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
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
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
4
Q
Secondary depression causes
A
- Medical disorders – thyroid disorder, malignancy, stroke, CHF/ MI, Parkinson’s
- Psychiatric disorders – alcoholism, schizophrenia, anxiety
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
6
Q
Major depression – time course
A
- Most last 6-24 months
- > 2 years in 5-10%
- Often recurrent episodes
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
8
Q
What determines the urgency of tx for depression
A
- Severity of depressive sx
- Severity in impairment of functioning
- Psychotic sx
- Suicidal thoughts
9
Q
Typical response for anxiety and insomnia to antidepressants
A
Few days
10
Q
Typical response for energy and somatic sx to antidepressants
A
2nd or 3rd week
11
Q
Typical response for sleep patterns to antidepressants
A
Several weeks
12
Q
Typical response for depressed mood and sexual dysfunction to antidepressants
A
4th week
13
Q
MOA of SSRIs
A
Increase 5-HT
14
Q
MOA of SNRIs
A
Increase 5-HT and NE
15
Q
MOA of NDRIs (norepinephrine dopamine reuptake inhibitors)
A
Increase NE and dopamine
16
Q
MOA of NaSSA (noradrenergic and specific serotonergic antidepressant)
A
Increase 5-HT and NE
17
Q
MOA of TCAs
A
Increase 5-HT and NE
18
Q
MOA of MAOIs
A
Increase 5-HT, NE, and DA
19
Q
MOA of RIMA (reversible inhibitor of monoamine oxidase)
A
Increase 5-HT, NE, and dopamine
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
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
