Depression

Question 1

Define depression

Answer 1

Common mental disorder characterized by loss of pleasure or interest in activities for a long time

Question 2

DSM-5 for diagnosis of Major depressive disorder

Answer 2

An individual must experience 5 or more symptoms during the same 2 week period and at least one of the symptom should either be depressed mood or loss of interest or pleasure
Not better accounted for by another illness
Symptoms must cause individual clinical distress or impairment of functioning ie work
Requires 5 or more symptoms for diagnosis:
Weight loss/gain
Fatigue
Suicidical thoughts
Diminished concentration
Feelings of worthlessness

Question 3

Using monoamine theories of depression explain the pathophysiology

Answer 3

Causative factor of depression is marked by functional decrease in levels of neurotransmitters such as serotonin , noradrenaline and dopamine.

Question 4

Give supportive factors of the monoamine theory

Answer 4

Support-TCA, MAOIs shown to be effective in treatment as they target level of neurotransmitters in the synapse .
Reserpine decreases level of neurotransmitters and has been associated with depression

Question 5

Give issues with monoamine theory

Answer 5

Atypical antidepressant do not affect monoamine pathway yet show effect
Drugs acting on depression manipulate monoamine transmission but effects of neurotransmitters are immediate yet antidepressant effects take several weeks to arise. Thus could be due to some secondary change such as neurogenesis , plasticity

Question 6

Other probable mechanism

Answer 6

Hypothalamic-pituitary-adrenal axis activated by stress enhances excitoxic effect of glutamate, mediated by NMDA and switches on expression of genes that promote neural apoptosis in the hippocampus and prefrontal cortex. Anti depressive pathway involve NA and 5-Hydroxytryptamine which act in kinase linked receptor switching on genes that protect neurons against apoptosis and promote neurogenesis

Question 7

Examples of quick screening tools

Answer 7

Patient health questionnaire 2 . Brief screening tool used to assess presence of depressive symptoms. It consists of 2 questions that asses frequency of depressed mood and anhedonia.
Questions also include any suicide -screening questions

Question 8

Differential diagnosis

Answer 8

Thyroid disorder-hyperthyroidism
Neurological disorder-Parkinson’s
Chronic illness -Cardiovascular disease, diabetes,cancer
Other psychiatric conditions -bipolar, PTSD, anxiety disorder

Question 9

Variants of depressive disorder

Answer 9

Major depressive disorder- persistent, and severe symptoms of depression that interfere with daily functioning
Post partum-occurs following childbirth
Seasonal affective disorder-due to seasonal changes ie presence of sun
Depression with catatonia such as motor and behavioral manifestation such as mutism, posturing

Question 10

Risk factors and mrps for depression

Answer 10

Asssess for dose of antidepressant ie setraline
Assess for need of 1st gen antihistamine as can lead to drowsiness
Alcohol interaction and antidepressant-ie TCA increase sedative effects, MAOI, hypertension and can also worsen depression
Alcohol impairs liver functions
Aspirin and setraline increase risk of bleeding
Transform with other antidepressant increase risk of serotonin syndrome
St. John’s wort- no known dose, increase risk of serotonin syndrome , not FDA approved
Asssess lag time as antidepressant effect could be seen at the 6th week
Nifedipine + captopril increase risk of depression
Risk factors -lifestyle, neurological factors(meningitis?), env , genetics ,

Question 11

Severity of depression assessment

Answer 11

Mild-not more than 5 , and functional impairment mild
Moderate - functional impairment moderate
Severe >5 symptoms
Marked impairment function with or out psychotic disturbances

Question 12

Non pharmacological

Answer 12

Physical activity
Gratitude journal
Limit alcohol , caffeine
Spend time with loved ones
Improve sleep hygiene
Eat nutritional meals
Spend alone time doing things they enjoy

Question 13

CBT

Answer 13

Cognitive behavioral therapy good for depression and anxiety . Tested scientifically and proven to be successful. Aids to face fears, tackle self limiting thoughts and behaviors, puts things into perspective, offers skill to cope with stress. Downside-expensive , need professionals , long waiting period

Question 14

List pharmacotherapy drugs available for depression with examples

Answer 14

TCA’s-impiramine, amitryptyline
SSRI-citalopram, setraline , fluoxetine
SNRI- venlafaxine, duloxetine
MAOI-selegiline, isocarboxazid, phenelzine

Question 15

Discuss MOA and S/E of SSRI and SNRI

Answer 15

SSRI-block serotonin receptor on presynaptic neurons thus prevent reuptake of serotonin in synaptic cleft thus increased serotonin which enhance mood
SE: N/V, sexual interest decrease, vivid dreams, headache, diarrhea
SNRI- inhibit reuptake of NA and Serotonin which aids to regulate mood and alleviate depressive symptoms
SE: similar to SSRIs - but due to NA cause tremor, sweating, hypertension

Question 16

MOA and SE for TCA

Answer 16

TCA- prevent reuptake of neurotransmitters of serotonin and NA , also antagonistic at various neurotransmitters receptors ie histamine, acetylcholine, alpha adrenergic
SE: Anticholinergic-dry mouth, blurred vision, constipation
Antihistamine-sedation
Alpha blocker-reflex tachycardia

Question 17

Monoamine oxidase inhibitors

Answer 17

Inhibit monoamine oxidase enzymes located in neurons and other cells throughout the body . Responsible for breakdown of dopamine, serotonin, and NE
SE: hypotension, tremors, convulsions, insomnia
Interacts cheese cause hypertensive crisis
Last line due to its drug interactions

Question 18

Atypical

Answer 18

Bupropion- dopamine and norepinephrine reuptake inhibitors
Mild antagonist effect at nicotine acetycholine receptors
SE: N/V , insomnia , fatigue

Question 19

Counseling on sertraline

Answer 19

SE: drowsiness, so give at night others include sexual dysfunction(increased risk with prolonged use)N/V ,
Lag time 3-4 weeks
Drug interaction ie alcohol increase CNS depression, St. John: serotonin syndrome ,
Finish course to avoid withdrawal symptoms which include sweating most common, git disturbances, dizziness , headaches , sleep disturbances
Within 5 days of stopping symptoms usually mild and self limiting , but if more than 8 weeks if one stops abruptly increased risk of severe withdrawal symptoms
Use of low dose can see symptoms of visual disturbances and palpitations

Basically taper down

Question 20

Serotonin syndrome

Answer 20

Sweating , fever , drowsiness, nausea( these similar to flu , withdrawal symptoms)
If severe serotonin syndrome seek emergency unit . Patient will be hydrated , clothes removed and cooled and discontinue meds till symptoms resolve . Use benzodiazepines/antihistamine/serotonin antagonists

Question 21

Use of SSRI in pregnancy

Answer 21

Carry risk benefit analysis
If severe depression treat patient as risk of harm to mother and child if untreated
Behind of pregnancy small increased risk of congenital heart defects
3rd trimester stopping suddenly can cause withdrawal symptoms in child and pulmonary hypertension
Small risk of post partum hemorrhage within month delivery with SSRI and SNRIs

Question 22

Optimal plan

Answer 22

Keep Sertraline at 50mg
• If patient non-responsive consider increasing to max dose before initiating alternative
• allow for lag time to pass 3-4 weeks before initiating new therapy

Discontinue Tramadol
• associated with increasing serotonin level when taken with Sertraline

Discontinue St. John’s Wort
• no clinical evidence to support its efficacy in treatment of depressive episodes

Discontinue Aspirin
• lab indicative of internal bleeding
•sertraline + Aspirin, increase risk of bleeding as shown by labs in patient could be due to this medication interaction

Antihistamines and decongestant
• does patient still have flu or ask patient if they feel the need to continue with this therapy
• if no discontinue therapy

Nifedipine + captopril
•substitute with appropriate therapy that doesn’t cause depression

Lifestyle changes
• exercise
• proper diet

CBT