Flashcards in Depression / Bipolar Disorders Deck (63):
How is depression identified and treated in a primary care setting?
Only recognized half of the time and only treated about half of those that are recognized.
Of patients who are diagnosed with Major Depression and started on pharmaceuticals, how many is treatment unsuccessful at improving their symptoms?
Only 2/3rds of patients improve with treatment and 1/3 of them do not improve and alternative should be pursued.
What are the most common somatic complaints in patients with depression?
- Sleep Disturbance
- Nonspecific Musculoskeletal Pain
- Abdominal / Back Pain / Headaches
- Loss of sexual interest
If a patient states over the last 2-3 months he has been tired on almost a daily basis no matter how much sleep he gets, but admits his sleep isn't the best quality frequently waking up. Additionally the patient complains of a vague back pain and headaches that are present most days without any agitating factors. What is the general rule in diagnosing mood disorders?
-- Major Depressive Disorder
(This patient most likely has)
Usually the most somatic/physical symptoms present the higher chance the patient has a psychiatric disorder
What non-psychiatric chronic conditions the highest rate of being associated with mental illness?
What are the types of depressive disorders?
- Major Depressive Disorder
- Dysthymic -- withdrawal from daily activities or stressful/anxiety provoking (on top of depressive symptoms)
- Agitated / Psychomotor Retardation
What is the criteria to diagnose depression?
-- Depressed mood or loss of interest/pleasure
AND -- 4 of the following
-- weight change
-- changes in sleep (more or less)
-- Psychomotor retardation/agitation
-- Worthlessness feeling
-- Decreased concentration
-- Thoughts, plans, acts of suicide
What are the conditions in which depression would be ruled out?
- Substance use
What is the categorical tool to remember depression symptoms?
S -- Sleep Change
I -- Interest loss
G -- Guilt feeling of worthlessness
E -- Energy Loss
C -- Concentration loss
A -- Appetite changes - loss
P -- Psychomotor agitation/retardation
S -- Suicidal, hopelessness
In primary care what is the best way to screen for depression?
Two-Question Screening Tool
-- Over the past 2 weeks have you felt down or hopeless?
-- Over the past 2 weeks have you felt less interest in doing things your typically enjoy?
if a patient is screened positive for depression, then what is the next step?
Conduct a thorough depression testing
- Patient Health Questionaire (PHQ-9) = Score
5-9 -- None -- education about depression
10-14 -- Minor Depression -- maybe start drugs, watch
15-19 -- Major Depression -- drugs or therapy
20+ -- Severe Major Depression -- drugs + therapy
What are the risk factors for suicide?
IS PATH WARM?
- Ideation -- communication
- Substance -- Substance Abuse
- Withdrawl from normal life
- Mood Changes
If a patient recently had a family member die and continually are blaming themselves, what stage are they in?
Stage 2 - Preoccupation with Deceased
What are the first symptoms to expect from a patient after a family member or close friend die?
- Numbness / Non-reality
Physical Symptoms -- Crying, Emptiness, Denial, Disbelief
How can you tell a patient is recovering from bereavement?
-- Regaining interest in activities and forming new relationships
What are the most common side effects of Tricyclic Antidepressants?
--Anticholinergic -- dry mouth, dry eyes, difficulty urinating
How do the courses of schizophrenia and bipolar differ?
Schizophrenia symptoms usually become worse, then go back to baseline or maintain at that higher level until the next peak of symptoms, then further increases baseline.
Bipolar symptoms usually include peaks and lows intermixed or just highs. Baseline symptoms/personality does not usually change.
What is one of the biggest concerns for bipolar individuals who are not being treated?
They have a very high rate of suicide ~15%
What are the common symptoms present if you are suspicious someone is in a manic episode?
Need 3-4 Symptoms to diagnose:
-- Decreased need for sleep
-- Pressured Speech, difficult to understand
-- Flight of Ideas / Racing thoughts
-- Easily Distracted
-- Increased goal directed activity
-- More pleasurable activities
If a patient is reported to abruptly leave town to travel to Vegas to "save everyone from sin" and while there stays up all night talking to people on the street about the savior. While out she maxes out credit cards and has sex with a multitude of prostitutes. What could she be experiencing?
- Increased goal directed activity
- Increased impulsive actions / pleasurable activities
What are the first symptoms that can be experienced by a person in a manic episode?
- Increased psychomotor activity / rate of speech
- Expansiveness in thoughts
- Increased religiousness, spending, letter writing, sexual interest
How does the 1st and 2nd stage of mania differ?
-- Pressured speech much increased
-- Hostility, explosive anger
-- Flights of ideas
If left untreated, what can a manic individual experience?
Stage 3 - Rare
- Increased stimulation - more panic stricken
- Frenzied behavior
- Ideas of reference -- thinks news/others are always talking about them when they are not. "loose associations"
Where is the nuclei / area that regulate norepinephrine neurons in the CNS?
Locus Coeruleus (Pons)
What does the Raphe Nuclei do?
Cell bodies of Serotonin-releasing neurons within the CNS
What is the mechanism of action of tricyclic antidepressants?
Block reuptake of NE into the pre-synaptic neuron increasing NE in the cleft, then over time the post-synaptic receptors down-regulate -- transmitting less signal per NE molecule.
How are Amitriptyline and Fluoxetine similar?
Amitriptyline blocks the NERT Receptor increasing NE int the cleft
Fluoxetine blocks the SERT Receptor increasing the amount of Serotonin in the cleft
How does Mirtazapine increase the neurotransmitter concentration in the clefts?
Antagonist to Alpha-2 receptors, thus the neurons are unable to detect how much NE is present in the clefts, thinking there is not enough, thus increases output of the NE.
How can Phenelzine increase concentration of more than one neurotransmitter?
Monoamine Oxidase Inhibitor -- prevents all of their breakdowns, thus increases concentration in the lefts and amount being released from the pre-synaptic.
Why are SERT inhibitors more desirable than NERT-inhibitors?
SERT Inhibitors -- Serotinin Specific Reuptake Inhibitors
- Better side effect profiles
- Less significant acute toxicity (harder to do too)
What are examples of 5-HT reuptake inhibitors? (SSRI)
What is a unique risk factor for adolescents taking SSRIs?
Actually can INCREASE the chance of suicidal thinking in people with psych disorders
What happens if a patient abruptly stops taking SSRIs?
SSRI Withdrawal happens:
- dizziness, light-headedness
- shock-like sensations down the extremities
If a 56 year old female patient is taking Paroxetine, what is the most likely reason?
Helps with hot flashes associated with menopause
What is the difference between Sertraline and Fluoxetine?
Fluoxetine -- longer half life, effects other drug metabolism
Sertraline - short half-life, less drug interactions
What SSRI is commonly used for panic attacks?
What SSRI is approved for OCD?
Fluvoxamine / Sertraline
What SSRI has the longest half-life?
Fluoxetine -- 7 days+
Besides mood disorders, what are other syndromes treated with SSRIs?
Chronic Pain Disorders
If a patient has been suffering from chronic lower back pain for many years and narcotics are not working and the patient does not want to take them anymore, what might be another treatment option?
Duloxetine -- Serotonin-Norepinephrine Reuptake Inhibitors
- Approved for Depression
- Approved for neuropathic and musculoskeletal pain
**Don't use with Liver Disease
What type of drug is Venlafaxine and what does it treat?
Serotonin-Norephinephrine Reuptake Inhibitor
What are the two drugs that are approved for Fibromyalgia?
- Milnacipran (Fibromyalgia only)
What is the major draw back of taking SNRI type drugs?
Strong Antimuscarinic side effects
-- side effects are more closely related to SSRI
What are the big side effects of taking SSRIs?
- sexual dysfunction
- if combined with MAOi "serotonin reaction" w/ hyperthermia and CV collapse.
What Atypical antidepressant weakly blocks NE and 5HT reuptake -- used for seasonal affective disorder and nicotine withdrawal?
What drug blocks pre-synaptic Alpha-2 receptors in the CNS?
- increases appetite
What atypical antidepressant has weak SSRI-like activity and is commonly used for insomnia?
- can cause priapism
- low incidence CV
- Sedating effects (taken a night)
What drug is commonly given with SSRIs to help minimize some of the side effects?
- increases sexual function
What is the mechanism of action of Vortioxetine?
What is the mechanism of Tricyclic Antidepressants?
-- Block the reuptake of NE and 5HT (Serotonin)
- Very long half-life
- lipophilic / protein bound
What is the major draw back of taking Tricyclic Antidepressants?
- Decreases REM Sleep
- Significant Anticholinergic Effects
- Cardiac Arrhythmias
If a patient is taking an antidepressant and continually experiences heart palpitations, tachycardia, and prolonged QRS intervals, what is the most likely drug?
- causes changes in heart conduction
What are tricyclic antidepressants higher risk for overdoses?
- Very long half-lives
- Lipophilic, can reside for prolonged amount of time
- Can cause heart dysfunction and hyperpyrexia
- Need to observe for 3 days after overdose
What drug can be used in children who frequently wet the bed?
Imipramine - tricyclic
-- side effect of antimuscarinic, prevents urination
What are the most common therapeutic uses for Tricyclic Antidepressants?
- Major Depressive Disorder
- Chronic Pain
- Enuresis / Urinary incontinence
What are the nonselective MAOis commonly used?
What is the mechanism of action of Phenelzine?
Irreversibly inhibits Monoamine Oxidase -- increasing the concentration of neurotransmitters in the cleft
- 2 weeks until effects
- improves sleep disorders in depressed patients
What is the biggest hurdle to overcome when treating with Phenelzine?
Sticking to a strict diet
- No Avocados, Figs, Aged Meats, Sausages, Cheese, Yeast extract, protein supplements
What is the consequence of a patient not sticking to a diet?
-- Tyramine is not properly broken down from foods and is sympathominetic -- elevates blood pressure and heart rate
What are the biggest side effects of MAO inhibitors?
- Orthostatic Hypotension
- Build up of Tyramine
- Can cause acute toxicity -- agitation, hallucinations, etc
What if antidepressant drug therapy is not effective alone?
Supplement with psychotic agents
- approved Olanzapine, Ariprazole, Quetiapine
- Transcranial Magnetic Stimulation
What is a beneficial side effect of taking St. John's Wort?
- Mild MAO inhibition, evidence for effects with mild depression
Bad Effects -- increased CYP3A4 expression lowing effectiveness of birthcontrol and other drugs.