Depression

Question 1

Initial workup of suspected new onset depression

Answer 1

• Complete medical history, H&P
• Routine labs
• Thyroid studies

Question 2

Weight gain without increase in appetite in association with new onset depression

Answer 2

Highly suggestive of a secondary etiology, especially hypothyroidism or Cushing syndrome

Question 3

Depression episode following stroke

Answer 3

The incidence of secondary depression induced by stroke is quite high

Question 4

Depression secondary to stimulant withdrawal

Answer 4

Education and substance abuse treatment aresthe most imporant things

Antidepressant is generally not needed initially, but if depressive symptoms continue an antidepressant is indicated.

If there is suicidal intent with plan, the patient should be hospitalized on an inpatient psychiatric unit until withdrawal-induced depression improves.

Question 5

Cocaine “crash”

Answer 5

Withdrawal from cocaine is known to produce a severely dysphoric mood, which may manifest with suicidal ideation/intent/plan

Question 6

There is some evidence to suggest that patients with co-occurring depression and cocaine use may respond to ___ better than to ___

Answer 6

There is some evidence to suggest that patients with co-occurring depression and cocaine use may respond to tricyclic antidepressants better than to SSRIs

Question 7

___ are probably the most common chronic medication which may induce depression

Answer 7

Beta blockers are probably the most common chronic medication which may induce depression

Used for cardiac care, hypertension, essential tremor, etc.

Question 8

If patients undergoing severe depression do not quite meet criteria for involuntary admission, it is often a good idea to. . .

Answer 8

. . . offer voluntary psychiatric admission just in case

Question 9

Even if a minor does not meet criteria for involuntary admission, their parents may. . .

Answer 9

. . . choose to admit them as the patient’s guardian

Question 10

“Vegetative” symptom

Answer 10

• Describes a symptom of depression that is physiologic or related to body functions. Examples include:
  
  • Loss of apetite
  • Insomnia
  • Decrease in energy levels
  • Decrease in sex drive

Question 11

For a patient to be diagnosed with a depressive episode, at least one symptom must be either:

Answer 11

Anhedonia

OR

Depressed mood

Question 12

When you diagnose a patient with x mood disorder with psychotic features, you should specify whether the psychotic features are. . .

Answer 12

. . . mood congruent or mood incongruent

Question 13

Somatic delusion

Answer 13

False belief about one’s body.

In depression, these are usually beliefs regarding illness: for example, that a patient has undiagnosed cancer and is on the verge of death.

Question 14

Risk factors for MDD

Answer 14

• Genetics/Family history
• Loss of a parent before age 11
• ACEs

Question 15

Suicide in males vs females

Answer 15

Females attempt more often

Males complete more often (since they use more lethal means)

Question 16

Can you make the diagnosis of major depressive episode in a period of bereavement?

Answer 16

Yes, if the person meets criteria AND it causes considerable impairment in function

Question 17

Hallucinatory phenomena in adolescents undergoing bereavement

Answer 17

Children and adolescents with normal bereavement often have hallucinatory phenomena where they will see or hear the deceased loved one, often with messages that are comforting or reassuring.

This is usually NOT a sign of psychotic depression.

However, hostile accusatory hallucinations may represent a major depressive episode with psychotic features.

Question 18

Treating depression

Answer 18

1. Try an SSRI
2. If this fails, try another SSRI
3. If this fails, try a different class

Question 19

If a child is suffering from an MDE with psychotic features and responds to a combination of antidepressant and atypical antipsychotic. . .

Answer 19

. . . the antipsychotic should be continued for 3 months, then tapered off.

Similarly, the antidepressant should be continued for 6-12 months, then tapered off over 2-3 months.

Question 20

Children and adolescents with MDD often self-describe their mood as. . .

Answer 20

. . . angry or mad rather than sad or depressed

Question 21

Whenever a patient with MDD has psychotic features, this should prompt. . .

Answer 21

. . . antipsychotic therapy and strong consideration for hospitalization

Question 22

In the diagnosis of MDD with psychotic features, the psychotic features. . .

Answer 22

. . . must have appeared after the onset of mood symptoms

If they pre-dated the mood symptoms, an alternative diagnosis such as schizoaffective disorder is more likely.

Question 23

Current medications considered equivalent first-line options for MDD

Answer 23

SSRIs

SNRIs

Buproprion (weak inhibitor of dopamine and norepinephrine reuptake)

Mirtazapine (alpha-2 receptor antagonist)

Question 24

Best option for a patient with MDD who wants to avoid sexual side effects

Answer 24

Buproprion

Question 25

Depressive disorder with postpartum onset

Answer 25

• Occurs in as many as 20-40% of women in the US
• “Peripartum” since 50% begin prior to delivery
• Must be dinstinguished from “baby blues”, which are mild postpartum depressive symptoms that do not constitute a major depressive episode
  
  • Baby blues last <1 week
• Once the diagnosis is made, treatment is the same as for any other MDD diagnosis
  
  • However, they should be educated that breastfeeding may be contraindicated as the antidepressant can appear in breastmilk

Question 26

1 year and lifetime recurrence risk of major depressive episode

Answer 26

1 year: ~40%

Lifetime: ~80%

Question 27

Treatment of uncomplicated recurrent episodes of major depression

Answer 27

• Not significantly different from treating the first episode
• If medication is poorly tolerated, rTMS is a good option for outpatients
• If severe or psychotic and rapid response is required, ECT should be strongly considered

Question 28

If a patient is going to develop GI side effects on an SSRI, it will be ___.

If a patient is going to develop sexual dysfunction on an SSRI, it will be ___.

Answer 28

If a patient is going to develop GI side effects on an SSRI, it will be early in the treatment course.

If a patient is going to develop sexual dysfunction on an SSRI, it will be late in the treatment course.

Question 29

Discontinuing antidepressant therapy

Answer 29

Can be considered in patients with one episode of major depression after a period of time, however the lifetime risk of another episode is high off of therapy (~85%)

Question 30

Diagnostic criteria for persistent depressive disorder

Answer 30

• Patient has a depressed mood that occurs almost all the time and has done so for at least 2 years
  
  • No gaps in depression lasting longer than 2 months
  • Can be 1 year for children and adolescents
  • As opposed to the ‘episodic’ major depression of MDD.
• Need 2 or more SIGECAPS symptoms

Question 31

“Double depression”

Answer 31

When a patient with PDD also has an MDD depressive episode

Worse prognosis than either diagnosis alone

Question 32

How is persistent depressive disorder treated?

Answer 32

Just like MDD

Question 33

rTMS is contraindicated in patients with. . .

Answer 33

. . . pacemakers

Question 34

___ are safe antidepressants for women who are breastfeeding and are often used for postpartum depression.

Answer 34

SSRIs are safe antidepressants for women who are breastfeeding and are often used for postpartum depression.

Question 35

Therapy for trichotillomania

Answer 35

CBT and SSRIs