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Psychiatric Pharmacotherapy > Depression > Flashcards

Depression Flashcards

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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
Context of Malignancy in depression?
Possible secondary cause of depression
26
One important drug induced cause of depression is __.
Withdrawal from alcohol and stimulants (i.e. substances of abuse)
27
Under the DSM-5 criteria for MDD, there must be __ present simultaneously in __, representing a change from previous functioning.
1. At least 5 symptoms | 2. 2 weeks
28
Either __ or __ must be present for a diagnosis of MDD based on DSM-5.
1. depressed mood | 2. loss of interest
29
Under the DSM-5 criteria for MDD, symptoms are expected to cause __.
significant distress and functional impairment
30
Major depressive disorder (MDD) clinically presents as __ and __ episodes.
1. single | 2. recurrent
31
What does HAM-D stands for?
Hamilton Rating Scale for Depression (HAM-D)
32
Remission is defined as __ in HAM-D.
a score of 7 or less
33
What does PHQ-9 stands for?
Patient Health Questionnaire (PHQ 9)
34
A PHQ-9 score of __ means that patients have __ and will not benefit from treatment.
1. 9 or less | 2. mild depression/minimal symptoms
35
Non-Pharmacological methods are best suited for patients with __.
Mild depression
36
In depression, Non-Pharmacological methods include __, __ and neurostimulation (ECT and rTMS).
1. sleep hygiene | 2. psychotherapy
37
*The 1st line pharmacological treatment for depression involves monotherapy with SSMB, which refers to: __, __, __ or __.
SSRI, SNRI, Mirtazapine or Bupropion.
38
*Medication choice should be guided by SCIPP, which refers to:
symptoms, comorbidities, interactions, prior response and preference.
39
An adequate trial (acute phase) of antidepressants involves __. In elderly, an adequate trial may __.
1. adequate dose at adequate duration (4-8wks) | 2. last up to 12wks
40
There is a delayed onset of antidepressants because __.
chronic exposure required to downregulate pre-synaptic autoreceptors
41
We expect physical symptoms of depression i.e. __ to improve in __.
1. sleep and appetite | 2. ~1-2wks
42
We expect Mood symptoms of depression to improve in __.
~4-6wks
43
A typical regimen of antidepressants involves 3 phases: __ + __ + __.
1. Initiation 2. Acute phase 3. Continuation phase
44
We can expect the patient to be on antidepressants for at least __.
6-12months
45
For a patient 1st presenting with depression, the continuation phase should last __ after the acute phase treatment.
at least 4-9months
46
Examples of SSRIs?
Fluoxetine, Fluvoxamine, Escitalopram, Sertraline, Paroxetine
47
Examples of SNRIs?
Venlafaxine, Duloxetine, Desvenlafaxine
48
Examples of NaSSAs?
Mirtazapine
49
During the initial phase of treatment, patients may __. This should gradually improve in 1-2 months. Therefore, pharmacists must __.
1. feel jittery and anxious | 2. counsel patients to be patient and emphasize adherence
50
*Which 1st line antidepressant(s) is/are also indicated for Bulimia Nervosa?
Fluoxetine
51
*Which 1st line antidepressant(s) is/are also indicated for OCD?
Fluoxetine Fluvoxamine Sertraline (FFS)
52
*Which 1st line antidepressant(s) is/are also indicated for anxiety disorders?
Escitalopram Paroxetine (EP)
53
*Which 1st line antidepressant(s) is/are also indicated for panic disorder?
Citalopram | Sertraline
54
*Which 1st line antidepressant(s) is/are also indicated for GAD?
Venlafaxine | Duloxetine
55
*Other than Depression and GAD, Duloxetine also has medical indications for __. (DCSF)
Diabetic neuropathy Chronic musculoskeletal pain Stress urinary incontinence Fibromyalgia
56
*Which 1st line antidepressant has seizure inducing and psychotic effects?
Bupropion
57
*Which 1st line antidepressant has GI and sexual dysfunction side effects?
SSRIs
58
*If a patient is concerned regarding GI and sexual dysfunction side effects, what are good alternative 1st line antidepressants?
Mirtazapine | Bupropion
59
*Which 1st line antidepressants are most likely to be sedating and cause weight gain in patients?
Paroxetine | Mirtazapine
60
*Among the 1st line agents, __ and __ have the lowest risk of antidepressant discontinuation syndrome, due to __.
Fluoxetine and bupropion | their very long half lives
61
*Generally when using SSRIs in the elderly, we should note: __.
``` Hyponatremia (SIADH) Bleeding risk (antiplatelet effects) ```
62
*Paroxetine is not a good choice in the elderly due to __
Anti-cholinergic effects
63
*Citalopram and escitalopram are not good choices in the elderly due to __.
QTC prolongation and CVS effects at high doses
64
If the patient is suffering from insomnia, hypnotic options include: __, __ and __.
BZDs, Z-hypnotics and anti-histamines
65
Benzodiazepine (BZD) adjunct use should be __.
limited to 2 wk PRN at lowest effective dose.
66
BZDs may cause the following adverse effects __ and __.
Sedation | amnesia
67
BZDs may predispose patients to __.
falls and motor accidents
68
The use of Zolpidem in ladies should be __.
accompanied by a 50% reduction dose
69
Z-hypnotics may cause __ especially if there is childhood history of __.
sleepwalking
70
The use of antihistamines may cause adverse effects of __ and __.
sedation and anticholinergic effects
71
* For Fluoxetine (prozac) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 20mg OM 2. 20-60mg/day 3. 80mg/day
72
* For Fluvoxamine (faverin) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 50-100mg/day 2. 50-300mg/day 3. 300mg/day
73
* For Escitalopram (lexapro) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 5-10mg/day 2. 10-20mg/day 3. 20mg/day
74
* For Citalopram (celexa) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 20mg/day 2. 20-40mg/day 3. 40mg/day
75
* For Paroxetine (seroxat CR) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 12.5mg/day 2. 12.5-50mg/day 3. 75mg/day
76
* For Sertraline (zoloft) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 25-50mg/day 2. 25-200mg/day 3. 200mg/day
77
* For Venlafaxine XR (efexor XR) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 75mg/day 2. 75-225mg/day 3. 375mg/day
78
* For Desvenlafaxine ER (pristiq ER) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 50mg/day 2. 50mg/day 3. 100mg/day
79
* For Duloxetine (cymbalta) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 60mg/day 2. 30-60mg/day 3. 120mg/day
80
* For Mirtazapine (remeron soltab) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. 15mg/day 2. 15-45mg/day 3. 45mg/day
81
* For Bupropion (wellbutrin) use in adults, state: 1. Usual Starting dose 2. Usual Dose range 3. Max recommended dose
1. SR: 150mg OM x 4d, then BD 2. SR: 150mg/day BD 3. SR: 300mg/day (2 divided doses)
82
When switching antidepressants, a wash out period is required for __.
Moclobemide
83
When cross titrating antidepressants, we have to watch out for __ if combining 2 agents.
Serotonin syndrome
84
Gradual cross tapering can reduce risk of __ when switching __. This is applicable only when __.
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
Hyponatremia is associated with all antidepressants and may manifest as __, __ or __.
Drowsiness, confusion or convulsions | DCC
86
For patients <25 years old, the use of antidepressants have been associated with __.
suicidality
87
The use of alcohol may increase the CNS depressant effect with antidepressants. Pharmacists should therefore counsel their patients to __.
avoid taking them together and spacing them out at least 4-6h apart
88
Other than antidepressants, serotonergic agents include: __, __, __ and __
``` Linezolid Opioids Sibutramine Triptans (LOST) ```
89
The use of BZDs and __ may increase mortality (CNS depression).
opioids
90
Fluvoxamine causes many DDIs i.e. with warfarin-R by virtue of it being a __.
Potent CYP1A2 and CYP2C19 inhibitor
91
Antidepressants such as __, __, __ may have DDIs with Metoprolol and opioids because they are CYP2D6 inhibitors.
Fluoxetine Paroxetine Bupropion (PFB)
92
1st line Antidepressants with fewer DDIs include: __.
``` Mirtazapine Escitalopram Venlafaxine Desvenlafaxine (MEVD) ```
93
Among 1st line agents, Antidepressant discontinuation syndrome is most common with __ and __.
Venlafaxine | Paroxetine
94
Antidepressant discontinuation syndrome usually occurs __ after stopping medication.
36-72h
95
Antidepressant discontinuation syndrome usually manifests as FINISH. What does 'F' stand for?
Flu-like symptoms - fatigue, muscle aches and headache
96
Antidepressant discontinuation syndrome usually manifests as FINISH. What does the 1st 'I' stand for?
Insomnia
97
Antidepressant discontinuation syndrome usually manifests as FINISH. What does 'N' stand for?
Nausea
98
Antidepressant discontinuation syndrome usually manifests as FINISH. What does the 2nd 'I' stand for?
Imbalance - dizziness
99
Antidepressant discontinuation syndrome usually manifests as FINISH. What does 'S' stand for?
Sensory - electric shock sensations
100
Antidepressant discontinuation syndrome usually manifests as FINISH. What does 'H' stand for?
Hyperarousal - anxiety and agitation
101
To avoid Antidepressant discontinuation syndrome, we may __ if patient has been on daily treatment for 2 or more months. Alternatively, we may use _/_ instead.
1. gradually taper over at least 4 wks | 2. Bupropion/Fluoxetine
102
BZDs should be gradually discontinued after __.
long term usage and/or high doses
103
Goal of therapy in Depression is __, __ and __.
Remission of symptoms Treatment Adherence Suicide prevention (RTS)
104
For a patient with hypertension, the 1st line antidepressant __ may worsen hypertension.
Venlafaxine
105
The following group of patients are pre-disposed to seizures:
``` Psychosis History of seizures Eating disorders Withdrawal from alcohol/BZDs (PHEW) ```
106
Why do we need to exclude bipolar/schizoaffective disorder before giving antidepressants?
Antidepressants can cause maniac switch in these patients

Psychiatric Pharmacotherapy (5 decks)

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