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Depression SBAQs- Shiromi Patrick 1. Sam is a 19 year old university student. He is struggling to concentrate during exams and is finding it very difficult to enjoy other things in life due to being stressed about the upcoming exams. He has been struggling to fall asleep and has been eating less. This has been happening for the past week. Normally he is able to cope with the stressors of exams well however is struggling currently. Which of these factors prevent a diagnosis of depression from being made? a) Struggling to concentrate b) Difficulty enjoying other things in life c) Struggling to fall asleep d) Eating less e) Symptoms for 1 week 2. Mr. Liam Smith presents to his GP practice with feelings of low mood and low self- worth for a month. The GP suspects he may be depressed and decides to use a screening tool to determine his level of depression and help decide the treatment plan. What screening tool was he most likely to have used? a) DSM-5 b) PHQ -9 c) GAD-7 d) ACE-III e) CAGE 3. Alice is a 30 year old female coming into the GP practice for a review of her depression. She has tried multiple forms of talking therapies and CBT which haven’t helped her depression. She mentions that her sleep has increased a lot in the past few weeks and she has seen a lot of weight gain which is exacerbating her depressive symptoms more. It is decided that it is best to start her on some medication. What medication would you avoid starting this patient on? a) Citalopram b) Fluoxetine c) Sertraline d) Venlafaxine e) Mirtazpine 4. 26 yr old female patient Ellie is coming into the GP for a review of her depression. She has tried CBT which hasn’t worked so the doctor started her on citalopram. She finds that her depressive symptoms aren’t going away. The GP decides to start her on venlafaxine. What is something that the GP should tell the patient? a) Keep taking the citalopram along with the venlafaxine b) Slowly reduce the dose of citalopram c) Immediately stop taking citalopram d) Swap the citalopram for sertraline e) Take a blood test before starting the venlafaxine5. I am thinking of a drug to help with depressive symptoms. It doesn’t not rely on one target to produce an effect however it has high specificity for the antidepressive effects. What is a side effect of this drug? a) sweating b) hyperkalaemia c) weight gain d) hypertension e) headache 6. What can be seen on an ECG as a side effect from taking citalopram with a certain antibiotic? a) QTc prolongation b) QTc reduction c) QRS complex broadening d) PR interval prolongation e) ST elevation 7. 50 yr old Pamela has gone to the GP for advice about symptoms she is experiencing. She has been feeling low in mood and having low self worth for more than 4 weeks. She has been taking some medication that her friend also uses for depression which she said helped for the depression however now she has noticed some weight gain. What medication was it likely that she took? a) Paracetamol b) Venlafaxine c) Mirtazapine d) Prednisolone e) Sertraline 8. This is a copy of a patients PHQ-9 questionnaire. What level of depression does she have? a) None b) Mild depression c) Moderate depression d) Moderately severe depression e) Severe depression 9. Depression is associated with a lack of certain substances. What may be a factor for this lack of certain substances? a) Not enough oat, bread, chocolate, prunes b) Taking too many NSAIDs c) Not enough vitamin D d) Lack of sleep e) Too much oat, bread, chocolate, prunes 10. A patient is currently taking citalopram for depression but is struggling to manage with some of the side effects. The doctor then decide to change him to venlafaxine. However the patient reports having the feeling of a fast heart beat, sweating and also anxiety. What other signs may you see during examination? a) peripheral neuropathy b) abdominal distension c) hyperreflexia d) hyporeflexia e) hypotonia Answers 1. Sam is a 19 year old university student. He is struggling to concentrate during exams and is finding it very difficult to enjoy other things in life due to being stressed about the upcoming exams. He has been struggling to fall asleep and has been eating less. This has been happening for the past week. Normally he is able to cope with the stressors of exams well however is struggling currently. Which of these factors prevent a diagnosis of depression from being made? a) Struggling to concentrate b) Difficulty enjoying other things in life c) Struggling to fall asleep d) Eating less e) Symptoms for 1 week Answer: E Symptoms of depression need to be present for at least 2 weeks. Whilst all the above symptoms are of depression, and are needed for a depression diagnosis, the Timeframe of the symptoms prevent this from being made.2. Mr. Liam Smith presents to his GP practice with feelings of low mood and low self- worth for a month. The GP suspects he may be depressed and decides to use a screening tool to determine his level of depression and help decide the treatment plan. What screening tool was he most likely to have used? a) DSM-5 b) HQ -9 c) GAD-7 d) ACE-III e) CAGE Answer: B PHQ-9 is a 9 question screening tool about how oZen a patient may have certain depressive symptoms. It is scored out of 27 and has different ranges for different levels of depression severity. It is not A – the DSM 5 contains the criteria for the depression which doctors may use to guide their diagnosis of depression, however it isn’t a screening tool that would help determine the severity of depression. It only helps with identifying whether they have depression. It is not C - GAD 7 is a questionnaire to screen for generalised anxiety disorder. It is not D – ACE III is the Addenbrookes cognitive examination use to screen for dementia or other cognitive memory impairment. It is not E – CAGE is a screening tool that doctors may use to identify if patients are excessively drinking alcohol. 3. Alice is a 30 year old female coming into the GP practice for a review of her depression. She has tried multiple forms of talking therapies and CBT which haven’t helped her depression. She mentions that her sleep has increased a lot in the past few weeks and she has seen a lot of weight gain which is exacerbating her depressive symptoms more. It is decided that it is best to start her on some medication. What medication would you avoid starting this patient on? a) Citalopram b) Fluoxetine c) Sertraline d) Venlafaxine e) Mirtazpine Answer: E Mirtazapine is an antagonist for H1 receptor – this has sedating effects which probably isn’t a good idea for someone who says they are sleeping a lot. Mirtazapine also causes weight gain as a side effect – the patient says the current weight gain is exacerbating the depressive symptoms so prescribing this would do no good for the patient. This should be avoided. The other medications mostly have GI side effects and there isn’t any contradiction for that so anyone of the others are fine to prescribe. 4. 26 yr old female patient Ellie is coming into the GP for a review of her depression. She has tried CBT which hasn’t worked so the doctor started her on citalopram. She finds that her depressive symptoms aren’t going away. The GP decides to start her on venlafaxine. What is something that the GP should tell the patient? a) Keep taking the citalopram along with the venlafaxine b) Slowly reduce the dose of citalopram c) Immediately stop taking citalopram d) Swap the citalopram for sertraline e) Take a blood test before starting the venlafaxine Answer: B When starting another medication, it is important to slowly reduce the dose of the original medication rather than abruptly stopping it. Otherwise this can lead to effects such as withdrawal symptoms, which may be uncomfortable for the patient. For this reason it is also not C. It is not A because citalopram and venlafaxine both act on serotonin reuptake transporter and used together it can lead to too much serotonin in the bloodstream leading to serotonin syndrome. It is not D because sertraline has the same targets as citalopram ( both SSRIs) and it is unlikely that sertraline will have any greater effect compared to citalopram. Again it also shouldn’t be taken alongside venlafaxine due to serotonin syndrome. It is not E as there is no indication for a blood test – it is not normally done before starting a patient on antidepressants and there isn’t anything in the patients background to suggest doing a blood test. 5. I am thinking of a drug to help with depressive symptoms. It doesn’t not rely on one target to produce an effect however it has high specificity for the antidepressive effects. What is a side effect of this drug? a) Sweating b) Hyperkalaemia c) Weight gain d) Hypertension e) Headache Answer: D The drug in question is venlafaxine. It acts on multiple targets, so this excludes SSRIs which act only on serotonin reuptake transporters. It is also not mirtazapine, which has multiple drug targets since mirtazapine has lower specificity since it binds to the H1 receptor (for sedating effects) first before the 5HT2 receptor for the antidepressant effects. Venlafaxine is the right drug as it acts on the serotonin and noradrenaline reuptake transporters and has higher specificity. A side effect of venlafaxine is hypertension. It is not A (this is not associated with any antidepressant drugs). It is not B which can be a side effect of ACE inhibitors or ARBs for hypertension. It is not C which is a side effect of mirtazapine which we said isn’t the drug in this case. It is not E as it isn’t associated with antidepressant drugs. 6. What can be seen on an ECG as a side effect from taking citalopram with a certain antibiotic? a) QTc prolongation b) QTc reduction c) QRS complex broadening d) PR interval prolongation e) ST elevation Answer: A The certain Abx in question is referring to erythromycin, which when used in combination with citalopram can cause QTc prolongation. The other options aren’t recognised complications of this combination of citalopram and erythromycin. 7. 50 yr old Pamela has gone to the GP for advice about symptoms she is experiencing. She has been feeling low in mood and having low self worth for more than 4 weeks. She has been taking some medication that her friend also uses for depression which she said helped for the depression however now she has noticed some weight gain. What medication was it likely that she took? a) Paracetamol b) Venlafaxine c) Mirtazapine d) Prednisolone e) Sertraline Answer: C A recognised side effect of mirtazapine is weight gain. B and E are associated with GI side effects such as nausea and diarrhoea but not weight gain. Paracetamol is unlikely to have helped with the depressive symptoms. it is not D because whilst prednisolone is a corticosteroid that can cause weight gain as a side effect, it is unlikely to have helped improve the depressive symptoms hence why it is less likely to have been that. 8. This is a copy of a patients PHQ-9 questionnaire. What level of depression does she have? a) None b) Mild depression c) Moderate depression d) Moderately severe depression e) Severe depression Answer: D - Total PHQ 9 score is 16. This falls into the moderately severe range. 9. Depression is associated with a lack of certain substances. What may be a factor for this lack of certain substances? a) Not enough oat, bread, chocolate, prunes b) Taking too many NSAIDs c) Not enough vitamin D d) Lack of sleep e) Too much oat, bread, chocolate, prunes Answer: A Depression is associated with a lack of monoamines such as serotonin. Tryptophan hydroxylase is an enzyme that is needed for serotonin synthesis. This enzyme comes from tryptophan which is found in foods such as oats, breads and chocolate. A diet lacking in these foods can lead to lower tryptophan hydroxylase so lower serotonin so depression. It is not D which is more so one of the symptoms of depression. The others aren’t associated with depression. 8. A patient is currently taking citalopram for depression but is struggling to manage with some of the side effects. The doctor then decide to change him to venlafaxine. However the patient reports having the feeling of a fast heart beat, sweating and also anxiety. What other signs may you see during examination? a) Peripheral neuropathy b) Abdominal distension c) Hyperreflexia d) Hyporeflexia e) Hypotonia Answer: C The patient likely has serotonin syndrome. This is when a patient may be taking too much antidepressants such as having citalopram and venlafaxine. It is possible this doctor didn’t slowly taper down the dose of citalopram before giving venlafaxine or the patient took both. The symptoms the patient is experiencing such as tachycardia, shivering and anxiety are of serotonin syndrome. A sign of serotonin syndrome is hyperreflexia. It is not D. It is not E – hypertonia can be seen in serotonin syndrome. A and B aren’t typically seen in serotonin syndrome