25. Depression (87%) / Suicide (14%) Flashcards
La décision de prise en charge en hospitalisation ou suivi étroit dépend de quoi ?
- la sévérité des symptômes
- les caractéristiques psychotiques
- le risque suicidaire
Nommez les patients à risque élevé de dépression
- certains groupes socioéconomiques
- toxicomanie
- les femmes en post-partum
- douleur chronique
près avoir posé un diagnostic de dépression, recherchez et diagnostiquez les affections psychiatriques coexistantes.
Nommez des exemples.
- anxiété
- trouble bipolaire
- trouble de la personnalité
Chez les patients qui consultent pour dépression, informez-vous de la possibilité de quoi ? (2)
- Violence sexuelle, physique et psychologique (passée et actuelle, avec témoins ou infligée).
- Addiction (p. ex., usage ou abus de substances, problèmes de jeu)
Advenant l’échec du traitement approprié chez un patient déprimé, considérez d’autres diagnostics, comme quoi ? (3)
- trouble bipolaire
- trouble schizoaffectif
- maladie organique
Chez les patients très jeunes et âgés qui consultent pour un changement de comportement, envisagez le diagnostic de quoi ?
Dépression
Durant l’élaboration d’un plan de retour au travail pour un patient traité pour dépression, il faut faire quoi?
- Évaluez l’impact des symptômes résiduels sur la tolérance au travail, le rendement et la sécurité.
- Communiquez avec le patient et l’employeur pour vous assurer que le plan est réaliste et clair
Devant un patient suicidaire, il faut évaluer quoi ?
évaluez le degré de risque (p. ex., pensées, plans précis, accès à des moyens, impulsivité) afin de déterminer une intervention et un plan de suivi appropriés (COQ)
Chez les patients qui se sont automutilés (p. ex. coupures), il faut faire quoi?
- Évaluez le risque de suicide, mais ne présumez pas qu’il s’agit d’un geste suicidaire (les personnes qui se coupent ne sont pas toutes suicidaires, mais certaines d’entre elles le sont.)
- Explorez la détresse émotionnelle sous-jacente.
- Discutez d’autres stratégies d’adaptation.
Décrire plan pour les patients à faible risque de suicide que vous suivez dans la communauté (2)
- Fournissez des instructions précises pour le suivi
- Concevez un plan d’urgence approprié avec le patient en cas où les idées suicidaires augmenteraient.
Describe tx if : Persistent subthreshold depressive symptoms or mild-moderate depression
- CBT
- CCBT (computerized)
- structured group physical activity program
When to tx depression with pharmaco ? (4)
- Past history of moderate/severe depression
- Long period (>2y) of subthreshold depressive symptoms
- Persistent symptoms after other interventions
- Moderate/severe depression in combination with CBT or IPT
Name possible tx for depression with : Anxious feature (4)
- Mirtazapine
- paroxetine
- sertraline
- venlafaxine
Name possible tx for depression with : Catatonic features (1)
Benzodiazepines
Name possible tx for depression with : Cognitive dysfunction (4)
- Vortioxetine
- Bupropion
- Duloxetine
- SSRI
Name possible tx for depression with : Melancholic features (2)
- Paroxetine
- Venlafaxine
Name possible tx for depression with : Mixed features (1)
Luprasidone (Latuda)
Name possible tx for depression with : Peripartum onset (2)
- Fluoxetine in pregnancy
- Sertraline in breastfeeding
Name possible tx for depression with : Psychotic features (3)
ECT, Antipsychotic and antidepressant cotreatment)
Name possible tx for depression with : Seasonal pattern (1)
Luminothérapie
Name possible tx for depression with : Sleep disturbance (3)
- Mirtazapine
- Quetiapine
- Trazodone
Name possible tx for depression with : Somatic sx (2)
- Duloxetine for pain/energy,
- Bupropion for fatigue
Name psychiatric DDX for depression (8)
- Bipolar (≥1w of energy/activity with ≥3 GST PAID)
- Depressive disorder due to another medical condition
- Persistent Depressive Disorder (>2y of 2SIGECAPS, with no MDE)
- Adjustment disorder with depressed mood (stressor <3mo, resolves in <6mo)
- Grief reaction (loss, usually <3mo)
- Schizoaffective
- Anxiety
- ADHD
Name MEDICAL DDX for depression (8)
- Insuffisance surrénalienne, hypercortisolisme, hypothyroïdie,
- Mononucleosis,
- Sclérose en plaques, maladie de Huntington, maladie de Parkinson, lupus érythémateux disséminé
- Apnée du sommeil
- AVC, traumatisme crânien
- Vitamin B12 insufficiency
- Médicaments : corticostéroïdes, interféron, antirétroviraux
- Substance-induced
Name investigations for depression (9)
- CBC (anemia)
- Electrolytes (creat),
- TSH
- B12/folate
- Bilan lipidique
- B-hCG
- UA, urine toxicology
- EKG (QT)
- Neuroimaging if focal neurological sign or elderly
How to evaluate suicidal risk ?
- Sex (male)
- Age>60yo
- Depression
- Previous attempts
- Ethanol abuse
- Rational thinking loss (psychosis)
- Suicide in family
- Organize plan
- No spouse/support
- Serious illness/pain
Name questions to ask in suicide evaluation (5)
- Passive vs. Active ideation
- Plan (time/place), Intent (would you actually carry out this plan)
- Past Attempts (Practiced/Aborted)
- Access to means
- Provocative/Protective factors
If low risk of suicide, consider safety plan.
Describe possible safety plan. (5)
- Keep home environment safe (remove access to weapons)
- Recognize early warning signs
- Coming up with ways to cope personally with suicidal thoughts
- Identify people to contact for help/distraction
- Identify place to go to for safety (eg. hospital)
Consider framing depression as an ___ , rather than a disease, can lead to better patient outcomes
Adaptation
Describe lifestyle recommendations in depression
- Regular exercise, adequate food, housing, sleep
- Stress management (mindfulness-based stress reduction, engaging in ≥1 pleasurable activity per day)
- Avoiding substance abuse
How to choose antidepressant ? What to consider ?
Choose based on comorbid, previously used antidepressants, interactions
How to monitor depression ?
Use objective scales (eg. PHQ-9) to monitor improvement
* If >20% improvement at 2-4w continue treatment and reassess at 6-8w
* If <20% improvement at 2-4w -> Increase dose OR Switch to another medication OR Adjunct/Augment
When to adjunct/augment antidepressants ? What to use?
- If ≥ 2 antidepressant trials, well tolerated, partial response, specific symptoms to target, less time to wait (severe, functional impairment), patient preference)
- Consider Aripripazole, Quetiapine, Risperidone
- Other options may include lithium, thyroid hormone
How long to use antidepressants ?
- Maintenance until 6-9 months minimum after remission
- Consider 2y minimum especially if high risk (frequent/recurrent episodes, severe, chronic, comorbid, residual symptoms, difficult to treat)
What happens if you stop antidepressants abruntly ?
Antidepressant discontinuation syndrome (Syndrome d’arrêt des antidépresseurs)
Describe : Antidepressant discontinuation syndrome (Syndrome d’arrêt des antidépresseurs)
- Symptoms include FINISH (Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal)
- Typically resolves in 1-2 weeks
Name types of Neurostimulation
- Repetitive transcranial magnetic stimulation (rTMS) if failed ≥1 antidepressant
- ECT
When to consider ECT ? (4)
- if severe (active suicidal ideation), psychotic, treatment-resistant
- medication intoleranc
- catatonic feature
- rapidly deteriorating physical status (eg. malnutrition due to food refusal)
Name complementary tx to depression
- Light therapy (phototherapy)
- Acupuncture
- Sleep deprivation (total for 40h or partial allowing 3-4h of sleep per night, employed 2-4 times over one week)
- Natural health products
Describe phototherapy (2)
- 10,000 lux for 30 minutes per day during early morning up to 6 weeks (response usually within 3 weeks)
- Consider especially in seasonal, shift work, sleep dysregulation
Name natural health products that could be used in depression (4)
- St John’s Wort (care for medication interactions)
- Omega-3 fatty acids (3-9g/day) or 1-2g of EPA + 1-2g of DHA per day
- SAM-e
- Zinc
Describe tx of depression in Children/Adolescents
- First line : CBT/IPT or internet-based psychotherapy
- Second line : Fluoxetine (level 1 evidence) OR Escitalopram, sertraline, citalopram (level 2 evidence
Name tx for depressive sx in Perimenopausal (2)
- Desvenlafaxine (Pristiq)
- CBT
Name tx for late-life (> 60 yo) in depression
- Level 1 evidence: Duloxetine, mirtazapine, nortriptyline
- Level 2 evidence: Buproprion, citalopram/escitalopram, desvenlafaxine, sertraline, venlafaxine, vortioxetine
