Depression: Dr. Kelso Flashcards by Alicia Daum

Factors in Depression Pathogenesis

Genetics
Early life adversity
Social factors
Psychological factors
Secondary depression

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Reasons for Secondary Depression

General medical disorders
Medications
Substance of abuse

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Define Epigenetics

Changes in expression of genes caused by early life experiences or chronic stress

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How does early life adversity potentially lead to depression?

Predisposes to major depression by altering sensitivity to stress and response to negative stimuli

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Social factors that could play into depression

Isolation
Poor social relationships
Criticism from family members
Depression in social networks

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Psychological factors that may lead to depression

Cognitive/Behavioral: negative/distorted patterns of thinking
Personality: neuroticism
Psychodynamic: early losses, interpersonal relationships

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Symptoms of Neuroticism

Anxiety
Moodiness
Envy
Frustration
Loneliness
Respond poorly to stressors
Interpret ordinary situations as threatening
Minor frustrations as hopelessly difficult

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Medical Conditions that may Lead to Depression

Sleep apnea
Hypothyroidism
Vitamin D deficiency
DM
Chronic pain
Stroke
HD: ischemic, HF, cardiomyopathy
Parkinson's 
MS
Epilepsy
Head injury
CA
COPD
Dementia
HIV/Neurosyphilis

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Medications that may Lead to Depression

Interferon
Corticosteroids
Benzodiazepines
Opioids
Varenicline (Chantix)
Beta-blockers

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Drugs of Abuse that may Lead to Depression

PCP (withdrawal)
Amphetamines (withdrawal)
Cocaine (withdrawal)
Marijuana (withdrawal)
Sedative-hypnotics (intoxication)
Alcohol (intoxication)
Opiates (intoxication)
Steroids (intoxication)

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Neurobiology of Depression

Altered brain structure and function

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Altered Brain Structure in Depression

Increased ventricular-brain ratio
Smaller frontal lobe volumes
Smaller hippocampal volumes
Number/density/size of neurons and glial cells are abnormal

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Altered Brain Function in Depression

Abnormal functioning of monoamines, GABA, glutamate
HPA axis- excess excretion of glucocorticoids may lead to suppression of neurogenesis & hippocampal atrophy
Abnormal neuronal networks
Sleep/circadian rhythms
Inflammation

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Categories of Symptoms of Major Depression

Psychologica
Neurovegetative
Psychomotor/physical

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Psychological Symptoms of Major Depression

Depressed mood
Numbness
Anhedonia: inability to experience joy
Decreased interest
Irritability/anxiety
Guilt/worthlessness
Suicidal ideation

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Neurovegetative Symptoms of Major Depression

Appetite
Sleep
Energy
Concentration

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Psychomotor/Physical Symptoms of Major Depression

Psychomotor: retardation, agitation
Physical: aches/pain, weakness/malaise, GI distress

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Qualifying Symptoms for Major Depression

Occur in same two weeks
Most of the day, every day
Distress or impairment
R/O substances, general medical condition, bereavement

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Subtypes of Depression

Anxious
Atypical
Catatonic
Melancholic
Mixed Features
Peripartum
Psychotic
Seasonal

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Subcategories of Depression

Bipolar

Secondary: medical illness, medications, drugs of abuse

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Co-morbid Psychiatric Conditions with Depression

Anxiety: generalized, panic disorder, OCD, PTSD

Substance abuse

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What does SIGECAPY stand for?

S: sleep
I: interest
G: guilt/worthlessness
E: energy
C: concentration
A: appetite
P: psychomotor disturbance
S: suicidal ideation

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Evaluation of Depression

Chronology of symptoms
Symptoms in the same two weeks
Most of the day, every day
Distress or impairment
Prior Hx of depressive episodes
Impact on functioning
Alleviating/aggravating factors
Address co-morbidity
Mania/hypomania
Distinguish major depression from persistent depressive disorder
Suicide risk
General medical illness
Family Hx: depression, suicide, psychosis, bipolar
Social Hx: interpersonal, occupational, financial stressors
\+/- complete physical &amp; euro exam
MMSE
Toxicological screen
Lab screen: CBC, TSH, LFT's, chem7, Ca, B12, Folate, HIV 
Brain imaging
\+/- EEG, LP

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Types of Psychotic Features

Delusions
Hallucinations
Disordered though
20% of patients
Higher suicide risk

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Suicide Risk Factors: SAD PERSONS

``` S: sex (male) A: age D: depression P: previous suicide attempts E: ETOH abuse R: rational thinking loss S: social supports lacking O: organized plan N: no spouse S: sickness ```

When to hospitalize a patient with psychosis?

Plan Intent Plan

Possible Safety Treatment Plan Items

Crisis Numbers ROI for family in chart Commitment to adhere to meds, appts., contact office with concerns Agree to remove lethal means

Alcohol CAGE Screening

C: cut down on drinking A: annoyed by people criticizing your drinking G: guilty about your drinking E: eye opener

Other Scales to Screen for Depression

Beck depression inventory Quick inventory of depressive symptomatology Mood disorder questionnaire Hamilton anxiety rating scale

Mental Status Exam Observation

``` Affect Cognition Psychomotor activity Ruminative thought process Speech Psychosis Suicidal thoughts ```

Antidepressant Classes

``` SSRI SNRI TCA MAOI Others: mirtazapine, buproprion, trazodone Atypical Antipsychotics ```

Examples of SSRI's

``` Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) FLuoxetine (Prozac) ```

Antidepressant SE

``` GI disturbance: nausea, diarrhea, appetite Sexual dysfunction Anxiety Insomnia or sedation Sweating Dizziness ```

Examples of SNRI's

Venlafaxine (Effexor) | Duloxetine (Cymbalta)

Examples of TCAs

Amitriptyline Clomipramine Doxepin Imipramine

TCA SE

Anticholinergic Antihistamine Orthostatic hypotension Cardiac

TCA Overdose

Lethal

Examples of MAOI's

Phenelzine (Nardil) | Tranylcypromine (Parnate)

What are the Drug-Druge Interactions with MAOIs

Serotonin syndrome | HTN crisis

What are the dietary restrictions for MAOIs?

Avoid tyramine containing foods

SE of Trazodone

Sedation Orthostasis Priapism Piloerection

Buproprion Considerations

``` Avoid seizure disorders Avoid in bulimia Enhances dopamine: anxiety, psychosis, dopaminergic agents No sexual side effects Smoking cessation Co-morbid ADHD Often used with SSRIs Consider with sleepy, slowed down patients Preg. Cat. B ```

Mirtazapine Considerations

Sedation Weight gain: good for chemo/elderly patients Less sexual side effects Good for patients with nausea

Positive Predictors of Depression Remission

Caucasian Female Employed Education

Negative Predictors of Depression Remission

``` Longer index episodes Drug abuse Anxiety disorders Medical disorders Lower functioning ```

Positives of Remission in Depression

Return of normal functioning Lower rates of relapse Lower risk of suicide Less ETOH & drug abuse

Acute Treatment of Mild Depression

Psychotherapy alone

Acute Treatment of Moderate-Severe Depression

Medication | +/- therapy

Acute Treatment of Bipolar Disorder

Mood stabilizer | +/- antidepressant

Acute Treatment of Psychotic Disorder

Antipsychotic | Antidepressant

Continuation Phase of Depression Treatment

4-6 months following remission High risk for relapse Use full therapeutic dosage

Maintenance Phase of Depression Treatment

Risk of recurrence: #/severity previous episodes, residual symptoms, co-morbid disorders Patient preference SE

Education on Antidepressant Medication

Minimum 2-4 weeks to be effective Take every day Duration: at least 4-6 months SE: time dependent

General Principles of Depression Treatment

``` Titrate to target dose Monitor for SE Monitor adherence No improvement: consider switch Limited response: consider increase or augmentation SE: switch or augment ```

Factors in Choosing an Antidepressant

``` Personal history Pharmacogenetics Family history Cost Overdose/safety SE/unique benefits Drug-drug interactions Co-morbid conditions Depression subtypes ```

Define Pharmacogenetics

Study of the role of genetic variation on drug response

Cheap Antidepressants

``` Citalopram Paroxetine Fluoxetine Sertraline Burprion SR, XL Mirtazapine ```

More Expensive Antidepressants

Escitalopram Bupropion XL Venlafaxine XR Duloxetine

TCA Overdose

Highly lethal

Lithium Overdose

Lethal

Process of Dealing with SE of Antidepressants

Wait Lower dose, slow titration Change dosing schedule Augment

Process for Dealing with Sexual SE

Drug holiday Augment Lower dose Wait

Which Benzodiazepines better than others for abuse potential?

Clonazepam | Lorazepam

Discontinuation of Antidepressants

``` Nausea Headache Irritability Vivid dreams Vertigo Slower taper +/- benzodiazepine ```

SSRI Drug Interactions

Fluoxetine Paroxetine Fluvoxamine Least interactions: escitalopram

Depression Subtypes

Psychotic depression | Bipolar depression

Psychotic Depression

Higher remission with combination of antidepressant & antipsychotic

Bipolar Depression

30-50% risk of cycling into mania on antidepressant without a mood stabilizer

Types of Psychotherapy

CBT: understand distortions in thinking; learn new coping strategy IPT: grief, role transition/role dispute interpersonal deficits

Augmentation Strategies

``` Bibliotherapy: self help books Relaxation techniques Meditation Exercise Apps/support groups/ telepsychology ```

Depression: Dr. Kelso Flashcards

(70 cards)