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Clinical 2 (Part B) > 8 - Depression > Flashcards

8 - Depression Flashcards

1
Q

List the symptoms of depression

SPACE DIGS

A
  • Suicide
  • Psychomotor
  • Appetite/weight
  • Concentration decreased
  • Energy decreased
  • Depressed mood
  • Interest decreased (anhedonia)
  • Guilt/worthlessness
  • Sleep affected
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2
Q

What is the criteria for major depression ?

A
  • Presence of symptoms for > 2 weeks
  • At least 5 symptoms present; at least 1 depressed mood or loss of interest/pleasure
  • Symptoms occur nearly every day
  • Symptoms cause significant distress or impairment of functioning
  • Symptoms not due to bereavement or last > 2 months
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3
Q

What are some additional emotional symptoms?

A
  • Anxiety

- Irritability

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4
Q

What are some additional cognitive symptoms?

A
  • Decreased concentration
  • Indecisiveness
  • Poor memory
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5
Q

What are some additional psychotic symptoms?

A
  • Bizarre behavior
  • Hallucination
  • Delusions
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6
Q

What are some additional physical symptoms?

A
  • Somatic complaints
  • Fatigue
  • Decreased libido
  • Decreased hygiene
  • Crying spells
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7
Q

What are some secondary causes of depression ?

A

Medical disorders:

  • Thyroid disorder
  • Malignancy
  • Stroke
  • CHF/MI
  • Parkinson’s
  • MS
  • AIDS
  • TB

Psychiatric disorders:

  • Alcoholism
  • Schizophrenia
  • Anxiety
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8
Q

What are 4 non-pharms for depression ?

A

1) Cognitive behavioural therapy:
- Change distorted thinking
- Alteration of target thoughts
- Change erroneous assumptions
- Promote self control over thinking

2) Interpersonal
3) Bright Light therapy - for seasonal affective disorder
4) Exercise

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9
Q

Response

A

50% reduction in symptoms

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10
Q

Remission

A

symptoms go away

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11
Q

Recovery

A

remission (symptoms go away) lasting 6-12 months

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12
Q

Treatment goals of depression

A
  • shorten episode
  • decrease symptoms (want a response)
  • restore function
  • eliminate symptoms (remission)
  • prevent relapse
  • minimize adverse effects of treatment
  • minimize drug interactions
  • promote adherence to therapy
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13
Q

When is treatment urgent ?

A
  • severe depressive symptoms
  • severely impaired functioning
  • psychotic symptoms
  • suicidal
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14
Q

Describe the symptom response rate to Antidepressant treatment:

Anxiety, insomnia

A

few days

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15
Q

Describe the symptom response rate to Antidepressant treatment:

Energy, somatic symptoms

A

2-3 weeks

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16
Q

Describe the symptom response rate to Antidepressant treatment:

Sleep patterns

A

several weeks

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17
Q

Describe the symptom response rate to Antidepressant treatment:

Depressed mood, sexual dysfunction

A

4 weeks

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18
Q

Can starting antidepressants make someone suicidal and want to harm themselves?

A

**POSSIBLY

Antidepressants can cause adverse effects. They are called agitation-type adverse events that can be coupled with self-harm or harm to others.

We should monitor them every 2 weeks within starting therapy to make sure that they are okay and not getting more irritable and making suicidal or harmful plans.

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19
Q

What are some neurotransmitters ?

A
  • Norepinephrine
  • Serotonin
  • Dopamine
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20
Q

Depression is a ______ in neurotransmitters.

A

decrease

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21
Q

Depression has an ______ number of receptors (upregulation).

A

enhanced

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22
Q

Antidepressants ________ neurotransmitters available at the receptor

A

increase

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23
Q

MOA of SSRIs

*selective serotonin reuptake inhibitors

A

increase serotonin by inhibiting the reuptake of serotonin

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24
Q

MOA or SNRIs

*selective serotonin and NE reuptake inhibitors

A

increase serotonin and NE by inhibiting the reuptake of serotonin and NE

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25
Q

MOA of NDRI’s

*norepinephrine and dopamine reuptake inhibitors

A

increase NE and dopamine by inhibiting the reuptake of NE and dopamine

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26
Q

MOA of NaSSA’s

*Noradrenergic and specific serotonergic antidepressant

A

increase serotonin and NE

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27
Q

MOA of TCA’s

*tricyclic antidepressants

A

increase serotonin and NE

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28
Q

MOA of MAOi’s

*monoamine oxidase inhibitors

A

increase serotonin, NE and dopamine

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29
Q

MOA of RIMA

*reversible inhibitor of monoamine oxidase

A

increase serotonin, NE and dopamine

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30
Q

Why do anti-depressants take 4-6 weeks to work ?

A

Because we are altering neurotransmitters and that takes a long time

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31
Q

What is the 1st line option for antidepressants for an uncomplicated, physically healthy outpatient without any CI to a specific class of antidepressants?

A

SSRI (the choice of which one depends on multiple factors)

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32
Q

What do you do if a patient responds to SSRI or has remission?

A

Maintain for at least 4-9 months for continuation and if necessary, 12-36 months for maintenance

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33
Q

What do you do if patient has partial response to SSRI (after maximizing dose) ?

A

Consider augmentation

-(non-SSRI antidepressant, lithium, thyroid hormone, atypical antipsychotic)
OR
-switch to alternative agent (different SSRI or non-SSRI antidepressant)

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34
Q

If they have a failed trial after switching, what do you do?

A

Switch to another agent (non-SSRI antidepressant)

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35
Q

If they have a partial response (after maximizing dose) after switching, what do you do?

A

consider augmentation (non-SSRI antidepressant, lithium, thyroid hormone, atypical antipsychotic)

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36
Q

What is the FIRST THING you do if patient fails trial of SSRI due to nonresponse of limiting adverse effect?

A

ENSURE MEDICATION ADHERENCE

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37
Q

If patient fails trial of SSRI due to nonresponse of limiting adverse effect, and after ensuring medication adherence, what is the next step ?

A

switch to alternative agent (different SSRI or non-SSRI antidepressant)

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38
Q

List some combination therapies that are possible

A
  • Venlafaxine and buproprion
  • SSRI and buproprion
  • SSRI and TCA

-TCA and MAOi (very cautiously !!)

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39
Q

What combo is NEVER EVER EVER allowed ?

A

SSRI and MAOi

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40
Q

What are types of augmentation treatment?

A
  • T4
  • T3
  • VPA
  • Atypical antipsychotics
  • Lithium
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41
Q

How long is treatment usually?

A

4-9 months after remission

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42
Q

Who gets lifelong treatment?

A

<40 and had 2+ episodes

any age and had 3+ epidoes

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43
Q

What is poop-out syndrome? How common is it?

A

Some drugs lose effectiveness over time and may require a switch or add-on therapy

20-30% at 18 months

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44
Q

Who are candidates for ECT (electroconvulsive treatment) ?

A
  • rapid response (suicidal, psychotic)
  • history of poor response to meds
  • pregnancy
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45
Q

What is ECT ?

A

It’s like a shock to the system. Just enough to elicit a seizure and kind of reset the neurotransmitters. Can come out of depression really quickly but can also relapse quickly so require maintenance therapy

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46
Q

Describe the course of ECT

A
  • 6-12 treatments
  • Unilateral or bilateral
  • 2-3 times weekly
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47
Q

What are some adverse effects of ECT ?

A
  • confusion
  • memory loss months pre and post ECT
  • CV dysfunction
  • headache
  • nausea
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48
Q

What are some factors that affect the choice of antidepressant ?

A
  • Past Hx
  • Family Hx
  • Subtype of depression (ex. if it’s seasonal, look at bright light therapy)
  • Medication Hx, concurrent meds
  • Potential for drug interactions
  • SE profile
  • Cost
  • Mechanism of antidepressant action
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49
Q

List examples of SSRI’s

A
  • fluoxetine
  • sertraline
  • paroxetine
  • fluxoamine
  • citalopram
  • escitalopram

“Ine’s and Pram’s”

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50
Q

SSRI’s:

Advantages?

A

Decreased side effect profile vs. TCA’s

-lack alpha1, M1, and H1 effects

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51
Q

SSRI’s:

What are some serotonin type adverse effects ?

A
  • activating effects: agitation, nervousness, restlessness
  • insomnia/drowsiness (paroxetine, fluvoxamine)
  • GI effects initially
  • weight gain (less than TCA’s)
  • initial loss then gain in some
  • sexual dysfunction (60%)

*LOTS OF DRUG INTERACTIONS WITH SSRI’S

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52
Q

SSRI’s:

What are some toxic effects?

A
  • tremor
  • sinus tachycardia
  • N/V/D
  • obtundation (less than full alertness)
  • seizures
  • serotonin syndrome
  • mild bradycardia
  • increase in vagal tone ?
53
Q

SSRI’s:

What is the treatment for toxic effects?

A

charcoal + supportive care

54
Q

SSRI’s:

Describe the symptoms of serotonin syndrome

A

1) Cognitive/behavioural:
- agitation
- mental status changes
- confusion, hypomania

2) Autonomic dysfunction:
- diaphoresis
- diarrhea
- fever
- shivering

3) Neuromuscular abnormalities
- Incoordination tremor
- Myoclonus (jerky muscle movements)
- Hyperreflexia

55
Q

What are some of the drugs that can cause serotonin syndrome ?

A

1) Drugs that inhibit breakdown of 5-HT:
- MAOi

2) Drugs that block reuptake of 5-HT:
- SSRI
- Clomipramine
- Dextromethorphan
- Meperidine
- Cocaine
- Venlafaxine
- Trazodone
- Pentazocine

3) Drugs that are 5-HT precursors or agonists:
- Lithium
- Buspirone
- Psilocybin
- L-tryptophan
- LSD

4) Drugs that enhance 5-HT release
- MDMA (ecstasy)

56
Q

How do you treat serotonin syndrome?

A
  • Supportive care (d/c agent and it should resolve)
  • Benzos to treat neuromuscular symptoms
  • Tylenol and cooling blankets to treat increased temp
  • Dantrolene for severe rigidity
  • Cyproheptadine, serotonin antagonists for severe symptoms
  • watch anticholinergic and antihistaminic properties
57
Q

What are some risks for serotonin syndrome?

A

Additive serotonin effects:

  • PK interaction
  • dosage of drug
  • amount and duration of 5-HT response
  • ability of drug to cross BBB
58
Q

What is a washout period ?

A

The time between stopping a drug and starting another.

Allows time for first drug to be cleared before administering the second drug to avoid “carry over” or “over lap”

59
Q

Onset of serotonin syndrome?

A

Rapid (2-72 hours)

60
Q

Describe the ‘FINISH’ pneumonic for SSRI withdrawal symptoms

A
  • Flu-like symptoms
  • Insomnia
  • Nausea
  • Imbalance
  • Sensory disturbance (parenthesis, electric shock, visual)
  • Hyperarousal
61
Q

When do SSRI withdrawal symptoms occur and how long do they last ?

A

-within 1-3 days (up to 1 week)

  • lasts up to 7-14 days (may be several weeks)
  • depends on half life, dose, active metabolites and Act effects
62
Q

What is the treatment for SSRI withdrawal symptoms ?

A
  • Prevent with gradual tapering
  • If appears - increase dose and taper more slowly
  • If severe - switch to fluoxetine !
63
Q

Why do we not usually use fluoxetine in adults? Why do we use it in children?

A
  • Don’t usually use in a adults because it has a really long half life and takes longer to start and stop
  • Use in children bc we have more data in children
64
Q

What drugs can increase SSRI levels?

A
  • Divalproex increases fluoxetine levels
  • Cimetidine increases sertraline and paroxetine levels
  • Clarithromycin increases fluoxetine levels
  • Grapefruit juice increases fluvoxamine and sertraline levels
65
Q

List examples of SNRI’s (there are only 2)

A
  • Venlafaxine

- Duloxetine

66
Q

Adverse effects of venlafaxine ?

A
  • blood pressure increases
  • dose related GI side effects and dizziness
  • sexual dysfunction
  • dry mouth, constipation
67
Q

List example of NDRI (there is only 1)

A

Bupropion

68
Q

D/c bupropion 2 days prior to ____

A

ECT

69
Q

Drug interactions with bupropion ?

A
  • Bupropion increases concentration of imipramine and desipramine
  • Bupropion conc decreases when taken with carbamazepine
70
Q

Adverse effects of bupropion ?

A
  • agitation, restlessness, anxiety, tremor, insomnia
  • seizures @ high dosages
  • dry mouth, headache, N&V, constipation, tremor, rash
71
Q

Advantages of bupropion ?

A
  • little sexual dysfunction

- little weight gain

72
Q

Why does bupropion not cause sexual dysfunction?

A

*sexual dysfunction is associated with serotonin and this is an NDRI

73
Q

List an example of NaSSA (there is only 1)

A

Mirtazapine

74
Q

What receptors does a NaSSA bind to and what affect do they have?

A
  • 5-HT (2A, 2C, and 3)
  • Histamine 1
  • Alpha 2
  • it enhances release of NE and 5-HT
  • it blocks 5-HT 2A and 2C to minimize anxiety, insomnia, and sexual dysfunction
  • blocking histamine causes weight gain and sedation
  • anticholinergic (dry mouth, constipation)
75
Q

Advantages of Mirtazapine?

A
  • Little sexual dysfucntion

- Less serotonergic effects

76
Q

What receptors does a TCA bind to and what affect do they have?

A
  • NRI
  • SRI
  • alpha
  • Histamine 1
  • Muscarinic 1
  • blocks serotonin and NE reuptake
  • blocks histamine, muscarinic and alpha adrenergic receptors
77
Q

TCA’s:

In usual doses, cardiac effects include ?

A
  • HTN, tachycardias
  • slowed cardiac conduction
  • antiarrhythmic properties
  • orthostatic hypotension
78
Q

TCA’s:

Who are high risk patients for cardiac effects?

A
  • elderly
  • CV disease
  • Drug interactions: increased levels
  • Overdose cases
79
Q

TCA’s:

List examples of Tricyclic Tertiary amines

A
  • Amitriptyline
  • Imipramine
  • Clomipramine
80
Q

TCA’s:

List examples of Tricyclic Secondary amines

A
  • Desipramine

- Nortriptyline

81
Q

TCA’s:

What are some central anticholinergic effects ?

A
  • agitation
  • hallucinations
  • confusion
  • sedation
  • coma
  • seizures
82
Q

TCA’s:

What are some peripheral anticholinergic effects?

A
  • hypertension
  • tachycardia
  • hyperthermia
  • mydriasis
  • dry, flushed skin
  • decreased GI motility
  • urinary retention
83
Q

TCA’s:

What are some antihistaminic effects?

A
  • sedation

- weight gain

84
Q

TCA’s:

What are some alpha adrenergic effects?

A

-Orthostatic hypotension

85
Q

TCA’s:

What are some Toxic Effects in Overdose ?

A

CV:

  • intraventricular conduction delay
  • sinus tachycardia
  • ventricular arrhythmias
  • hypotension

CNS:

  • coma
  • delerium
  • myoclonus
  • seizures

Other:

  • hyperthermia
  • ileus
  • urinary retention
86
Q

TCA’s:

What is the withdrawal syndrome due to?

A

cholinergic and adrenergic rebound

87
Q

TCA’s:

What are the symptoms of withdrawal?

A

Dizziness, nausea, diarrhea, anxiety, insomnia, restlessness, diaphoresis, hot or cold flashes, delirium, mania

Taper over 2-4 weeks

88
Q

TCA’s:

Treatment for withdrawal symptoms ?

A
  • Restart at low dosage

- Anticholinergic agent

89
Q

Washout period is required for which antidepressant?

A

MAOi

Exception: add to TCA with caution

90
Q

How long should the washout period be for:

Antidepressant to MAOi

A

5 half lives of the antidepressant

91
Q

How long should the washout period be for:

MAOi to Antidepressant

A

10-14 days

92
Q

Cheese has a lot of _____

A

tyramine

93
Q

Describe the Cheese Reaction

A

Hypertensive crisis:

  • indirect acting amines
  • directa chino do not require MAO for their metabolism
  • catabolized by COMT

Tyramine - major dietary amine - indirect acting aognist

  • Peripheral effects (does not cross BBB)
  • Causes NE release from peripheral noradergic neurons
94
Q

What foods should you avoid if on MAOi?

A
  • cheese
  • alcohol
  • fish
  • meat (fermented/aged, salami)
  • fruit (spoiled or overripe banana peels)
  • yeasts
  • sauerkraut
  • beans
95
Q

When are MAOi’s indicated?

A
  • atypical depression

- resistant depression

96
Q

What are adverse effects?

A
  • orthostatic hypotension
  • dry mouth
  • constipation
  • sexual side effects (impotence, increased libido)
  • insomnia
  • sedation
97
Q

Drug interactions with MAOi’s can cause _____ ______

A

serotonin syndrome

98
Q

MAOi’s: Watch OTCs and herbals such as ?

A

-dextromethorphan, appetite suppressants, decongestants, tryptophan, St. John’s Wort

99
Q

Give an example of a RIMA (there is only 1)

*reverse inhibitor of MAO-A

A

Moclobemide

100
Q

SE of Moclobemide

A
  • HTN
  • tachycardia
  • orthostatic hypotension
  • insomnia, headache
  • stimulating
101
Q

St. John’s wort used for ____ to ______ depression (level 1 evidence for first line use)

A

mild to moderate

*not effective for severe depression

102
Q

Adverse effects of St. John’s Wort

A

serotonin syndrome, hypomania

103
Q

List 3 other possible OTC antidepressants

A
  • crocus sativus
  • SAM-e
  • omega 3 fatty acids
104
Q

see slide 64/65 for Washout recommendations

A

ok

105
Q

What antidepressants should you avoid in seizure disorders?

A
  • bupropion

- TCAs

106
Q

What antidepressants should you avoid if concerned about sexual dysfunction ?

A
  • SSRI’s
  • Venlafaxine
  • TCA’s
  • MAOi’s
107
Q

Why don’t we use trazodone as an antidepressant?

A

It is super sedating!

108
Q

What antidepressants should you avoid if you’re concerned about weight gain?

A
  • TCA’s
  • MAOi’s
  • Mirtazapine
109
Q

_____ should get lower initial dosages

A

Eldelry

110
Q

What do we need to evaluate elderly for?

A

orthostatic hypotension

cognition

111
Q

Which antidepressants will cause excessive sedation?

A

TCA’s, trazodone, mirtazapine

112
Q

What antidepressants will cause urinary retention (anticholinergic) ?

A

TCA’s, mirtazapine

113
Q

Cardiac patients:

_____ will increase BP with increased dose

A

venlafaxine

114
Q

Cardiac patients:

______ effect of certain antidepressants will increase HR

A

anticholinergic

115
Q

Cardiac patients:

Caution _____ in those with arrhythmias

A

TCAs

116
Q

Cardiac patients:

Rare bradycardia with ______

A

SSRI’s

117
Q

Cardiac patients:

_____ have been seen in overdose with venlafaxine

A

arrhythmias

118
Q

In _____, we need to weigh the risks vs benefits

A

Pregnancy

119
Q

Pregnancy:

Most evidence for safety of ________, and then _____.

A

Fluoxetine, TCA’s

120
Q

Pregnancy:

Can you use ECT ?

A

yes

121
Q

Pregnancy:

How do you handle depression after delivery?

A
  • Watch for direct drug effects and transient withdrawal symptoms in infants
  • No long term neurodevelopment effects
122
Q

Breastfeeding:

Which ones have evidence?

A

paroxetime, sertraline, fluoxetine, clomipramine, and notriptyline

*monitor infant daily

123
Q

Children:

What is first line for moderate to severe depression?

A

fluoxetine, citalopram

124
Q

Children:

What is second line for moderate to severe depression?

A

other SSRI’s (paroxetine > adverse effects)

125
Q

Children:

What is third line for moderate to severe depression?

A

venlafaxine

126
Q

Children:

What therapy provides the best outcome ?

A

combining CBT with antidepressant

127
Q

Children:

___ not recommended

A

TCA’s

128
Q

Children:

Continue tx if effective for 6 months, gradually d/c over __ weeks

A

6

129
Q

Children:

What 4 things do parents need to think about when their child is prescribed an antidepressant ?

A

1) There is a risk of suicidal thoughts or actions
2) How to try to prevent suicidal thoughts or actions in your child
3) You should watch for certain signs if your child is taking an antidepressant
4) There are benefits and risks when using antidepressants

Clinical 2 (Part B) (30 decks)

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