Module

Question 1

what est % of diagnosed depressed pts reported unexplained physical symptoms as their chief complaint?

Answer 1

69%

Question 2

which pts have poorer outcomes than those without depression?

Answer 2

pts with diabetes, ischemic heart disease, stroke, or lung disorders

Question 3

what % of pts with severe mood disorders die from suicide?

Answer 3

15%, one study showed 20% visited their PCP the same day they committed suicide

Question 4

what is the risk of having depression if pts first degree relative has recurrent major depression?

Answer 4

1.5-3 times higher
27% of children with one parent with a mod disorder will develop the disorder themselves, and 50-75% if both parents are affected

Question 5

what is mood?

Answer 5

a range of emotions that a person feels over a period of time

Question 6

what is affect?

Answer 6

how a person displays his or her mood

Question 7

what is pseudodementia?

Answer 7

severe cognitive impairment due to depression

Question 8

when should depression screening be highly considered?

Answer 8

pts with:
personal previous history of depression or bipolar disorder, first degree biologic relative with history of depression or bipolar disorders, chronic dz, obesity, chronic pain, impoverished home environment, financial strain, experiencing major life changes, pregnant or postpartum, socially isolated, multiple vague and unexplained symptoms, fatigue or sleep disturbance, substance abuse, loss of interest in sexual activity, elderly age

Question 9

what is the USPSTF recommendation on screening for depression?

Answer 9

screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow up is recommended
-without access to these resources there is fair evidence that the screening will not improve outcomes

Question 10

what is lack of improvement in depression most related to?

Answer 10

lack of treatment NOT insufficient case identification

Question 11

what are some of the formal screening tools available?

Answer 11

Zung self assessment depression scale, Beck depression inventory, General Health Questionnaire, Center for epidiologic study depression scale and the patient health questionaire (PHQ2) the USPSTF does not recommend one screening test over another

Question 12

what PHQ9 score is needed for diagnosing depression?

Answer 12

> 10, 88% sensitivity and 88% specificity

Question 13

what is the DSM IV criteria for Major Depressive Episode?

Answer 13

at least 5 of the following symptoms present in a two week period nearly everyday and an impairment, one of them must be anhedonia or depressed mood 
P: psychomotor retardation or agitation
W:worthlessness 
A: Anhedonia
D: Depression
C: Concentration 
A: Appetite
F: fatigue
S: suicidality 
S: sleep
symptoms not accounted for by a mood disorder due to a general medical condition, substance induced mood disorder or bereavement 
and are not accounted for by a psychotic disorder

Question 14

What types of special features can be associated with a major depressive episode?

Answer 14

melancholic, psychotic, or atypical

Question 15

how will patients with depression with melancholic features present?

Answer 15

mainly anhedonia, must have three of the following: diurnal variation (depression worse in the morning), pervasive and irremediable depressed mood, marked psychomotor retardation or agitation, significant weight loss or anorexia, excessive or inappropriate guilt and early morning awakening
-have the best response to pharmacotherapy

Question 16

What do depressed pts with psychotic features typically have?

Answer 16

hallucinations and delusions

• very high risk for suicide even if they deny suicidal ideation
• should be hospitalized immediately

Question 17

what do atpical depressed pts exhibit?

Answer 17

milder depressed symptoms, must experience mood reactivity and two of the following: leaden paralysis (enormous effort to walk or exert, hypersomnia, rejection hypersensitivity, overeating or weight gain
-respond less to tricyclic antidepressants

Question 18

what initial lab testing might be helpful when first evaluating a pt for depression?

Answer 18

TSH, CBC, and chem panel

Question 19

what prescription drugs can casue substance induced depresion?

Answer 19

blood pressure meds (reserpine, propanolol, anticholinergics, steroids, oral contraceptives, psychotropic medications and antieoplastic drugs

Question 20

what is dysthymic disorder?

Answer 20

chronic form of depression, signs and symptoms are milder but can cause much distress and dysfucntion, more chronic an dunremitting, less responsive to pharmacotherapy

Question 21

what is the DSM IV criteria for dysthymic disorder?

Answer 21

depressed mood for most of the day for more days than not, for at least two years (kids and adolescentas 1 year)
with:
A: poor appetite or overeating
S:sleep-insomnia or hypersomnia
F:fatigue
S:low self esteem
C: poor concentration
H:hopelessness
-never without symptoms for more than two months at a time
not MDE present during first two years of disturbance,
-never been a manic, mixed episode or hypomanic episode, and not cyclothymic, does not occur during the course of a chronic psychotic disorder like schizo or delusional,
-not due to a durg or medical condition
-must cause significant distress or impairment in social, occupational or other importnat areas of functioning

Question 22

when should bereavement resolve?

Answer 22

usually resolve within 2 months (do not require pharmacotherapy) but if persist major depression should be considered

Question 23

what is adjustment disorder with depressed mood?

Answer 23

pt has depressive symptoms or complaints within 3 months of an identifiable psychosocial stressor, stressors may include academic failure, job loss, or divroce, the stressor causes depressed symptoms that do not meet the criteria for major depression or dysthymic disorder
treatment is psychotherapy over pharmacologic

Question 24

what are seasonal affective disorders?

Answer 24

major depressive episodes that have a seasonal pattern

• dx not made if there is a clear psychosocial stressor related to the change in season
• respond to standard antidepressants and psychotherapy

Question 25

what is poor neonatal adaptation?

Answer 25

irritability, tachypnea, hypoglycemia, thermal instability, and weak or absent cry usually mild and transient lasting no more than two weeks, caused by use of SSRIs in thid trimester

Question 26

what are the agents of choice in treating pregnant pts with depression?

Answer 26

SSRIs, or psychotherapy if mild/.moderate sx paroxetine use in first trimester may increase risk for congenital malformations particularly cardiac -mood stabilizers (phenytoin, VPA, carbamazepine are teratogenic

Question 27

which pts recommended to remain on their medication through pregnancy?

Answer 27

bipolar, suicide attempts, recurrent MDD, or psychotic disorders

Question 28

what is postpartum depression?

Answer 28

occurs within one month of giving birth can begin as soon as 24 hrs post delivery

Question 29

what are some risk factors for depression in elderly adults?

Answer 29

history of depression, chronic medical illness, male sex, being single or divorced, brain disease, alcohol abuse, use of certain medications and stressful life events

Question 30

what are common complaints in elderly patients

Answer 30

insomnia, anorexia, and fatigue | -SSRIs can be useful

Question 31

which pts are at higher risk for developing chronic and recurring depression?

Answer 31

pts who are elderly wehn they have their first episode of depression and young -it may take longer to achieve remission in older pts

Question 32

what are the symptoms of pseudodementia?

Answer 32

marked psychological distress, inability to concentrate or complete daily tasks, marked cognitive dysfunction - usually exhibit profound concern about their impaired cognitive dysfunction - pts with dementia tend to minimize their disability

Question 33

what is a manic mood characterized by? hypomania?

Answer 33

irritability or abnormal euphoria, hypomania is a lesser degree of mania that lasts for a shorter duration, usually can contiue on with normal life and do not require hospitalization

Question 34

what is the DSM IV criteria for a manic episode?

Answer 34

distinct period of abnormally and persistently elevated, expansive, or ittitable mood lasting 1 week, during the period 3 or more persist: -grandiosity, inflated self esteem -decressed need for sleep -more talkative -flight of ideas -distractibility -excessive involement in pleasurable activites taht have a high potential for painful consequences -increase in goal oriented activity *symptoms must not meet the criteria for a mixed episode, *mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activites or relationhips with other, or to necessitate hospitalizaion *not due to a substance of a medical condition

Question 35

what is the DSM IV criteria for a hypomanic episode?

Answer 35

distinct period of elecated, expansive or irritable mood lasting at least 4 days that is clearly different form the usual non depressed mood during the 4 days, 3+ have persisted -graniosity, inflated self esteem -decreased need for sleep -more talkative -flight of ideas -distractibility -increase in goal directed activity -excessive involement in pleasureable activites that have a high potential for consequences *change in fxn *observable by others *not severe enough to cause marked impairment or not needing hospitalization *not due to another substance or medical condition

Question 36

which antidepressants are more lethal in overdose?

Answer 36

tricyclics (cardiotoxicity, convulsions) | -risk of suicide in all pts who are recovering from major depression may increase during initial treatment

Question 37

which antidepressant is used in children and adolescents?

Answer 37

fluoxetine (SSRIs)

Question 38

what is the average risk of suicide in general with antidepressants? with placebo?

Answer 38

antidepressants 4% | placebo 2%

Question 39

what are the steps in planning a treatment regimen for a pt?

Answer 39

1. perform a diagnostic evaluation to determine if the diagnosis of depression is warranted or it other psychiatric or medical conditions exist 2. evaluate for the safety of the pt and of others* 3. evaluate functional impairment (relationships, work, living conditions, health and medical related needs) 4. determine a treatment setting (safest and most effective) 5. establish and maintain a therapeutic alliance 6. continue to montior the patient's psychiatric status and safety 7. provide patient education and, it appropritae to the pts family 8. enhance treatment adherence 9. work with the pt to address early signs of relapse

Question 40

what is a contraindication for tricyclic antidepressant use?

Answer 40

cardiac disease | block H1 receptors, block parasympathetic cause tachycardia, urinary retention, dry mouth

Question 41

what are the three phases of treatment?

Answer 41

acute phase: remission is induced (min 6-8 weeks) continuation phase: remission is preserved and relapse prevented (usually 16-20 weeks in duration) maintenance phase: susceptible patients are protected against recurrence or relapse of subsequent major depressive episodes (duration varies with frequency (duration varies with frequency and severity of previous episodes)

Question 42

what is remission?

Answer 42

return to the pts baseline level of symptom severity and runctioning

Question 43

what is relapse?

Answer 43

the re-emergence of significant depressive symptoms or dysfunction after remission has been achieved

Question 44

what is the goal of the acute phase of treatment?

Answer 44

to induce remission

Question 45

what should initial therapy be?>

Answer 45

pharmaco therapy or pharmacotherapy and psychotherapy

Question 46

when should pts be seen after starting antidepressants?

Answer 46

within 1-2 weeks for re assessment

Question 47

when is readjustment of meds considered?

Answer 47

if after the initial 4-8 week trial ther eis not a moderate im provement in baseline symptoms in the acute phase, medication can be increased, if after another 4-8 weeks there is still no moderate improvement of symptoms another review should occur

Question 48

what dose is used in the continuation phase?

Answer 48

same dose in the acute phase that achieved remission

Question 49

how often should a pt be seen in the continuation phase?

Answer 49

once every 2-3 months if stable, can vary though | if in active psychotherapy may be seen several times a week

Question 50

who can be considered candidates for discontinuation of treatment?

Answer 50

pts who remain stable throughout the continuation phase and who ar enot candidates for the maintainence phase (eg recurrent relapsing chronic depression)

Question 51

what is the minumim total length in treatment of an uncomplicated pt for their first MDE?

Answer 51

6 months (6 weeks acute 16-20 weeks continuation)

Question 52

what % of pts with a single MDE will have another?

Answer 52

50-85%

Question 53

what is the goal of maintenance treatment>

Answer 53

to prevent relapse

Question 54

what treatment should be used in the maintenance phase?

Answer 54

same treatment that was effective in the acute and continuation phase, optimal length unknown

Question 55

what are the factors that should be considered when deciding if pt can dc treatment?

Answer 55

frequency and severerity of recurrent episodes, dysthymic symptoms between episodes, the presence of other psychiatric disorders, the presence of chronic general medical disorders or patient preference

Question 56

how should maintenance pharmacotherapy be discontinued?

Answer 56

tapered over several weeks

Question 57

what are discontinuation syndromes?

Answer 57

mood disturbances, sleep, energy, appetite appear like relapses but due to lack of tapering medications -more likely in short acting medications

Question 58

which is the most effective medication for depression?

Answer 58

all classes are equally effective

Question 59

what is the general order of use of antidepressants?

Answer 59

1. SSRIs 2. dual action reuptake inhibitors venlafaxine, buproprion 3. tricyclics 4. MAOis

Question 60

which antidepressants may be more effective in severe depression or depression with melancholic features?

Answer 60

TCAs and NRIs or depression that has predominant physical symptoms or pain - have cardiac conduction effects contraindications: cardiac effects, BPH, urinary retention and closed angle glaucoma

Question 61

how do venlafaxine, milnacipran and duloxetine work?

Answer 61

serotonin-NE reuptake inhibitors | -less cardiac effects

Question 62

which antidepressants are useful in treating chronic pain and diabetic neuropathy?

Answer 62

duloxetine and paroxetine

Question 63

what is buproprion?

Answer 63

inhibits NE and dopamine but not serotonin - less diarrhea, nausea, somnolescence and sexual side effects - can be used in smoking cessation

Question 64

How do MAOIs work?

Answer 64

nonselectively block Mao A and B isoenzymes | -need to adhere to a low tyramine diet to prevent HTN crisis

Question 65

which class of sntidepressants are used for atypical depression?

Answer 65

MAOis | atypical: extremem fatigue, sensitivity to rejection, troubled relationhips, mood reactivity

Question 66

what is nefazodone?

Answer 66

blocks 5HT receptors, efficacy similar to SSRIs and tends to be sedating

Question 67

what is mirtazapine?

Answer 67

adrenergiv receptor, specific serotonin receptors and histamine recetprs to enhance NE in synaptic cleft. wight gain, sedating

Question 68

what are some of the adjunct medicaiton?

Answer 68

lithium-mood stabilizer, can prevent manic and depressive edpisodes in bipolar pateitns, -antipsychotic

Question 69

what is used to treat anxiety and depression?

Answer 69

SSRIs (anxiety initially worsened) and benzos - improve antidepressant response but can cause sedation, memory loss and dependence and withdrawal syndromes - be careful in those with alcohol abuse, older pts who cant metabolize well,

Question 70

when is psychotherapy considered for first line?

Answer 70

for mild depression, particulary if associated with psychosocial stress, interpersonal problems, or with concurrent development or personality disorders

Question 71

when is psychotherapy most effective?

Answer 71

in the acute phase of treatment, and in preventing relapse during continuation phase

Question 72

what are the most effective forms of psychotherapy?

Answer 72

those with structured and brief approaches-CBT, interpersonal therapy, certain problem solving therapies

Question 73

what is cognitive behavioral therapy CBT?

Answer 73

targets thoughts and behaviors that need to be changed, goal to recognize what triggers certain thoughts and behaviors and to alter routines through direction and action - teach pts to substitute healthy thoughts for negative ones-behaviour change is the primary goal with internal change as the byproduct - emphasis on present rather than on past

Question 74

what is interpersonal therapy?

Answer 74

based on belief that depression is caused by problems in important interpersonal relationships, - compiling an interpersonal history examining all of the pts relationships - pts taught to identify and deliberately tolerate feelings - does not involve formal homework like CBT

Question 75

what is problem solving therapy?

Answer 75

brief, focused form of cognitive therapy that focuses on the problems a person is currently facing and on helping to find solutions to these problems -link between poor problem solving abilities and the etiology and maintenance of psychological disorders -can change ones situation with oneself of changing ones reaction to something -individuals are taught to identify, discover and invent effective responses for specific problematic situations provide tools on how to effectively manage life's stress in order to decrease distress, enhance sense of control and improve quality of life -can be in group or individual sessions

Question 76

when is electroconvulsive therapy considered first line?

Answer 76

in severe depression with psychotic features, psychomotor retardation or resistance to medications -suicidal and pregnant pts may have rapid benefits from ECT

Question 77

how is ECT used? Is it effective?

Answer 77

6-12 treatments 2-3 times a weeek remission rates around 60-80 % in severe major depressive disorders relapse rate more than 50% -most start prophylactic treatment with antidepressants and adjuvants medications like lithium

Question 78

is St Johns wart effective?

Answer 78

not effective in treatment of major depression unknown if effective when used in combination therapy -contraindicated in HIV pts taking antiretroviral therapy

Question 79

what do most pts suffering form depression complain of?

Answer 79

anhedonia or vague unexplained symptoms

Question 80

when does having a first major depression episode usually lead to higher lieklihood of developing chronic and recurring depression?

Answer 80

pts who are older higher chance of having chronic and recurring depression

Question 81

who has a better prognosis for recovery old or young adults?

Answer 81

same, but older pts may take longer to achieve remission (elderly usually start at lower doses)

Question 82

what situations require referral to psychiatrist?

Answer 82

suicide risk, bipolar disorder or manic episode, psytchotic symptoms, severe decrease in level of functioning, recurrent depression and chronic depression, depression that is refratory to treatment, cardiac diease taht requires TACs, need for ECT lack of available support system and any diagnostic or treatment questions

Question 83

when is psychotherapy condisered for first line?

Answer 83

in mild depression , or in mild to moderate--> most effective in the acute phase and in presenting relapse during the continuation phase,

Question 84

what do PHQ 9 scores mean?

Answer 84

1-4 minimal depression