MDD Flashcards by Linda Chen

what are some differences between depressive disorders

duration, timing, etiology

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T or F: treating parental depression has no effect on psychiatric symptoms in children

F- lowered psyc sx in children

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T or F: MDD is the second leading cause of global disabiltiy

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which of the following does not describe MDD diagnosis
1. you must have 5 symptoms from criteria A
2. patients often present with physical symptoms
3. criteria B states that the sx could not be from something else
4. diagnosis is 5 sx from criteria A, then B + C in addition

3- criteria B = clinically sig distress/ impaired functioning
C = not from substance/ other med condition

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what are the 9 criteria from criteria A for MDD? What are the 2 points that the pt must have at least 1 of?

2 points: loss of interest, depressed mood
change in appetite and weight, fatigue, changes in sleep, psychomotor agitation or retardation, slowed thought process, feelings of worthlessness/ guilt, thoughts of suicide/ death

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what is considered mild MDD

few if any sx if excess + distressing but manageable and minor fxn impairment

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what is considered severe MDD

many sx in excess + seriously distressing and impacting function

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how can medical conditions be associated with MDD through physical/ chemical mechs

shared sx
MDD causes bio changes that leads to other sx
other sx has bio effects that promotes MDD

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name 3 clinical RF for MDD

Hx/ FamHx of depression
Psychosocial adversity
Higher users of med system
Chronic med conditions (esp CVD, DM, neuro)
Other psych conditions
Times of hormonal challenge (ex- peripartum)

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name 3 symptom RF for MDD

Unexplained physical sx
Chronic pain
Fatigue
Insomnia
Anxiety
Substance abuse

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Using rating scales can improve outcomes like ________ and _______

sx remission
adherence

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what is the 2 question screen

in the last month, have you been bothered by little interest/ pleasure in doing things + have you been feeling down/ depressed/ hopeless → yes to either = further assessment

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what are some clinician rated symptom rating scales

HAM-D, MADRS, IDS, GDS

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what are some patient rated symptom rating scales

PHQ-9, IDS-SR

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onset of MDD

any age, risk increases with puberty, peaks in 20s but late onset is not uncommon

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regarding the disease course of MDD
1. most patients are episodically depression and hypomanic
2. most patients feel well between MDEs
3. the duration of episodes increases with age
4. the pattern is more frequent in females

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Partial remission: sx of prev MDE present but _________(or ____without any sig sx of MDE following end of an episode)

full criteria not met
<2mths

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________: no sig sx of MDE in last 2 mths (or 1-2sx to no more than a mild degree)

Full sx remission

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Full sx remission: no sig sx of MDE in_______(or ___________ degree)

last 2 mths
1-2sx to no more than a mild

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which of the following does not apply to psychotherapy
1. more frequency sessions may have beneficial results, esp in the acute phase
2. less than 2 sessions are not proven to be beneficial
3. psychotherapy + AD is more effective than AD alone
4. 1+2

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3 NHPs for MDD

st john’s wort
omega 3s
SAM-e

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st john’s wort indication in MDD

1st line mono tx for mild-mod MDD

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AEs of st john’s wort

serotonin sx
hypomania when combined with ADs- CYP3A4 inducer

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st john’s wort is a CYP3A4 ___

inducer

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waht is first line for mild MDD

psychoeducation, self management, psyc tx, pharm tx (consider + SDM)

what is first line for mod-severe MDD

2nd gen AD

what are some first line SSRIs

citalo/escitalopram, fluoxetine, fluvoxamine

what are some first line SNRIs

desvenlafaxine, venlafaxine, duloxetine

what is a first line NDRI

bupropion

first line adjunctive drugs to ADs

aripiprazole, quetiapine, risperidone

ketamine is a __________ that _______- pick from the following list - selective or nonselective - ______ receptor agonist/ antagonist - decreases/ increases ___________

nonselective NMDA receptor antagonist decreases glutamate

what limits the use of NMDA outside of psyc spec

hallucinogenic/ abuse potential

what is considered early improvement from AD

>20-30% improvement from baseline after 2-4wks at target dose

what is considered a response to AD tx? what about a partial response or a nonresponse?

>50% improvement in 6-12wks partial: 25-49% nonresp: <25%

what is considered a remission from MDE

no sig s/s in the last 2 mths or based off a predefined cut off or 1-2 sx that are mild at 6-12wks

if there is no early improvement, but no AEs at 2-4wks, what should you do?

optimize dose and wait another 2-4wks

if at 2-4wks dose is maxed and there is still no early improvement, ....

switch or adjunct

a patient has had 3 AD trials in the past, doses are maxed, and no early improvement is seen at 4wks. what should you do?

switch to a second line or third line AD

when should you switch ADs?

first AD trial AEs felt no response <25% improvement no time crunch pt pref to switch

when should you adjunct ADs

=>2 AD trials no/ mild AEs AEs may be targeted by other tx partial response >25% improvement time crunch pt pref adj

what should you do after a pt has been at target dose for 4 weeks and early improvement of 30% is seen

continue tx for 6-8wks

after 8 wks of continued tx, a pt is not in remission. what should you do?

make sure target dose is achieved- if already achieved, switch/ adjunct

after 6-8 wks of maintenance, sx are in remission, what should you do now?

RF present = conmt for =>2yrs no RF = cont for 6-9mths

list 3 RF for remission

Early age of onset Greater number of prev episodes Severity of initial episode (# of sx, suicidal ideation, psychomotor agitation) Disruptions of sleep-wake cycle Presence of comorbid psychopathology (esp persistent depressive disorder/ dysthymia) FamHx of psych illness Presence of negative cognitions High neuroticism Poor social support Stressful life events

treatment resistent depression is defined as

inadequate response to =>2 AD

discontinuation syndrome from ADs happens in _______ after stopping/ dramatic dose reduction and resolves in ______ with no intervention

happens in 1-7days resolves in 1-3wks

list 3 acute withdrawal sx

Somatic sx: dizziness/ incoordination, lethargy, N/V/D, headache, fever/ sweating/ chills, malaise, insomnia, vivid dreams Neuro sx: myalgia, paresthesias, electric shock like sensations, dyskinesias, visual discoordination Psychological sx: anxiety, agitation, crying, irritability, confusion, slowed thinking, disorientation

how to prevent discontinuation sx

lower by no more than 25%/wk fluoxetine can be faster due to long hafl life

how to manage discontinuation sx

can add back some drug + taper more slowly or substitute limited doses of fluoxetine

what is a direct AD switch? when is it recommended?

stop 1st AD, start new AD next day. Recommended if 1st AD <6wks and/or switching to AD with similar MOA

what is a taper, stop, switch? when is it recommended

gradually taper 1st AD, start new AD immediately after d/c. Recommended if 1st AD >6wks

what is a taper, stop, washout, switch

gradually taper 1st AD, start new AD after washout period

what is a cross taper

add on new AD and taper up, when at lowest effective dose then decrease dose of first AD usually takes 1-2 weeks or longer

when is a washout period required in switching AD

when you have any switch involving a MAOi or RIMA

washout period from fluoxetine to RIMA or MAOi

5wks`

washout period from other SSRI to RIMA/MAOi

2wks

washout period from SNRI, NDRI, NaSSA, SARI, TCA to a RIMA or MAOi

1wk

washout from RIMA to any other AD

1-2d

washout period from MAOi to any other AD

2wks

if a pt stops AD due to unfortunate start, they have a ____ chance of relapse

2x higher

N/V from AD are due to

5HT receptors in GIT activated by SSR

which of the following is false 1. N/V from AD usually goes away in 1-2wks due to desensitization of 5HT3R 2. constipation from SSRIs is usually continuous 3. GI bleed from SSRIs is due to increased 5HT uptake by platelets, resulting in less clotting and more GI acid production 4. diarrhea from SNRIs are dose dependent and transient

3- DECREASED 5HT uptake by platelets

when does N/V stop from ADs

1-2wks

what increases risk of GI bleed from ADs, what decreases it?

↑RF with antiplatelets, anticoagulants, NSAIDs// ↓ R with PPIs

sleep changse from ADs usually resolve in

1-2wks

what are 3 more sedating ADs

mirtazapine and trazodone low dose, TCAs

what are 3 ADs that cause insomnia/ anxiety

bupropion, SSRIs, SNRIs

rank the following based on weight gain TCAS, SNRIs, SSRIs, mirtazapine

mirtazapine >TCAs >SSRIs >SNRIs

symptoms of serotonin syndrome usually start within ________ and resolves within ___________

24hrs of increased dose resolves in 24hrs after d/c

mild serotonin syndrome sx

HPTN, tachy, dilated pupils, sweating/ shivering, tremor/ myoclonus/ hyperreflexia, afebrile

mod serotonin syndrome sx

hyperthermia, hyperactive bowel sounds, ocular clonus, agitation, hypervigilance, pressured speech

severe serotonin syndrome sx

dramatic changes in pulse/ BP, delirium, muscle rigidity May result in complications + death

what are some sx of sexual dysfunction on AD

↓interest/ libido, ED or ↓ arousal (clitoris), ↓ ability to achieve orgasm (anorgasma)

does sexual dysfunction from AD improve over time?

what are some lower risk AD options for sexual dysfunction

bupropion (1st line), mirtazapine, moclobemide, vortioxetine, vilazodone

what are the 2 ADs that are most likely to cause sexual dysfunction

SSRIs (esp paroxetine) >SNRIs

treatment options for sexual dysfunction from ADs

adjunctive buproprion (for anorgasma) or PDE5i fro both sexes

when should you refer before starting an AD due to TdP risk

if prolonged QTc interval >500ms

which ADs are most associated with increased QTc interval

Citalopram/ escitalopram, TCAs, mirtazapine, venlafaxine

does prolonged Qtc interval resolve on its own

which AD cause HPTN? under what circumstances?

MAOi (HPTN crisis with tyramine foods), SNRI (esp venlafaxine), bupropion, mirtazapine

which AD are most likely to cause orthostatic hypotension

MAOi, TCAs, trazodone, buproprion

T or F: SSRIs can increase suicidality in adolescence

both,,, is associated with higher risk, but may just be because we're only giving them to the highest risk youth

list the 3 potent CYP2D6 inhibitors

paroxetine, fluoxetine, buproprion

what is a CYP 2C9, 2C19, and 3A4 inducer

st john's wort

st john's wort is a P-gp pump ____ 1. inhibitor 2. inducer

inducer- decreases effect by pumping out of brain

MAOi + serotonergic or sympathomimetic drugs = _____ risk

HPTN crisis

T or F: there is no single order set to cover AD regimens

T- depends on each therapy regimen

what is first line for childhood MDD

fluoxetine and SSRIs

what is second line for childhood MDD

escitalopram/ citalopram, sertraline

in childhood MDD, start at a low dose and increase after a minimum of ______, then once remission is achieved, treat for - _____ if no prev hx - _________ if hx of 2 or more MDE or 1severe/ chronic episode

min 4wks 6-12mths if no prev hx >1yr if hx

how long is maintenance tx for MDD in peripartum

6-12mths after remission, longer for higher risk

first and second line tx for perinatal depression

first: CBT, IPT second: citalo/escitalopram, sertraline

what are some SEs on the newborn from ADs

↓BW, Apgar score, gestational duration ↑cortisol lvls, spontaneous abortion, potential discontinuation sx

what type of ADs should be pref in breastfeedign

those with shorter half lives

what is considered late life depression

MDD in >60yrs old

how to screen for late life depression

using the Geriatric depression scale (GDS)

which of the following is false about late life depression 1. trials of AD must be for 10-12wks instead of the usual 2-4wks 2. outcomes are generally better 3. maintanence treatment may go on for longer than average 4. must use caution with antiACh agents

2- worse

MDD Flashcards

(98 cards)