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depression Flashcards

1
Q

suicide inquiry

A

1) ideation: frequency, intensity, duration
2) suicide plan
3) intent
4) explore ambivalence

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2
Q

suicide risk factors

A

1) prior attempt of suicide/self harm
2) past/current psychiatric diagnosis
3) ley symptoms
4) family history
5) Stressors
6) Access

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3
Q

aetiology for depression

A

1) biological: neuroendocrine theories

  • hormonal influences: increases cortisol
  • monoamine hypothesis: decrease neurotransmitters in brain (norepinephrine, serotonin, dopamine)

2) psychological
3) psychosocial

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4
Q

secondary causes for depression tldr

A

1) medical
2) psychiatric
3) drug-induced

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5
Q

medical secondary cause for depression

A

1) endocrine disorder

  • hyperthyroidism
  • Cushing’s syndrome
  • bidirectional association between depression and T2DM in women

2) deficiency states

  • anemia
  • Wernicke’s encephalopathy

3) metabolic disorders

  • electrolyte imbalance
  • hepatic encephalopathy

4) cardiovascular

  • CAD, CHF, MI
  • depression risk factors for poor diagnosis among patients w ACS

5) neurological
6) malignancy

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6
Q

psychiatric secondary causes for depression

A

alcoholism, anxiety, eating, Schizophrenia

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7
Q

drug-induced secondary cause for depression

A

1) lipid soluble BB
2) psychotropic: CNS depressant
3) withdrawal
4) systemic corticosteroids
5) isotretinoin
6) interferon beta-1a

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8
Q

DSM-5 criteria for depression

A

1) depressed mood or loss of interest and at least 5 symptoms present during the same 2 week period and is change from previous functioning (In.SAD.CAGES)

  • Interest: decreased interest and pleasure from normal activities
  • sleep: insomnia or hypersomia
  • Appetite: decreased appetite, weight loss
  • Depressed: depressed mood, maybe irritable mood in children
  • Concentration: impaired concentration and decision making
  • Activity: psychomotor retardation or agitation
  • Guilt: feelings of guilt and worthlessness
  • Energy: decreased energy or fatigue
  • Suicidal thoughts or attempts

2) Symptoms cause significant distress or impairment in functioning
3) symptoms not caused by underlying medical condition or substance

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9
Q

common characteristics of depression

A
  • cyclical onset
  • unimpaired consciousness
  • intact memory
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10
Q

classifications of depression

A

1) major depressive disorder (MDD)

  • single and recurrent episode
  • ≥ 5 symptoms including depressive mood and loss of interest

2) persistent depressive disorder (dysthymia)

  • depressed mood + ≥ 2 symptoms for 2 years but not fulfilling MDD diagnosis

3) disruptive mood dysregulation

  • children up to 18 yo

4) unipolar depression

  • reactive depression: non-familial, associated with life events, + anxiety and agitation
  • endogenous depression: familial pattern, not directly related to external stress
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11
Q

general assessment of depression

A
  • same as Schizophrenia but psychiatric assessment assess for history of maniac/hypomanic episodes
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12
Q

differential diagnosis for depression

A

1) adjustment disorder

  • with anxiety and/or depressive mood
  • symptoms occur within 3 months of onset of a stressor but once stressor is terminated, symptoms do not persist for additional 6 months

2) acute stress disorder

  • symptoms occur within 1 month of traumatic event and last 3 days - 1 month
  • intense fear, helplessness, horror, with dissociation, re-experiencing, avoidance, increased arousal

3) bipolar

4) delirium

  • acute onset, impaired consciousness, poor memory

5) dementia

  • insidious, step-wise change
  • clear consciousness until later stage
  • poor short and long term memory

6) withdrawal/intoxication

  • acute onset
  • continuum of unimpaired to impaired consciousness
  • intact memory
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13
Q

assessments for depression

A

1) psychiatric rating scales

  • HAM-D
    ** goal: HAM-D score ≤ 7
    ** response = 50% improvement

2) self-related

  • PHQ-9 (start antidepressant if ≥ 10
    ** 1-4: minimal symptoms
    ** 5-9: mild depression
    ** 10-14: moderate depression
    **15-19: moderately severe depression
    ** ≥ 20: severe depression
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14
Q

non-pharmaco for depression

A

1) therapeutic lifestyle/behavioural change

  • sleep hygiene, exercise, relaxation techniques

2) nutritional

  • Vit B12, L-methylfolate, Vit D, omega-3

3) Herbal

  • St John’s Wort
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15
Q

principles of pharmaco therapy for depression

A
  • indication: moderate - severe depression
  • which to consider first
    ** mirtazapine, SSRI, SNRI, bupropion, agomelatine > TCA > MAOi
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16
Q

phases of depression therapy

A

1) acute phase treatment

  • adequate trial = adequate dose + duration (4-8 wks)
  • delayed onset of effectiveness
    ** physical symptoms improve 1-2 wks
    ** mood symptoms improve 4-8 wks
    ** if patient feel good right after meds then bipolar mania

2) continuation phase

  • continue for at least another 4-9 months after acute phase treatment
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17
Q

Selective serotonin reuptake inhibitors (SSRI) - types

A

1) fluoxetine -> norfluoxetine
2) fluvoxamine
3) escitalopram
4) paroxetine

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18
Q

Selective serotonin reuptake inhibitors (SSRI) - MOA

A

block reuptake of 5-HT selectively

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19
Q

Selective serotonin reuptake inhibitors (SSRI) - SE

A

1) GI, sexual dysfunction
2) initiation: headache, transient nervousness
3) hyponatremia, bleeding risk, EPSE
4) N, insomnia

  • discontinuation/rebound symptoms of withdrawal when plasma levels of drug drop between doses

5) serotonin syndrome

20
Q

Selective serotonin reuptake inhibitors (SSRI) - PGx testing

A

for CYP2D6 and CYP2C19

  • why?
    ** poor metaboliser -> reduced SSRI metabolism -> more exposure to SSRI -> increased AE risk
  • who?
    ** experience inadequate response or AE from SSRI
    ** before initiation for high toxicity risk patients
  • actions to take after testing
    ** intermediate metaboliser = reduce dose
    ** poor metaboliser/ultrarapid metaboliser = alternative therapy or adjust dose
21
Q

Selective serotonin reuptake inhibitors (SSRI) - notes

A
  • fluoxetine long t1/2
  • paroxetine most anticholinergic, sedating, increase weight and short t1/2
  • escitalopram QTc prolongation if high dose in elderly
22
Q

serotonin norepinephrine reuptake inhibitors (SNRI) - types

A

1) Venlafaxine -> desvenlafaxine
2) duloxetine

23
Q

serotonin norepinephrine reuptake inhibitors (SNRI) - MOA

A

block reuptake of NE and 5HT

24
Q

serotonin norepinephrine reuptake inhibitors (SNRI) - SE

A
  • same as SSRI
  • venlafaxine: increase BP
  • duloxetine: urinary hesitation
  • withdrawal effect stronger and more common
25
Q

noradrenergic and specific serotonergic antidepressant (NaSSA) - types

A

mirtazapine

26
Q

noradrenergic and specific serotonergic antidepressant (NaSSA) - MOA

A
  • alpha2 adrenoreceptor antagonist
  • increase 5HT, NE
  • 5-HT2, 5-HT3, H1 antagonism
27
Q

noradrenergic and specific serotonergic antidepressant (NaSSA) - SE

A

somnolence, increased appetite, weight gain

28
Q

noradrenergic and specific serotonergic antidepressant (NaSSA) - notes

A

reversible GI and sexual SE of SSRI/SNRI

29
Q

norepinephrine - dopamine reuptake inhibitors (NDRI) - types

A

bupropion

30
Q

norepinephrine - dopamine reuptake inhibitors (NDRI) - MOA

A

block reuptake of NE and DA

31
Q

norepinephrine - dopamine reuptake inhibitors (NDRI) - SE

A

seizure, insomnia, psychosis

32
Q

norepinephrine - dopamine reuptake inhibitors (NDRI) - notes

A
  • not suitable for eating disorder cuz risk of electrolyte imbalacne
  • decreased sexual SE for SSRI/SNRI
  • smoking cessation aid
33
Q

tricyclic antidepressant (TCA) - types

A

1) amitriptyline -> nortriptyline
2) imipramine -> desipramine
3) dothiepin
4) clomipramine

34
Q

tricyclic antidepressant (TCA) - MOA

A
  • block reuptake of NE and 5HT
  • anticholinergic
  • H1 and alpha-adrenergic antagonism
35
Q

tricyclic antidepressant (TCA) - SE

A

1) GI and sexual function
2) anticholinergic
3) fatal on overdose

36
Q

MAOi - types

A

moclobemide

37
Q

MAOi - serotonin physiology

A
  • serotonin released into synapse
  • reuptake of serotonin into pre-synaptic space -> broken down by MAO
  • if not broken down by MAO -> repackaged into vesicles for release -> more 5HT
38
Q

MAOi - AE

A

1) postural hypotension

  • sympathetic block produced by accumulation of dopamine in cervical ganglia

2) restlessness and insomnia due to CNS stimulation

39
Q

MAOi - drug interaction

A

X combine with drugs enhancing serotonergic function

  • hyperexcitability, increased muscular tone, myoclonus (jerking, involuntary movement), loss of consciousness
40
Q

MAOi - food interaction

A

Cheese, concentrated yeast products

  • pathophysiology
    ** amines in food broken down by MAO in intestine and liver
    ** MAOi = accumulation of tyramine = displace noradrenaline from vesicle = unregulated flood of noradrenaline = sympathomimetic effect
  • symptoms
    ** acute HTN, severe throbbing headache, intracranial haemorrhage
41
Q

tldr approaches to partial/no response therapy for depression

A

1) switch antidepressant
2) augmentation of therapy
3) what to do for treatment resistant depression

42
Q

partial/no response to therapy for depression - switch antidepressant

A

switch when ineffective/intolerable to adequate dose in 2-4 wks

1) if cross titration

  • gradually decrease first then gradually increase second to therapeutic dose
  • watch for serotonin syndrome

2) if direct switch

  • stop totally then initiate

3) if daily serotonergic for 2 months then switch to non-serotonergic

  • gradual cross-tapering over several weeks to reduce risk of antidepressant discontinuation syndrome

4) if change to or change from MAOi: require washout period

  • moclobemide to another: 24hr washout
  • another to moclobemide: 1 wk washout
  • fluoxetine to moclobemide: 5 wk washout
43
Q

partial/no response to therapy for depression - augmentation

A
  • combine 2nd antidepressant with another MOA
  • or combine with adjunctive antipsychotic
44
Q

partial/no response to therapy for depression - treatment resistant depression

A
  • no response to ≥ 2 adequate trial of antidepressant
  • neurostimulation (ECT, RTMS)
  • symbax oral (olan + fluoxetine)
  • Spravato nasal (esketamine) + SSRI/SNRI
45
Q

special population for depression

A

1) pregnancy: nortriptyline for late pregnancy
2) breastfeeding: sertraline or mirtazapine
3) postpartum depression: brexanolone
4) bipolar depression: lithium, lamotrigine, lurasidone, quetiapine
5) renal impariment: vortioxetine
6) post MI depression: sertraline
7) elderly: X TCA
8) hyponatremia

  • symptoms: Drowsy, confusion, convulsions
  • usually in elderly
  • associated with all antidepressants
  • lower risk with agomelatine, mirtazapine, bupropion
  • monitor serum Na at baseline, 2nd wk, 4th wk then q3

9) suicidality
10) underweight: consider mirtazapine, avoid bupropion
11) chronic pain/neuropathy: duloxetine
12) young < 18 yo: escitalopram, fluoxetine, amitriptyline, nortriptyline

46
Q

DDI for antidepressants

A

1) PD

  • serotonergic syndrome
    ** severity
    –> mild: insomnia, anxiety, N/D, HTN, tachycardia, hyper-reflexia
    –> moderate: agitation, myoclonus, tremor, mydriasis, flushing, diaphoresis, fever
    –> severe: severe hyperthermia, confusion, rigidity, respiratory failure, coma, death
  • SSRI increase risk of bleeding
  • increase CNS depressant effect: separate 4-6 hrs alcohol

2) CYP interactions

  • fluvoxamine: CYP1A2 and CYP2C19 inhibitor
  • fluoxetine, paroxetine, bupropion: CYP2D6 inhibitor
  • lesser CYP interactions: mirtazapine, escitalopram, venlafaxine, desvenlafaxine
  • agomelatine: major substrate of CYP1A2 so can be affected by fluvoxamine
47
Q

antidepressant discontinuation syndrome

A
  • symptoms (FINISH)

1) flu-like symptoms
2) insomnia (vivid dreams or nightmare)
3) nausea
4) imbalance
5) sensory disturbances (electric like sensation)
6) hyperarousal (anxiety, irritability, jerkiness)

  • not life threatening
  • onset 36-72 hrs
  • self-limiting 1-2 wks
  • avoid by gradually tapering if pt on regular dose for ≥ 6-8 wks
    ** taper by 1/2 tablet of lowest strength every 1-2 wks
    ** X need for fluoxetine and bupropion cuz long t1/2 and active metabolites

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