common condition characterised by the following few symptoms
- low mood
- loss of interest or pleasure in most activities
- range of associated emotional, cognitive, physical and behavioural symptoms (sleep and appetite disturbance, lack of conc, low self-confidence
risk factors for depression
- P/FHx depressive illness
- Hx other mental health conditions
- other chronic comorbids
- female
- recent childbirth
- older age
- psychosocial issues e.g. relationship problems, bereavement, unemployment, poverty or homelessness
M or F - who is more likely to have depression
F
Depression severity depends on …
intensity, freq, and duration of symptoms and their impact on daily functioning
Depression severity can be classified as (4)
LESS SEVERE: sub threshold and mild
MORE SEVERE: moderate and severe
Pt classified as having chronic depressive symptoms include (2)
- for at least 2 years, pt continually meets criteria for diagnosis of a major depressive episode
- for at least 2 years, pt has has persistent sub threshold symptoms, or persistent low mood (with or without concurrent episodes of major depression)
Is depression recurrent
High risk
Increases with each depressive episode
Risk of depression recurrence is high and increases with each depressive episode - true or false
true
Sometimes the symptoms of depression are different and non-specific in elderly. For example, older people may only present with ….
Physical symptoms or deteriorated cognitive functioning
This sleep disturbance is characteristic of depression
early morning wakening
What are the 2 depression identification questions?
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you been bothered by having little interest or pleasure in doing things?
What are some self administered depression questionnaires used in primary care? (aka the patient answers them) And which ones use the DSM-5 criteria?
- 3
- PHQ9
- HADS (does not use DSM5 criteria)
- BDI-II
Management of pt with new episode of less severe depression and does not want treatment, or feels that symptoms are improving (3)
- offer active monitoring with option to consider treatment at any time if needed
- ensure adequate social support and awareness of sources to help if symptoms worsen
- arrange initial review, usually within 2-4 weeks and ensure follow up if pt does not attend
management of pt with new episode of less severe depression & wishes to consider treatment
- match treatment to clinical needs and wishes
- consider offering guided self help first line
- do not routinely offer ADs as 1st line, but if they do wish to start this, 1st line is SSRIs
- arrange initial review usually 2-4 weeks after starting treatment and ensure follow up if pt does not attend
management of patient with new episode of more severe depression
- match treatment to clinical needs and wishes
- offer any treatment as 1st line depending on wishes, previous experiences and local referral pathway and services
- arrange initial review usually 2-4weeks after starting treatment and ensure follow up if pt does not attend
- if they wish to start AD, 1st line is SSRI or SNRI
- do not drive and notify DVLA if significant memory or conc problems, agitation, behavioural disturbance, suicidal thoughts
Arrange regular monitoring and follow up depending on clinical judgement. Consider using a validated depression questionnaire to monitor response to treatment e.g.
PHQ-9
If a pt needs to be admitted to hospital for specialist mental health input, every attempt should be made to persuade them to go voluntarily. If admission necessary and pt declines, compulsory admission can be arranged under sections …. of the Mental Health Act
2,3,4
MHA allows compulsory admission of people who
Have mental disorder of a nature or degree that warrants assessment or treatment in hospital, and
Need to be admitted in the interests of their own health or safety, of for the protection of other people
If patient is at risk of suicide, you would avoid this AD drug class (with the exception of one drug), and you would also avoid this drug
avoid TCAs except lofepramine
avoid venlafaxine (SNRI)
this is due to risk of death from overdose
If the patient has a chronic physical health condition, these 2 SSRIs may be preferred 1st line as lower likelihood of drug interactions
sertraline
citalopram
A patient has been taking sertraline for 3 years says that they have heard antidepressants are addictive and they are worried and want to stop it. Is this true?
They are not addictive but withdrawals can occur if the medication is stopped abruptly, doses missed, or full dose is not taken as directed
A patient has just started antidepressants. You tell them that if the antidepressant is going to work, it will usually start to work within this time frame
within 4 weeks
A patient is about to be started on antidepressants. You counsel them on what to expect. What do you say?
symptoms of anxiety, agitation, hopelessness or suicidal ideas may increase when starting treatment
if it is going to work, it will usually work within 4 weeks
Following remission, how long should antidepressant treatment be continued for?
continue at the same dose for at least 6 months (12 months in elderly, 2 years if recurrent depression)
at least 12 months in patients receiving treatment for generalised anxiety disorder (likelihood of relapse is high)
