8 - Depressive Disorders Flashcards

(50 cards)

1
Q

Major depression sx

A

D SIG E CAPS

  • Depressive mood
  • Sleep (decreased > increased)
  • Interest decreased (anhedonia)
  • Guilt/worthlessness increased
  • Energy (decreased > increased)
  • Concentration decreased
  • Appetite/weight (decreased > increased)
  • Psychomotor (decreased > increased)
  • Suicide/thoughts of death increased
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2
Q

Major depression – DSM IVR criteria for diagnosis

A
  • Presence of sx for > 2 weeks
  • At least 5 sx present; at least 1 depressed mood or loss of interest/ pleasure
  • Sx occur nearly every day
  • Sx cause significant distress or impairment of functioning
  • Sx not due to bereavement or last > 2 months
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3
Q

Additional sx of depression

A
  • Emotional – anxiety, irritability
  • Cognitive – decreased concentration, indecisiveness, poor memory
  • Psychotic – bizarre behaviour, hallucination, delusions
  • Physical – fatigue, decreased libido, decreased hygiene, crying spells
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4
Q

Secondary depression causes

A
  • Medical disorders – thyroid disorder, malignancy, stroke, CHF/ MI, Parkinson’s
  • Psychiatric disorders – alcoholism, schizophrenia, anxiety
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5
Q

Non-pharms for depression

A
  • Cognitive behavioural therapy
    • Change distorted thinking
    • Alteration of target thoughts
    • Change erroneous assumptions
    • Promote self-control over thinking
  • Interpersonal
  • Bright light therapy – for seasonal affective disorder
  • Exercise & good nutrition
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6
Q

Major depression – time course

A
  • Most last 6-24 months
  • > 2 years in 5-10%
  • Often recurrent episodes
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7
Q

Tx goals for depression

A
  • Shorten episode
  • Decrease sx (response)
  • Restore function
  • Eliminate sx (remission)
  • Prevent relapse
  • Minimize adverse effects of tx
  • Minimize drug interactions
  • Promote adherence to therapy
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8
Q

What determines the urgency of tx for depression

A
  • Severity of depressive sx
  • Severity in impairment of functioning
  • Psychotic sx
  • Suicidal thoughts
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9
Q

Typical response for anxiety and insomnia to antidepressants

A

Few days

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10
Q

Typical response for energy and somatic sx to antidepressants

A

2nd or 3rd week

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11
Q

Typical response for sleep patterns to antidepressants

A

Several weeks

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12
Q

Typical response for depressed mood and sexual dysfunction to antidepressants

A

4th week

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13
Q

MOA of SSRIs

A

Increase 5-HT

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14
Q

MOA of SNRIs

A

Increase 5-HT and NE

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15
Q

MOA of NDRIs (norepinephrine dopamine reuptake inhibitors)

A

Increase NE and dopamine

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16
Q

MOA of NaSSA (noradrenergic and specific serotonergic antidepressant)

A

Increase 5-HT and NE

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17
Q

MOA of TCAs

A

Increase 5-HT and NE

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18
Q

MOA of MAOIs

A

Increase 5-HT, NE, and DA

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19
Q

MOA of RIMA (reversible inhibitor of monoamine oxidase)

A

Increase 5-HT, NE, and dopamine

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20
Q

Describe the general guidelines for depression tx

A
  • Uncomplicated (physically healthy, outpatient, no CI) –> SSRI (all about equally effective; choice of one over another depends on pt profile & drug profile)
    • Failed trial due to non-response or limiting adverse effect –> ensure adherence, maximize dose (try to wait 8 weeks until increasing); then consider switching to alternative agent (different SSRI, non-SSRI)
  • Partial response –> consider augmentation w/ 2nd antidepressant, lithium, or T3 or T4 or switch to alternative agent
    • Failed trail –> switch to alternative agent
    • Consider ECT?
  • Response/ remission = maintain for at least 4-9 months for continuation & if necessary 12-36 months for maintenance
  • Similar response rates for all antidepressants
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21
Q

Which antidepressants can be used in combination?

A
  • Venlafaxine + bupropion
  • SSRI + bupropion
  • SSRI + TCA
  • TCA + MAOI **very cautiously
  • *Never use SSRI + MAOI (will get serotonin syndrome)
22
Q

Duration of tx for depression

A
  • 4-9 months after remission
  • Lifelong is < 40 y/o and 2+ episodes or any age and 3+ episodes
  • Poop-out syndrome (initially have response but short lived)
23
Q

Describe ECT (electroconvulsive treatment)

A
  • Candidates = rapid response (suicidal, psychotic), hx of poor response to meds, pregnancy
  • Course = 6-12 tx, unilateral or bilateral, 2-3 times/week
  • Adverse effects = confusion, memory loss months pre & post ECT, CV dysfunction, headache, nausea
24
Q

SSRIs - options, advantage, SE, toxic effects

A
  • Fluoxetine, sertraline, fluvoxamine, paroxetine, citalopram, escitalopram
  • *Remain on a dose for 8 weeks before increasing
  • Advantage –> less SE vs. TCAs b/c lack alpha 1, M1, and H1 effects
  • SE –> agitation, nervousness, restlessness, insomnia/ drowsiness (paroxetine, fluvoxamine), GI effects initially
  • Toxic effects –> tremor, sinus tachycardia, N/V, diarrhea, seizures, serotonin syndrome
25
What determines the choice of an antidepressant over another?
- Personal and family hx - Subtype of depression - Medication hx/ concurrent meds - Potential for drug interactions - Adverse effect profile - Cost - Antidepressant MOA
26
Describe serotonin syndrome
- Diagnosis of exclusion - Cognitive/behavioural = agitation, mental status changes (confusion, hypomania) - Autonomic dysfunction = diaphoresis, diarrhea, fever, shivering - Neuromuscular abnormalities = incoordination tremor, myoclonus, hyperreflexia
27
Causes of serotonin syndrome
- Drugs that inhibit breakdown of 5-HT (MAO inhibitors) - Drugs that block reuptake of 5-HT (SSRIs, venlafaxine, clomipramine, dextromethorphan, trazodone) - Drugs that are 5-HT precursors or agonists (lithium, buspirone) - Drugs that enhance 5-HT release (MDMA)
28
Tx for serotonin syndrome
- Supportive care - BZD for neuromuscular sx - Tylenol for fever - Cyproheptadine 4 mg q4h for severe sx
29
SSRI withdrawal sx
- Somatic: - - Disequilibrium – dizziness, vertigo, ataxia - - GI – N/V - - Influenza-like – fatigue, lethargy, myalgia - Psychological – anxiety, agitation, irritability, crying spells * *FINISH – flu-like sx, insomnia, nausea, imbalance, sensory disturbance, hyperarousal - Occur w/in 1-3 days (up to 1 week) - Last up to 7-14 days (may be several weeks) - Tx: - - Prevent w/ gradual tapering - - If begins to appear, increase dose & taper more slowly - - If severe, switch to fluoxetine
30
Briefly describe the grapefruit interaction
- Single glass can decrease intestinal 3A4 content more than 50% - Duration of action several hours or longer, so separating juice from dose may not prevent interaction - Toxicity can occur when pt given higher than usual doses of susceptible med & drinks grapefruit juice for the first time
31
Venlafaxine (SNRI) -- MOA and SE
- Increases NE & 5-HT - Regarding overdose, not as safe as SSRI but safer than TCAs; once you get up to high doses then similar to TCAs - SE = BP increases (dose dependent response, usually reversible on d/c, risk greater w/ increased age), dose related GI effects, dizziness, sexual dysfunction, dry mouth, constipation
32
Bupropion (NDRI) - MOA, SE, advantages
- Good option for px previously on venlafaxine but can’t tolerate GI side effects or BP was increasing too much - Increased NE & DA - SE = tremor, insomnia, agitation, restlessness, anxiety; seizures at high doses; dry mouth, headache, N/V, rash - Advantages = little sexual dysfunction & little weight gain (b/c doesn’t affect serotonin) - Other agents can cause disruptions to REM sleep, but bupropion doesn’t (quality of sleep can be better)
33
Mirtazapine (NaSSA) - MOA, advantages
- Affects serotonin as antagonist & affects alpha receptors (would cause orthostatic hypotension, so not great for elderly px) & has some histamine properties (not as bad as TCAs but can be fairly sedating) - Advantages --> little sexual dysfunction, less serotonergic effects
34
TCAs - MOA, SE
- Gold standard of therapy; if others don’t work then go to this one (don’t pick this first b/c very non-selective) - Increases NE & serotonin; affects histamine, alpha & muscarinic receptors (gives anti-cholinergic side effects) - - Antihistaminic effects = sedation, weight gain - In usual doses, cardiac effects include – hypertension, tachycardia, slowed cardiac conduction, antiarrhythmic properties, orthostatic hypotension
35
"High risk" px for TCA use
- Elderly - CV disease - Drug interactions - Overdose cases
36
Toxic effects of TCAs in overdose
- CV (sinus tachycardia, ventricular arrhythmias, hypotension) - CNS (coma, delirium, seizures), other (hyperthermia, urinary retention)
37
TCA withdrawal sx and tx
- Cholinergic and adrenergic rebound - Sx = dizziness, nausea, diarrhea, insomnia, hot or cold flashes - Taper over 2-4 weeks, tx = restart at low dose or anticholinergic agent
38
MAOIs - MOA, indication, SE
- Irreversible inhibitors of MAO A & B - Indicated for atypical or resistant depression - Don’t combine w/ other antidepressants (can add to TCA w/ caution) - SE = orthostatic hypotension, dry mouth, constipation, sexual side effects (impotence, decreased libido), insomnia - Dosed in AM & mid-day to avoid overstimulation
39
General recommendations for washout w/ MAOIs
- Antidepressant --> MAOI = washout 5 t1/2 of antidepressant | - MAOI --> antidepressant = washout 10-14 days
40
RIMA -- MOA, example, SE
- Reversible inhibitor of MAO-A - Moclobemide - SE = HTN, tachycardia, orthostatic hypotension, insomnia
41
General taper/ washout recommendations for all antidepressants
- Can taper when switching from SSRI, novel, or TCA to SSRI, novel or TCA - Must washout when switching any antidepressant to a RIMA or MAOI or switching from RIMA or MAOI to another antidepressant
42
Antidepressant recommendations for seizure disorders
- Avoid bupropion and TCAs | - SSRIs, venlafaxine, mirtazapine (?) have less effect on seizure threshold
43
Antidepressant recommendations for sexual dysfunction
- Avoid SSRIs, venlafaxine, TCAs, MAOIs | - Bupropion, mirtazapine, trazodone have little to no effect
44
Antidepressant recommendations for weight gain
- Avoid TCAs, MAOIs, and mirtazapine | - Bupropion, venlafaxine have little to no effect
45
Antidepressant recommendations for elderly
- Use lower initial dosages - Evaluate for orthostatic hypotension & cognition - Can get excessive sedation from histamine blockade, TCAs, trazodone, & mirtazapine - Can get urinary retention (anticholinergic) from TCAs & mirtazapine
46
Antidepressant recommendations for cardiac px
- Venlafaxine increases BP w/ increasing dose - Orthostatic hypotension – caution in angina & CHF - Increased HR w/ anticholinergic effect – watch in unstable angina - Use TCAs w/ caution in hx of arrhythmia + IHD
47
Antidepressant recommendations for pregnancy
- Weigh risks vs. benefits to mother & fetus - Most evidence for safety of fluoxetine, then TCAs - Can do ECT - After delivery – watch for direct drug effects & transient withdrawal sx in infants
48
Antidepressant recommendations for breastfeeding
- Safety evidence for paroxetine, sertraline, fluoxetine, clomipramine, and nortriptyline - Monitor infant daily for changes in sleep, feeding patterns, and behaviour; monitor for drowsiness and difficulty feeding
49
Antidepressant recommendations for children and adolescents
- Moderate to severe MD (major depression) - - First line = fluoxetine and citalopram - - Second line = other SSRIs (paroxetine > adverse effects) - - Third line = venlafaxine - - Best outcomes w/ combine CBT w/ antidepressant - TCAs not recommended b/c risks >> benefit (lethal in overdose, rare cases of sudden death) - Increased risk for suicidal behaviour; *monitor suicidal thoughts - Continue tx if effective for 6 months; gradually d/c over 6 weeks
50
Response vs. remission vs. recovery
- Response = 50% reduction in sx - Remission = sx go away - Recovery = remission lasting 6-12 months