Major Depressive Disorder Flashcards
(47 cards)
1
Q
What criteria is used for the diagnosis of MDD?
A
DSM V is used for the diagnosis of Major Depressive Disorder
2
Q
What is MDD?
A
MDD is a mood state characterised by significantly lowered mood and a loss of interest or pleasure in activities that are normally enjoyable
3
Q
A major depressive episode can be distinguished from ‘normal’ depression by what?
A
A major depressive episode can be distinguished from ‘normal’ depression by its severity, persistence, duration and the presence of characteristic symptoms e.g. sleep disturbances
4
Q
What are the Signs of Depression
- Emotional/Mental Signs
- Physical Signs
A
- Emotional/Mental Signs
- Depressed mood
- Anhedonia
- Low self-esteem
- Anxiety
- Pre-occupation with negative thoughts
- Poor concentration
- Confused and indecisive
- Physical Signs
- Headache
- Chronic fatigue
- Disturbed sleep
- GI complaints
- Sexual dysfunction
- Menstrual problems
5
Q
Assessing Severity
What is a Mild Episode?
A
Few symptoms beyond the minimum required to make the diagnosis
6
Q
Assessing Severity
What is a Severe Episode?
A
- Most criteria present
- Marked interference with social and/or occupational functioning, producing clear-cut observable disability
7
Q
When Assessing Severity, what else should be considered?
A
Nature of symptoms (e.g. suicidal thoughts and behaviour) should also be considered in assessing severity
8
Q
What is the Self-Test for Depression?
A
PHQ-9
9
Q
What are the 5 Subtypes of Depression?
A
- Severe with psychotic features
- Hallucination, delusions
- Chronic depression
- MDD for at least 2 years and several episodes
- The more recurrent episodes left untreated → becomes chronic
- With atypical features
- Eat a lot, weight gain, sleep a lot
- With seasonal pattern
- Don’t see much sunlight
- Postpartum onset
- Happens within 4 wks after birth
10
Q
What factors should be assessed when assessing a patient with depression?
A
- Risk – suicide, self-harm
- Psychosocial aspects
- Premorbid personality – how they manage stress
- Medication – change in meds, new drugs
- Bipolar disorder
- Comorbid anxiety
- Comorbid substance abuse
- Other physical conditions
11
Q
What is the Aim of Treating MDD?
A
- Relieve psychological and physical symptoms
- Improve functional capacity
- Reduce the likelihood of self-harm or suicide
12
Q
What are the 2 Treatment Options for MDD?
A
- Non-pharmacological: psychological, ECT, others
- Pharmacological: Antidepressants, complementary therapies
13
Q
List the Types of Non-Pharmacological Therapies
A
- Psychotherapy
- Cognitive Behavioural Therapy
- Interpersonal Therapy
- Electroconvulsive Therapy (ECT)
- Others
14
Q
Non-Pharmacological Therapies: Psychotherapy
- When is it used?
- Is it used in Combination?
A
- First line in mild to moderate disease if patient is able and willing to participate
- Combination of psychotherapy and medication may be advantageous for those who have partial response to either treatment alone or those with chronic course of illness
15
Q
Non-Pharmacological Therapies: Electroconvulsive Therapy (ECT)
- What is it?
- Does it work quickly?
- How is it administered?
- Is treatment the same for everyone?
A
- Passing an electric current through the brain to produce a seizure for a therapeutic purpose
- Quick results
- Administered under GA and muscle relaxant
- Personalised treatment to reduce risk of adverse effects and also look at brain
16
Q
Non-Pharmacological Therapies: Electroconvulsive Therapy (ECT) should be considered in who?
A
- Should be considered in severely depressed patients who have any of the following (first line):
- Psychotic depression
- Poor response to several adequate courses of antidepressant drug
- Severe reduction in food and fluid intake
- Strong suicidal ideation
- Catatonia
- Previous good response to ECT
17
Q
Non-Pharmacological Therapies: Electroconvulsive Therapy (ECT)
- What drugs need to be stoped in ECT?
A
- ECT and psychotropic drugs
- BZDs – tapered and ceased
- Anti-epileptics – different approaches
- Antidepressants – taper and discontinue before ECT
- Lithium – doesn’t impair effectiveness but can cause severe postictal confusion even at low serum concentration
18
Q
Non-Pharmacological Therapies: What are the Other Therapies?
A
- To reserve unhealthy or destructive lifestyle habits and consider other activities that may relieve stress and facilitate well-being
- Exercise
- Light therapy (SAD)
- Relaxation therapy
- Message
- Yoga
19
Q
The choice of drug in MDD is determined by what?
A
- Antidepressant safety in overdose
- Response (or lack of) to previous antidepressant treatment
- Adverse effect profile (or previous treatment)
- Family history of response to treatment
- Patient comorbidities
- Risks of drug interaction with other concomitantly administered drugs
20
Q
The choice of drug in MDD is determined by what: Antidepressant safety in overdose
- Most Toxic:
- Mid-Range:
- Least Toxic:
A
- Most Toxic: TCAs and MAOis
- Mid-Range: Venlafaxine
- Least Toxic: SSRis, Mirtazapine, Reboxetine, Mianserin, Moclobemide
21
Q
The choice of drug in MDD is determined by what: Adverse effect profile (or previous treatment)
A
- Weight gain and sedation (mirtazapine)
- Shouldn’t be taken in morning but suitable for patients with depression + insomnia (taken at night)
- Concurrent use with other meds that increases the risk of weight gain
- Not significant especially depression + anorexia
- Anti-cholinergic side effects (TCAs)
- Dry mouth, cracked lips, constipation, mydriasis, blurred vision
22
Q
Expectations of Starting Treatment
- Time after starting: 4-6 Weeks
- Expectation of Treatment:
A
- Time after starting: 4-6 Weeks
- Expectation of Treatment: Adequate Trial Period
23
Q
What are the Recommendations for someone who has initiated treatment?
- Responder
- Partial Repsonder
- Non-Responder
A
- Either way, initiate treatment and assess response after 2-4 weeks
- Responder = continue treatment at this dose
- Partial Repsonder = increase dose
- Non-Responder = increase dose
- Then
- Assess response after 2-4 weeks
- Partial responder
- Increase dose further if possible
- Change drug
- Non-Responder
- Change drug
- Partial responder
- Assess response after 2-4 weeks
24
Q
If Treatment Fails what do you have to consider?
A
- If patient cycling - is patient bipolar?
- Is patient adhering?
- Underlying conditions?
- Patient experiencing A/Es so not taking meds?
- Is dose and duration adequate to identify non-responder?
- Is there concomitant drug and substance abuse?
- Drug interactions affecting serum levels?
25
What is a washout period?
An appropriate interval when changing from one antidepressant to another is recommended to avoid interactions (washout period)
26
What do you have to be mindful of when switching antidepressants?
* Patient’s particular situation (concurrent medication, drug history, physical health, considerable inter-individual variation in elimination half-lives)
* Dose of old and new drugs (includes PK of parent drug, presence of an active metabolite)
27
List the 3 types of Switching Strategies
* Conservative switch
* Moderate switch
* Direct switch
28
Switching Strategies: What is Conservative Switch?
* Gradually reduce and stop first A/D
* Drug-free washout interval of five half-lives of the first A/D
* The new A/D is started according to its dose recommendation
29
Switching Strategies: What is Moderate Switch?
* Gradually reduce and stop first A/D
* Drug-free washout interval of 2-4 days
* The new A/D is started at low dose
30
Switching Strategies: What is Direct Switch?
* The first A/D is stopped
* The second A/D is started the next day at the usual therapeutic dose
31
List the 4 options for Treatment-Resistant Depression
* ECT
* Augmentation with lithium
* Augmentation with second generation antipsychotics
* Augmentation with T3
32
Treatment-Resistant Depression: Discuss ECT
Quick response, follow up with drug treatment
33
Treatment-Resistant Depression: Discuss Augmentation with lithium
Has unfavourable ADR profile and long-term risk of thyroid and renal dysfunction
34
How Long should Treatment Last in MDD?
* To reduce the risk of relapse?
* People at high risk?
* Risk factors include
* To reduce the risk of relapse, continue for 6-12 months after remission of symptoms
* People at high risk of recurrence should continue for 2-3 years or more
* Risk factors include:
* Residual depressive symptoms
* History of 3 or more prior episodes, or 2 or more in the last 5 years
* History of severe depression (with psychotic symptoms or serious suicide attempt)
35
How should treatment be discontinued?
* Should be tapered slowly, rather than stopped abruptly, to reduce the risk of discontinuation syndrome (insomnia, nausea, postural imbalance, sensory disturbances, hyperarousal and flu-like symptoms)
* General rule: every week, reduce by half until patient is taking half the lowest dose possible after which you can stop a week later
* If ceasing completely, tapering may need to be undertaken more slowly to prevent relapse
36
How to avoid withdrawal effects?
* End of Rx course
* Changing drugs
* End of Rx Course: Taper slowly and monitor for withdrawal
* Changing Drugs: Stopping or rapid tapering to minimise disruption to Rx. Patients should be educated about possible effects to watch out for
37
What are 4 issues to consider with A/Ds?
* Bleeding
* Hyponatraemia
* Serotonin syndrome (toxicity)
* SSRIs and hepatic enzymes
38
Issues to Consider with A/Ds: Bleeding
* What do SSRIs inhibit?
* Is the risk high?
* Increased risk with what?
* SSRIs inhibit uptake of serotonin into platelets
* Risk is relatively low
* Increased with use of NSAIDs, anti-platelet
39
Issues to Consider with A/Ds: Hyponatraemia
* What drugs have the risk?
* Is risk high?
* If SSRI?
* SSRIs, SNRIs, TCAs and MAOIs
* Risk may be low
* Can be severe: could lead to coma and death
* If SSRI, cease agent and use different SSRI, if not successful, consider moclobemide or reboxetine
40
Issues to Consider with A/Ds: Serotonin Syndrome (toxicity)
* How can it occur?
* A high dose of single drug
* More than 1 serotonergic agents are used together
* Inadequate washout period when switching from one to another
41
Issues to Consider with A/Ds: Serotonin Syndrome (toxicity)
* What are the causes?
* Neuromuscular effects: hyper-reflexia, tremor, incoordination
* Autonomic effects: diarrhoea, abdominal cramps, hyperthermia, shivering, fever, tachycardia
* Mental status effects: agitation, anxiety, confusion, restlessness
42
Issues to Consider with A/Ds: SSRIs and Hepatic Enzymes
* What can SSRIs inhibit?
* Are SSRIs metabolised by the same enzymes?
* What SSRIs have the least potential to interact with enzymes?
* SSRIs are metabolised in the liver by CYP450. They can inhibit the metabolism of many other drugs, causing increased plasma drug concentrations and possible toxicity
* Individual SSRIs are metabolised by different isoenzymes, therefore their potential for interactions varies
* Citalopram, escitalopram and sertraline have the least potential to interact in this way
43
What are the Pharmacodynamic Interactions among antidepressants
* Serotonergic syndrome/toxicity (SSRIs, SNRIs, MAOa inhibitors)
* Combination with serotonergic drugs
* Absolute contraindication = SSRIs + MAO inhibitors
* Prolongs QT Interval (SSRIs)
* Combination with drugs that also prolongs QT interval
* Risk is higher in patients with pre-existing arrhythmia
* Reduce Seizure Threshold (TCAs, MAO inhibitors)
* Risk of seizures, especially in patients with high risk of epileptic episodes
* Includes interaction with OTC or supplements (ginkgo + fluoxetine)
44
What are the Pharmacokinetic Interactions among antidepressants
* Half life
* Fluoxetine and sertraline have long half life and need to be converted to active metabolite also with long half life
* Paroxetine short half life – anti depressant change over and wash out periods
* Interaction with CYP enzymes
* Fluvoxamine affects all CYP enzymes
* **Long half life – cleanest** = Citalopram and escitalopram
* **Short half life – cleanest** = paroxetine
45
What are the Medical Condition Interactions among antidepressants?
* CV disorders (SNRIs)
* Venlafaxine increase risk of HTN, palpitations, tahcycardia and orthostatic hypotension
* Reduce seizure threshold (TCAs, MAOiS)
* Concurrent administration with drugs that reduces seizure threshold, or drugs that raise seizure threshold
* Risk of seizures
* Presentation with bipolar disorder
46
Depression and Pregnancy
* What happens if A/D is stopped?
* How should mild-moderate depression be treated?
* How should severe depression be treated?
* Choice of A/D dependent on?
* What's first line?
* Majority of women will relapse if their A/D is stopped on confirmation of pregnancy
* Mild-moderate depression should be treated with psychological therapies
* Severe depression = A/D should be considered
* Choice of A/D dependent on clinical factors, particularly previous efficacy, tolerability and patient preference
* SSRIs considered first line (caution with fluoxetine and paroxetine)
47
Antidepressants and Breastfeeding
* Is there transfer of A/D?
* What do studies suggest?
* TCAs?
* Moclobemide?
* Placental transfer and foetal exposure to A/D in utero \> breastmilk exposure
* Most studies suggest infant plasma concentrations are either low or not detected (except fluoxetine)
* Breastmilk transfer of TCAs is low, generally considered safe
* Moclobemide has very low transfer into breastmilk and is probably safe
