Depression and Treatment Flashcards
(39 cards)
1
Q
List the risk factors for major depressive disorder
A
- Past or family history
- chronic medical condition
- substance use
- psychosocial adversity
- high users of the medical system with many somatic complaints
2
Q
List the good and poor prognostic features of depression
A
- 40% recover within 3 months and 80% recovery within 1 year
- those with 1 episode have 50% risk of relapse and those with two have 75%
Good - recent onset
- short duration of depression
Poor - chronic or severe depression
- psychotic features
- melancholic features
- anxiety
- personality disorder
- young age
- multiple episodes
3
Q
List the MSIGECAPS diagnostic criteria
A
M: Mood that is depressed everyday or nearly every day
S: Sleep is increased or decreased
I: Interest is lost or loss in pleasure in almost all activities
G: Guilt/Worthlessness feelings everyday
E: Energy is lost or severely decreased
C: Concentration is decreased
A: Appetite is increased or decreased
P: Psychomotor retardation or agitation
S: Suicide recurrent thoughts of death with or without plan
4
Q
List the diagnostic criteria for a major depressive episode
A
- > =5 of the MSIGECAPS symptoms for at least two weeks where mood or interest must be included
- symptoms must cause distress and impair functioning
- not due to substances or medical condition
- not another psychotic disorder
- no manic or hypomanic episode
5
Q
List the specifiers for major depressive disorder
A
- mixed features when 3 manic or hypomanic symptoms are present
- anxious distress
- melancholic features when have loss of pleasure and at least 3 of (PAGE MD):
- psychomotor agitation or retardation
- anorexia
- guilt
- early morning awakenings
- morning worsening of depression
- different quality of depressed mood
- atypical features when have reactive mood and 2 of the following (WILL):
- weight gain
- increased sleep
- leaden paralysis
- longstanding pattern of intepersonal rejection
- with psychotic features
- with catatonia when have greater than 2 of the following (SPENT):
- stupor/motor immobility
- peculiar voluntary movements
- echolalia
- negativism
- too much motor activity
6
Q
List the investigations for major depressive disorder
A
- CBC for anemia or infection
- electrolytes
- Metabolic work up (Ca, Glucose, B12)
- kidney function
- liver function
- TSH
- albumin
7
Q
List common medical conditions and substances that can cause depression
A
Medical conditions - stroke - Parkinsons - hypothyroidism - cancer - anemia - coronary artery disease - HIV - SLE - OSA Substances - alcohol - sedativ - opioid - steroids
8
Q
List the diagnostic criteria for persistent depressive disorder (dysthymia)
A
>=2 years of depressed mood for most days with >=2 of the following (ACHEWS) - appetite change - concentration decreased - hopelessness - energy decreased - worthlessness - sleep change Not symptom free for >2 months No manic or hypomanic episode Not other psychotic disorder or susbtance Cause distress and impair function
9
Q
List the diagnostic criteria for premenstrual dysphoric dirsorder
A
Cyclical pattern of depressed mood coinciding with menstrual cycle
- Present in majority of cycles with >=5 symptoms
- Group 1: affective liability, irritability, depressed mood, anxiety
- Group 2: Sleep, interest, energy, concentration, appetite, physical symptoms
- must have 1 symptoms from group 1 and group 2
- symptom onset week prior to menses and subside few days after menses
- symptoms cause distress and impair functioning
- confirmed by prospective daily rating of at least 2 symptomatic cycles
10
Q
Discuss the pathophysiology of depression
A
Have insufficient mono-amine neurotransmitter resulting in upregulation of neurotransmitter receptors -> decreased gene expression and abnormal mood state
11
Q
List the function of each of the primary neurotransmitters have on symptoms of depression
A
Psychomotor activity - serotonin - norepinephrine - dopamine Mood - serotonin - norepinephrine - dopamine Sleep - serotonin - norepinephrine - dopamine Appetite and Weight - serotonin Guilt and Worthlessness - serotonin Suicide - Serotonin Interest - Norepinephrine - dopamine Energy - Norepinephrine - dopamine Executive function - norepinephrine - dopamine
12
Q
List the mechanism of action of SSRI and a few examples
A
- act at dendrite synapses of the pre-synaptic neuronto increase serotonin in the synapse Examples - paroxetine (paxil) - fluoxetine (prozac) - citalopram (celexa) - sertraline (zoloft) - cipralex (escitalopram)
13
Q
List the side effects of SSRIs
A
- transient increase risk of suicide that decreases after few weeks Common (HANDS) - headache - anxiety and agitation - nausea - diarrhea - sexual dysfunction and sleep disruption Rare - upper GI bleed, especially when used with NSAID - Syndrome of inappropriate ADH release - Osteoporosis - Serotonin syndrome
14
Q
List the features of SSRI discontinuation syndrome
A
- Occur 3 days after discontinuation
- Greatest risk with paxil and effexor
FINISH - flu-like symptoms
- insomnia
- nausea
- imbalance
- sensory disturbance
- hyperarousal
15
Q
List the contraindications to starting a SSRI
A
- use of a MAO inhibitor, triptan or other serotonergic drug due to risk of serotonin syndrome
- pregnancy
- bipolar
16
Q
Discuss the mechanism of action of NDRI and provide an example
A
- norepinephrine and dopamine are prevented from reuptake at pre-synaptic neuron
Example - Bupropion (wellbutrin)
17
Q
List the side effects of NDRI
A
SHAARES
- seizures (cannot use with bulimia or electrolyte disturbance)
- headaches, hypertension
- Agitation
- Anticholinergic symptoms
- flushing
- dry mouth
- blurred vision
- delirium
- hyperthermia
- urinary retention and constipation - rash
- emesis
- sleep disruption
18
Q
Discuss the mechanism of action and provide examples of SNRI
A
- blockade of serotonin at lower doses
- blockade of serotonin and norepinephrine at mid doses
- blockade of serotonin, norepinephrine and dopamine at high doses
Examples - Venlafaxine (effexor)
- Duloxetine (cymbalta)
19
Q
Discuss the mechanism of action and provide examples of NaSSA (noradrenergic and specific serotonergic antidepressants)
A
- block alpha 2 auto receptor on norepinephrine receptor and heteroreceptor on 5HT neurons increasing release of norepinephrine and serotonin
- also block 5HT2 so not sleep or sexual side effects, 5HT3 so no GI side effects and H1 histamine receptor leading to sedation and weight gain
Example - Mirtazepine (remeron)
20
Q
List the side effects of NaSSA
A
Common (WADE) - weight gain - anticholinergic effects - drowsiness - equilibrium problem Rare - neutropenia - serotonin syndrome - hepatoxicity - SIADH
21
Q
Discuss the mechanism of action and provide examples of SARI (Serotonin 2A antagonist reuptake inhibitor)
A
- weak serotonin reuptake inhibitor
- block 5HT2A so no sleep disruption or sexual dysfunction
- block H1 histamine so sedating
- block alpha 1 so orthostatic hypotension
Example - trazodone (desyrel)
22
Q
List the side effects of SARI
A
- headache
- sedation
- orthostatic hypotension
- vivid dreams
- dry mouth
- priapism
- serotonin syndrome
23
Q
Discuss the mechanism of action and provide examples of TCA
A
- block all three monoamine reuptake
- block 5HT2 so no sex or sleep side effects
- block H1 histamine, muscarinic, alpha 1 adrenergic, and sodium channels in heart and brain
Examples - amitriptyline
24
Q
List the side effects of TCAs
A
Common
- weight gain
- sedation
- anticholinergic
- orthostatic hypotension
- prolonged QTc
Rare
- serotonin syndrome
- Torsade de Pointes
- Before starting: ECG to rule out bradycardia or prolonged QTc, electrolyte imbalance, taking type 1 or 3 antiarrhythmic
- SIADH
25
Discuss the mechanism of action and provide examples of MAOI (Monoamine oxidase inhibitor)
- irreversible bind and inhibit MAO thereby increasing 5HT, NE and DA levels
- irreversible inhibition last for 2 weeks
Examples
- moclobemide
26
List the rare side effects of MAOI
3Hs
- hyperthermia due to serotonin syndrome
- Hypertensive crisis
- Hepatotoxicity
- Teratogenicity
- Blood dyscrasia
27
Discuss the features of serotonin syndrome
HARMED
- hyperthermia
- agitation and autonomic instability (tachy, diarrhea)
- rigidity and reflexes increased
- myoclonus
- encephalopathy
- diaphoresis
28
List the indications for treatment in depression
- medication indicated for mild to moderate if patient prefer over psychotherapy
- medication required in moderate to severe with or without psychotherapy or ECT
- psychotic depression require ECT or antidepressant and antipsychotic
29
List the first line medications and how they are started
```
First Line
- SSRI: escitalopram or sertraline
- SNRI: venlafaxine or duloxetine
- NaSSA: mirtazapine
Starting
- begin at lowest possible dose and increase weekly until:
- intolerable side effects
- full response
- maximum dose
- usually do not find subjective benefit until 4-6 weeks, objective benefit after 2 weeks
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30
List the starting and target doses for the common medications from each class
```
SSRI
- Escitalopram 10mg/10-20mg
- Fluoxetine 20mg/20-80mg
- Sertraline 50mg/50-200mg
SNRI
- Venlafaxine 75mg/75-375mg
- Duloxetine 60mg/60-120mg
NDRI
- Buproprion 150mg/150-300mg
NaSSA:
- Mirtazapine 30mg/30-60mg
MAOI/RIMA
- Moclobemide 300mg/300-600mg
SARI:
- Trazadone 150-200mg/150-300mg
TCA
- Nortriptyline 25mg/150-250mg
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31
Discuss response after assessing at 4 weeks following achievement of therapeutic dose
Remission
- maintain antidepressant for 1 year post-remission months
- if more severe depression may require continued therapy for 2 years
Little to No Improvement (<20% reduction in score)
- re-evaluate diagnosis
- switch to another antidepressant with evidence of superiority
- if no benefit with switch then add-on another agent
- or combine with atypical antipsychotic or lithium
32
List the indications for ECT
- severe major depressive disorder when lack of response to medication, intolerant to medication or require fast improvement
- mania in bipolar
- mixed state
- catatonia
- psychosis
33
List the predictors of good outcome with ECT
- older age
- shorter duration of symptoms
- unipolar depression
- depression with psychotic features
- adequate seizure of adequate duration
34
Discuss the mechanism of action of ECT
- use electricity to ellicit seizure that results in
- neurotransmitter theory: ECT enhances action of monoamines
- neuroendocrine theory: ECT releases prolactin, TSH, ACTH, endorphines, brain derived neurotrophic factor (BDNF) and BDNF-R in frontal cortex
- neurogenesis: ECT increases neuroplasticity via BDNF increasing neuron connection and growth
- anticonvulsant theory: ECT alters GABA
35
List the investigations required before ECT
- CBC, electrolytes
- creatinine, BUN
- liver function
- drug levels
- pregnancy
- ECG
- CXR
36
Discuss the ECT procedure
- Anesthesia to establish airway and provide bite block and induction
- EEG to assess seizure quality
- beta blocker (esmolol) to prevent tachycardia
- Electrodes placed on patient along bilateral temporal temporal or bifrontal or right unilateral temporal (ranked in greatest effectiveness and increasing side effects)
- Monitor EEG for recruitment (low amplitude, high frequency), tonic (high amplitude, high frequency, spike and poly-spike activity), clonic (high amplitude, spike and slow wave complexes) termination (slow wave amplitude and frequency) and post ictal silence
37
Discuss the treatment regimen for ECT
- provided for 8-12 sessions where receive ECT 2-3 times per week
- have high relapse rate following conclusion so must continue with medication
38
List the side effects of ECT
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Common
- headache
- nausea
- muscle pain
Severe
- cardiovascular: vagal stimulation leading to bradycardia/asystole, sympathetic discharge leading to tachycardia and hypertension or rebound parasympathetic effect causing secondary bradycardia
- prolonged seizure (>3 minutes)
- prolonged apnea
Cognitive
- amnesia which is transient and disappear within 6 months
- delirium post-ictal
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39
List the contraindications for ECT
Relative
- brain disease (space occupying lesion, subdural hematoma, raised ICP)
- cardiovascular disease (recent MI/stroke or aortic stenosis)
- retinal detachement
- pheochromocytoma
