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Psychiatric Pharmacotherapy > Depression > Flashcards

Depression Flashcards

1
Q

*What does the letter ‘In’ refer to in the acronym In.SAD.CAGE S ?

A

(1) In terest : Decreased interest and pleasure in normal activities

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2
Q

*What does the first letter ‘S’ refer to in the acronym In.SAD.CAGE S ?

A

(2) S leep : Insomnia or hypersomnia

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3
Q

*What does the 1st letter ‘A’ refer to in the acronym In.SAD.CAGE S ?

A

(3) A ppetite : Decreased appetite, weight loss

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4
Q

*What does the letter ‘D’ refer to in the acronym In.SAD.CAGE S ?

A

(4) D epressed : Depressed mood (adults); NB: may be irritable mood in children

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5
Q

*What does the letter ‘C’ refer to in the acronym In.SAD.CAGE S ?

A

(5) C oncentration : Impaired concentration and decision making

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6
Q

*What does the 2nd letter ‘A’ refer to in the acronym In.SAD.CAGE S ?

A

(6) A ctivity: Psychomotor retardation or agitation

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7
Q

*What does the letter ‘G’ refer to in the acronym In.SAD.CAGE S ?

A

(7) G uilt : Feelings of guilt or worthlessness

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8
Q

*What does the letter ‘E’ refer to in the acronym In.SAD.CAGE S ?

A

(8) E nergy : Decreased energy or fatigue

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9
Q

*What does the last letter ‘S’ refer to in the acronym In.SAD.CAGE S ?

A

(9) S uicidal thoughts or attempts

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10
Q

What is the lifetime prevalence of Major depressive disorder (MDD) in the community?

A

5.8%

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11
Q

Among persons with a mental illness, 50.6% of them also had a ___.

A

chronic physical illness

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12
Q

Among persons with a chronic physical illness, __ of them also had a mental illness

A

14.3%

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13
Q

What is the lifetime prevalence of Obsessive Compulsive Disorder (OCD) in the community?

A

3%

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14
Q

What is the lifetime prevalence of Generalized Anxiety Disorder (GAD) in the community?

A

0.9%

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15
Q

It is important to note that most people with serious mental problems do not __.

A

seek any professional help.

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16
Q

The general risk factors for suicide in the general population are described by PELMCA: “A __, __, __, __, with physical/mental __ and previous __.

A 
poor 
elderly 
lonely 
man 
comorbidities 
attempts
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17
Q

The monoamine hypothesis theorizes that the reduction of NSD neurotransmitters is the cause of depression. What does NSD refer to?

A

Norepinephrine (NE), Serotonin (5-HT), dopamine (DA)

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18
Q

Before starting pharmacological treatment for depression, it is critical to first rule out __ and __.

A

Medical disorders and drug induced causes

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19
Q

Endocrine disorders such as CHD can be secondary causes or even worsen depression. What is CHD?

A

Cushing’s syndrome, Hypothyroidism and Diabetes (T2DM)

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20
Q

Deficiency states such as __ and __ are secondary causes for depression.

A

Anemia and Wernicke’s encephalopathy

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21
Q

Infections such as __, __, and __ may be secondary causes for depression.

A

CNS infections
HIV/STD
TB

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22
Q

Metabolic disorders such as __ and __ may be secondary causes for depression.

A
  1. Electrolyte imbalance

2. Hepatic encephalopathy

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23
Q

Cardiovascular disorders such as __, __ and __ may be secondary causes for depression.

A

CHF
MI
CAD

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24
Q

Neurological disorders such as AEPPP may be secondary causes for depression. What is AEPPP?

A 
Alzheimer's 
Epilepsy
Parkinson's
Pain 
Post-stroke
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25
Q

Context of Malignancy in depression?

A

Possible secondary cause of depression

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26
Q

One important drug induced cause of depression is __.

A

Withdrawal from alcohol and stimulants (i.e. substances of abuse)

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27
Q

Under the DSM-5 criteria for MDD, there must be __ present simultaneously in __, representing a change from previous functioning.

A
  1. At least 5 symptoms

2. 2 weeks

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28
Q

Either __ or __ must be present for a diagnosis of MDD based on DSM-5.

A
  1. depressed mood

2. loss of interest

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29
Q

Under the DSM-5 criteria for MDD, symptoms are expected to cause __.

A

significant distress and functional impairment

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30
Q

Major depressive disorder (MDD) clinically presents as __ and __ episodes.

A
  1. single

2. recurrent

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31
Q

What does HAM-D stands for?

A

Hamilton Rating Scale for Depression (HAM-D)

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32
Q

Remission is defined as __ in HAM-D.

A

a score of 7 or less

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33
Q

What does PHQ-9 stands for?

A

Patient Health Questionnaire (PHQ 9)

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34
Q

A PHQ-9 score of __ means that patients have __ and will not benefit from treatment.

A
  1. 9 or less

2. mild depression/minimal symptoms

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35
Q

Non-Pharmacological methods are best suited for patients with __.

A

Mild depression

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36
Q

In depression, Non-Pharmacological methods include __, __ and neurostimulation (ECT and rTMS).

A
  1. sleep hygiene

2. psychotherapy

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37
Q

*The 1st line pharmacological treatment for depression involves monotherapy with SSMB, which refers to: __, __, __ or __.

A

SSRI, SNRI, Mirtazapine or Bupropion.

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38
Q

*Medication choice should be guided by SCIPP, which refers to:

A

symptoms, comorbidities, interactions, prior response and preference.

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39
Q

An adequate trial (acute phase) of antidepressants involves __. In elderly, an adequate trial may __.

A
  1. adequate dose at adequate duration (4-8wks)

2. last up to 12wks

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40
Q

There is a delayed onset of antidepressants because __.

A

chronic exposure required to downregulate pre-synaptic autoreceptors

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41
Q

We expect physical symptoms of depression i.e. __ to improve in __.

A
  1. sleep and appetite

2. ~1-2wks

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42
Q

We expect Mood symptoms of depression to improve in __.

A

~4-6wks

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43
Q

A typical regimen of antidepressants involves 3 phases: __ + __ + __.

A
  1. Initiation
  2. Acute phase
  3. Continuation phase
44
Q

We can expect the patient to be on antidepressants for at least __.

A

6-12months

45
Q

For a patient 1st presenting with depression, the continuation phase should last __ after the acute phase treatment.

A

at least 4-9months

46
Q

Examples of SSRIs?

A

Fluoxetine, Fluvoxamine, Escitalopram, Sertraline, Paroxetine

47
Q

Examples of SNRIs?

A

Venlafaxine, Duloxetine, Desvenlafaxine

48
Q

Examples of NaSSAs?

A

Mirtazapine

49
Q

During the initial phase of treatment, patients may __. This should gradually improve in 1-2 months. Therefore, pharmacists must __.

A
  1. feel jittery and anxious

2. counsel patients to be patient and emphasize adherence

50
Q

*Which 1st line antidepressant(s) is/are also indicated for Bulimia Nervosa?

A

Fluoxetine

51
Q

*Which 1st line antidepressant(s) is/are also indicated for OCD?

A

Fluoxetine
Fluvoxamine
Sertraline
(FFS)

52
Q

*Which 1st line antidepressant(s) is/are also indicated for anxiety disorders?

A

Escitalopram
Paroxetine
(EP)

53
Q

*Which 1st line antidepressant(s) is/are also indicated for panic disorder?

A

Citalopram

Sertraline

54
Q

*Which 1st line antidepressant(s) is/are also indicated for GAD?

A

Venlafaxine

Duloxetine

55
Q

*Other than Depression and GAD, Duloxetine also has medical indications for __. (DCSF)

A

Diabetic neuropathy
Chronic musculoskeletal pain
Stress urinary incontinence
Fibromyalgia

56
Q

*Which 1st line antidepressant has seizure inducing and psychotic effects?

A

Bupropion

57
Q

*Which 1st line antidepressant has GI and sexual dysfunction side effects?

A

SSRIs

58
Q

*If a patient is concerned regarding GI and sexual dysfunction side effects, what are good alternative 1st line antidepressants?

A

Mirtazapine

Bupropion

59
Q

*Which 1st line antidepressants are most likely to be sedating and cause weight gain in patients?

A

Paroxetine

Mirtazapine

60
Q

*Among the 1st line agents, __ and __ have the lowest risk of antidepressant discontinuation syndrome, due to __.

A

Fluoxetine and bupropion

their very long half lives

61
Q

*Generally when using SSRIs in the elderly, we should note: __.

A 
Hyponatremia (SIADH) 
Bleeding risk (antiplatelet effects)
62
Q

*Paroxetine is not a good choice in the elderly due to __

A

Anti-cholinergic effects

63
Q

*Citalopram and escitalopram are not good choices in the elderly due to __.

A

QTC prolongation and CVS effects at high doses

64
Q

If the patient is suffering from insomnia, hypnotic options include: __, __ and __.

A

BZDs, Z-hypnotics and anti-histamines

65
Q

Benzodiazepine (BZD) adjunct use should be __.

A

limited to 2 wk PRN at lowest effective dose.

66
Q

BZDs may cause the following adverse effects __ and __.

A

Sedation

amnesia

67
Q

BZDs may predispose patients to __.

A

falls and motor accidents

68
Q

The use of Zolpidem in ladies should be __.

A

accompanied by a 50% reduction dose

69
Q

Z-hypnotics may cause __ especially if there is childhood history of __.

A

sleepwalking

70
Q

The use of antihistamines may cause adverse effects of __ and __.

A

sedation and anticholinergic effects

71
Q
  • For Fluoxetine (prozac) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 20mg OM
  2. 20-60mg/day
  3. 80mg/day
72
Q
  • For Fluvoxamine (faverin) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 50-100mg/day
  2. 50-300mg/day
  3. 300mg/day
73
Q
  • For Escitalopram (lexapro) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 5-10mg/day
  2. 10-20mg/day
  3. 20mg/day
74
Q
  • For Citalopram (celexa) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 20mg/day
  2. 20-40mg/day
  3. 40mg/day
75
Q
  • For Paroxetine (seroxat CR) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 12.5mg/day
  2. 12.5-50mg/day
  3. 75mg/day
76
Q
  • For Sertraline (zoloft) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 25-50mg/day
  2. 25-200mg/day
  3. 200mg/day
77
Q
  • For Venlafaxine XR (efexor XR) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 75mg/day
  2. 75-225mg/day
  3. 375mg/day
78
Q
  • For Desvenlafaxine ER (pristiq ER) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 50mg/day
  2. 50mg/day
  3. 100mg/day
79
Q
  • For Duloxetine (cymbalta) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 60mg/day
  2. 30-60mg/day
  3. 120mg/day
80
Q
  • For Mirtazapine (remeron soltab) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. 15mg/day
  2. 15-45mg/day
  3. 45mg/day
81
Q
  • For Bupropion (wellbutrin) use in adults, state:
    1. Usual Starting dose
    2. Usual Dose range
    3. Max recommended dose
A
  1. SR: 150mg OM x 4d, then BD
  2. SR: 150mg/day BD
  3. SR: 300mg/day (2 divided doses)
82
Q

When switching antidepressants, a wash out period is required for __.

A

Moclobemide

83
Q

When cross titrating antidepressants, we have to watch out for __ if combining 2 agents.

A

Serotonin syndrome

84
Q

Gradual cross tapering can reduce risk of __ when switching __. This is applicable only when __.

A
  1. antidepressant discontinuation syndrome
  2. from serotonergic agent to non-serotonergic agent
  3. the serotonergic agent has been in long term use (i.e. 2 months)
85
Q

Hyponatremia is associated with all antidepressants and may manifest as __, __ or __.

A

Drowsiness, confusion or convulsions

DCC

86
Q

For patients <25 years old, the use of antidepressants have been associated with __.

A

suicidality

87
Q

The use of alcohol may increase the CNS depressant effect with antidepressants. Pharmacists should therefore counsel their patients to __.

A

avoid taking them together and spacing them out at least 4-6h apart

88
Q

Other than antidepressants, serotonergic agents include: __, __, __ and __

A 
Linezolid
Opioids
Sibutramine 
Triptans
(LOST)
89
Q

The use of BZDs and __ may increase mortality (CNS depression).

A

opioids

90
Q

Fluvoxamine causes many DDIs i.e. with warfarin-R by virtue of it being a __.

A

Potent CYP1A2 and CYP2C19 inhibitor

91
Q

Antidepressants such as __, __, __ may have DDIs with Metoprolol and opioids because they are CYP2D6 inhibitors.

A

Fluoxetine
Paroxetine
Bupropion
(PFB)

92
Q

1st line Antidepressants with fewer DDIs include: __.

A 
Mirtazapine
Escitalopram
Venlafaxine
Desvenlafaxine
(MEVD)
93
Q

Among 1st line agents, Antidepressant discontinuation syndrome is most common with __ and __.

A

Venlafaxine

Paroxetine

94
Q

Antidepressant discontinuation syndrome usually occurs __ after stopping medication.

A

36-72h

95
Q

Antidepressant discontinuation syndrome usually manifests as FINISH. What does ‘F’ stand for?

A

Flu-like symptoms - fatigue, muscle aches and headache

96
Q

Antidepressant discontinuation syndrome usually manifests as FINISH. What does the 1st ‘I’ stand for?

A

Insomnia

97
Q

Antidepressant discontinuation syndrome usually manifests as FINISH. What does ‘N’ stand for?

A

Nausea

98
Q

Antidepressant discontinuation syndrome usually manifests as FINISH. What does the 2nd ‘I’ stand for?

A

Imbalance - dizziness

99
Q

Antidepressant discontinuation syndrome usually manifests as FINISH. What does ‘S’ stand for?

A

Sensory - electric shock sensations

100
Q

Antidepressant discontinuation syndrome usually manifests as FINISH. What does ‘H’ stand for?

A

Hyperarousal - anxiety and agitation

101
Q

To avoid Antidepressant discontinuation syndrome, we may __ if patient has been on daily treatment for 2 or more months. Alternatively, we may use / instead.

A
  1. gradually taper over at least 4 wks

2. Bupropion/Fluoxetine

102
Q

BZDs should be gradually discontinued after __.

A

long term usage and/or high doses

103
Q

Goal of therapy in Depression is __, __ and __.

A

Remission of symptoms
Treatment Adherence
Suicide prevention
(RTS)

104
Q

For a patient with hypertension, the 1st line antidepressant __ may worsen hypertension.

A

Venlafaxine

105
Q

The following group of patients are pre-disposed to seizures:

A 
Psychosis
History of seizures
Eating disorders
Withdrawal from alcohol/BZDs
(PHEW)
106
Q

Why do we need to exclude bipolar/schizoaffective disorder before giving antidepressants?

A

Antidepressants can cause maniac switch in these patients

Psychiatric Pharmacotherapy (5 decks)

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