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Depression (Risk factors (Female, FH, Chronic medical condtion,…
Depression
Risk factors
Female
FH
Chronic medical condtion
Psychiatric disorder
Previous abuse
Unemployment
Divorce
Financial issues
Poor support
Epidemiology
Common
Leading cause of disability
3rd most common GP consult
F>M
Pathophysiology
Monoamine hypothesis (low 5HT, NA, DA)
Endocrine abnormalities (HPA and low cortisol/T3)
Genetic predisposition plus environment
(life events, parental deprivation, learned helplessness)
Immunological abnormalities (high cytokines, HPA)
Diagnosis
Examination
General, MSE
Investigation
Bloods
If suspected organic cause e.g. TFTs,
LFTs, U+Es, glucose, FBC, CRP/ESR
Questionnaires
PHQ9 (depression, 12+/27 for intervention)
HAD14 (depression + anxiety, 10+ for intervention
History
Current symptoms, duration, severity
Past psych, admissions, tx
Self harm/suicide, safeguarding
Alcohol and drugs, social issues
ICD-10 criteria
Criteria
Duration 2+ weeks, no mania/hypomania,
not due to organic cause or substance misuse
Classification
Mild
2+ cardinal plus 2 others (4)
Continue ADLs
Moderate
2+ cardinal and 3-4 others (5-6)
Difficulty with ADLs
Severe
3 cardinal plus 5+ others (8+)
Unable to do ADLs
Severe with psychosis
Above with hallucinations/delusions
Aetiology
Endocrine
Hypothyroidism
Degenerative
Dementia
Drugs
Prescription - methyldopa, B-blockers, opioids, isotretinoin
Illegal - cannabis, cocaine, narcotics, anabolic steroids
Alcohol
CO poisoning
Functional/psychiatric
Grief reaction
Depression
Management
Psychological
Low intensity
Indication: 1L mild-mod
E.g. CBT (group, computerised), group physical activity
High intensity
Indication: 1L mod-severe with SSRI
E.g. CBT, IPT, behavioural act, couples therapy
Medical
1st ep, continue 6m after remission
2nd ep, continue for 2+ years
Gradual weaning over 4wk
SSRI
Indication: 1L mod-sev, 2L in mild-mod
MOA: 5HT reuptake inhib
E.g. citalopram, sertraline, fluoxetine
SEs: GI upset, sweat, insomnia, sexual dysf, hypo-Na, reduced seizure threshold, inc Q-T (citalopram), discontinuation syndrome
ECT
Indication: complex, severe, life-threatening
CI: nil absolute
MOA: anaesthetic and muscle relax, brief pulse of electricity
to produce grand-mal seizure, bilateral or unilateral
SE: mortality, headache, short-term memory loss
SNRIs
Use: resistant disease
MOA: 5HT and NA reuptake inhib
E.g. venlafaxine, duloxetine
SEs: per SSRI, HTN
NRIs
Use: refractory
E.g. reboxetine
TCAs
Indication: resistant disease
E.g. amitriptyline, imipramine
MOA: 5HT/NA antagonist, also anti-musc, H1, a1
SEs: dry mouth, blurred vision, constipation, sedation,
arrhythmias, tremor, GI upset, sweats
CI: cardiac disease
MAOIs
Indication: atypical cases (rarely used)
MOA: inhibit MAO, increase MA levels and tyramine
E.g. phenelzine (irreversible), moclobomide (reversible)
SE: cheese reaction (HTN, strokes, death)
Interactions: many!
A2-antagonist
Indication: resistance
MOA: a2-antagonist (autoreceptor)
E.g. mirtazapine, minaserin
SE: sedation, weight gain (mirtazapine),
blood dyscrasia (minaserin)
Conservative/social
Housing, finances, employment
Respite, support, charities
Crisis resolution and home treatment, admission
Manage alcohol and drugs
Information
Sleep management, exercise
Psychosurgery
Indication: intractible depression, rare
MOA: cingulotomy, subcaudate tractotomy
Definitions
Subthreshold depression
Defining symptoms of depression that doesn't fulfil criteria
Dysthymia/persistant subthreshold
Subthreshold depression for 2+ years
Depression
Persistent low mood and/or anhedonia plus emotional, social and behavioural symptoms for 2+ weeks
Complications
Social dysfunction
Relationships, family breakup,
finance and employment
Substance misuse
Mortality
Comorbid conditions, suicide
Prognosis
Duration
Episodes typically 6-8m
10% persistent
Recurrence
50% after 1 ep, 70% after 2, 90% after 3
Poor features
Psychosis
Personality disorder
Severe symptoms
Clinical
presentation
Core symptoms
Anhedonia
Fatigue
Depressed mood
Additional symptoms
Reduced concentration
Reduced confidence/esteem
Guilt/worthlessness
Bleak/pessimistic views
Ideas of harm/suicide
Disturbed sleep
Appetite and weight change
Psychomotor change
(agitation/retardation)