Depression (PSY)

Question 1

Define major depressive disorder.

Answer 1

Episodic mood disorder primarily characterised by depressed mood and anhedonia, lasting for at least 2 weeks

Question 2

Which demographics does major depressive disorder affect? (4)

Answer 2

• F>M
• 3rd decade of life
• affects 5-10% of patients in primary care setting
• 1/5 nursing home residents without dementia are diagnosed with depression

Question 3

What causes major depressive disorder?

Answer 3

Lack of monoamines (serotonin, noradrenaline, dopamine)

Question 4

What are some risk factors for major depressive disorder? (7)

Answer 4

• female
• recent childbirth (postnatal status)
• stress
• trauma
• co-existing medical conditions e.g. dementia
• medications: corticosteroids, propranolol, OCP
• personal/Fx depression

Question 5

What is persistent depressive disorder?

Answer 5

Characterised by at least 2 years of a depressed mood for most of the day, for more days than not, for at least 2 years

Question 6

What are the two major criteria for depression?

Answer 6

• depressed mood - most of the day, nearly every day, for 2 weeks
• anhedonia - markedly diminished interest/pleasure in all activities for 2 weeks

Question 7

What are the ‘minor’ criteria for depression? (7)

Answer 7

• sleep disturbance (insomnia/hypersomnia)
• guilt/worthlessness
• fatigue
• diminished concentration/cognition
• weight change (due to appetite change)
• agitation (change in activity)
• suicidal ideation

Question 8

What is the diagnostic criteria for major depressive disorder according to DSM-V?

Answer 8

Five or more of the symptoms (as above) during the same two-week period and represent a change from previous functioning

At least one is either depressed mood OR anhedonia + 4 others (mood, anhedonia, sleep, guilt, fatigue, concentration, weight, agitation, suicidal)

Question 9

How do we diagnose major depressive disorder?

Answer 9

Clinical diagnosis (DSM-V or ICD-11 criteria)

Question 10

What investigations can we do to exclude organic causes of major depressive disorder? (3)

Answer 10

• FBC - anaemia
• TFTs - hypothyroidism
• metabolic panel

Question 11

What questionnaire can we give in depression?

Answer 11

Patient Health Questionnaire 9 (PHQ-9)

Question 12

What scale can we put patients with depression on?

Answer 12

Hospital Anxiety and Depression (HAD) scale

Question 13

What two diagnostic criteria are used to diagnose major depressive disorder?

Answer 13

• ICD-11 (mild, moderate and severe depression)
• DSM-V: major depressive disorder ( 5+ symptoms >2wk, including low mood or anhedonia) vs subthreshold/minor depression (not defined but refers to 2-4 symptoms >2wk, including low mood or anhedonia)

Question 14

What are the first-line medications for depression? (4)

Answer 14

• SSRIs - sertraline, citalopram, fluoxetine
• SNRIs - venlafaxine, duloxetine
• MAO inhibitors - isocarboxazid
• TCAs - amitriptyline

Question 15

What are some issues of SSRIs? (5)

Answer 15

• GI side effects
• GI bleed risk if used with NSAIDs (co-prescribe PPI)
• erectile dysfunction
• hyponatraemia (SIADH)
• citalopram –> prolongs QT interval

Question 16

What is a side effect of citalopram (SSRI)?

Answer 16

Prolongs QT interval

Question 17

Who do we give fluoxetine (SSRI) to?

Answer 17

SSRI of choice in children and adolescents

Question 18

Who do we give sertraline (SSRI) to?

Answer 18

SSRI of choice in post-MI

Question 19

How long should we give antidepressants for?

Answer 19

• should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
• when stopping them, doses should be reduced gradually over 4 weeks

Question 20

What psychotherapy is there for major depressive disorder?

Answer 20

CBT

Question 21

What lifestyle changes are there for major depressive disorder? (5)

Answer 21

• exercise
• nutrition
• sleep hygiene
• social support
• stress reduction

Question 22

What are the NICE guidelines for depression?

Answer 22

• provide advice on activities to improve sense of wellbeing
• urgent referral to specialist mental health services if patient has more severe depression or psychotic Sx
• discuss options for Rx - SSRIs, CBT, group exercise, counselling etc

Question 23

What antidepressants do you avoid if patient at risk of suicide?

Answer 23

Avoid TCAs (e.g. amitriptyline) and venlafaxine (SNRI) - risk of death from OD

Question 24

What do you need to do after prescribing antidepressants for depression?

Answer 24

Arrange follow up two weeks after starting - check response, concordance, adverse effects or suicidal ideas since it gets worse before improving

(1 week follow up if 18-25y or concern for suicide)

Question 25

What are some complications of major depressive disorder? (3)

Answer 25

- self harm / suicide - weight gain from antidepressants - sexual adverse effects of SSRIs

Question 26

Describe the prognosis of major depressive disorder.

Answer 26

For patients in their first episode of depression, treatment to remission may take several months and should be continued for 9-12 months after remission