eg. TCAs
• Associated psychiatric disorders or medical conditions
• Current medication and potential interactions

Normally, use SSRI due to favourable risk-benefit ratio