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4. Mood Disorders > CANMAT Guidelines: Depression (+trials + DSM general section) > Flashcards

CANMAT Guidelines: Depression (+trials + DSM general section) Flashcards

1
Q

list the possible depressive disorders in the DSM

A

DMDD

MDD/MDE

PDD

premenstrual dysphoric disorder (PMDD)

sub/med induced

due to another medical condition

other/unspecified depressive disorders

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2
Q

what is the common feature in the depressive disorders? what differs between them?

A

sad, empty or irritable mood accompanied by somatic and cognitive changes that significantly affect the individuals capacity to function

what differs is issues of duration, timing or presumed etiology

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3
Q

why was disruptive mood regulation disorder (DMDD) added to the DSM

A

in order to address concerns about the potential for overdiagnosis of and treatment for bipolar disorder in children

refers to the presentation of children with persistent irritability and frequent episodes of extreme behavioural dyscontrol

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4
Q

why is DMDD in the depressive disorders chapter

A

it is found that kids with this symptom pattern typically develop unipolar depressive disorders or anxiety rather than bipolar disorders as they mature into adolescence and adulthood

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5
Q

does bereavement typically induce an episode of MDD

A

no

when they do occur together, the depresive symptoms and functional impairment tend to be more severe and the prognosis is worse compared with bereavement that is not accompanied by MDD

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6
Q

What was the name of the STAR*D trial

A

“sequenced treatment alternatives to relieve depression”

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7
Q

what was the research question in the STAR*D trial

A

what are the outcomes and remission rates for depression? what are the long term outcomes, especially the relapse rates, for patients receiving sequential depression therapies?

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8
Q

when was the STAR*D trial published

A

2006

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9
Q

what was the study design/algorithm in the STAR*D trial

A
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10
Q

what was the study design in the STAR*D trial

A

participants with depression were treated in a stepwise fashion–> patients who improved after any step could exit treatment and were followed for 12 months. those who did not remit continued into the next treatment step.

they all started on citalopram treatment as first step

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11
Q

what was the primary endpoint of the STAR*D trial

A

“response rate” defined as 50% or more reduction on the QIDS-SR16

other endpoints included remission rate, time to response/remission, relapse rate during followup and treatment intolerance/exit

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12
Q

what were the results of the STAR*D trial

A

overall 67% of the patients who started treatment in the study remitted from treatment

patients in later treatment steps demonstrated progressively lower remission rates

patients who entered later treatment steps also had higher relapse

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13
Q

why do we care about the STAR*D trial

A

was a landmark study exploring the natural history of patients receiving sequential treatment strategy for depression

showed that 67% of patients treated according to the sequential management strategy utilized in the study remitted

also demonstrated that patients with depression who fail multiple treatment trials have lower remission rates and higher relapse rates

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14
Q

what was the title of the TORDIA trial

A

treatment of resistant depression in adolescents

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15
Q

what was the structure of the TORDIA trial

A

The Treatment of Resistant Depression in Adolescents (TORDIA) study (3) was a six-site study designed to examine second-step interventions in adolescents with depression who had not responded to an initial selective serotonin reuptake inhibitor (SSRI) trial. Participants were randomly assigned to one of the following four treatments: 1) switch to another SSRI; 2) switch to venlafaxine; 3) switch to another SSRI plus cognitive-behavioral therapy (CBT); or 4) switch to venlafaxine plus CBT.

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16
Q

what were the results of the 12week acute phase of the TORDIA trial

A

during the first 12-week acute phase of the study, 47.6% of participants responded to treatment, with greater response to medication switch plus CBT (54.8%) than to medication switch alone (40.5%) but no difference in the response rate between the two medication switch strategies (3).

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17
Q

what % of teens in the TORDIA trial achieved remission at the 6 month mark

A

40% (lower than the 60% reported in the TADS trial)

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18
Q

what was the title of the TADS trial

A

treatment for adolescents with depression study

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19
Q

what did the TADS trial look at

A

The Treatment for Adolescents With Depression Study evaluates the effectiveness of fluoxetine hydrochloride therapy, cognitive behavior therapy (CBT), and their combination in adolescents with major depressive disorder.

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20
Q

what were the results of the TADS trial

A

In adolescents with moderate to severe depression, treatment with fluoxetine alone or in combination with CBT accelerates the response. Adding CBT to medication enhances the safety of medication. Taking benefits and harms into account, combined treatment appears superior to either monotherapy as a treatment for major depression in adolescents.

(suicidal events were more common in those receiveing fluoxetine therapy than combination or CBT therapy)

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21
Q

what was the title of the SADHART trial

A

safety and efficacy of sertraline for depression in patients with heart failure

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22
Q

what was the objective of the SADHART trial

A

to test the hypothesis that heart failure patients treated with sertraline will have lower depression scores and fewer cardiovascular events compared to placebo

*randomized, double blind, placebo controlled trial

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23
Q

why did they bother looking at treatment of depression in heart failure in the SADHART trial

A

depression is common amongst HF patients and is associated with hospitalization and mortality

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24
Q

what were the results of the SADHART trial

A

Sertraline was safe in patients with significant HF. However, treatment with sertraline compared with placebo did not provide greater reduction in depression or improved cardiovascular status among patients with HF and depression.

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25
Q

what level of evidence is required for a treatment to be first line in the CANMAT Depression Guidelines

A

level 1 or 2 evidence, plus clinical support

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26
Q

what level of evidence is required for a treatment to be second line in the CANMAT Depression Guidelines

A

level 3 evidence plus clinical support

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27
Q

what level of evidence is required for a treatment to be third line in the CANMAT Depression Guidelines

A

level 4 evidence plus clinical support

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28
Q

what constitutes level 1 evidence in the CANMAT Depression Guidelines

A

meta-analysis with narrow confidence interval

and/or

2 or more RCTs with adequate sample size, preferably placebo controlled

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29
Q

what constitutes level 2 evidence in the CANMAT Depression Guidelines

A

meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size

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30
Q

what constitutes level 3 evidence CANMAT Depression Guidelines

A

small sample RCTs or nonrandomized, controlled prospective studies or case series or high quality retrospective studies

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31
Q

what constitutes level 4 evidence in the CANMAT Depression Guidelines

A

expert opinion/consensus

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32
Q

where does depression rank in terms of causes of global disability

A

it is the SECOND leading cause of global disability

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33
Q

mixed features are found in what % of those diagnosed with MDE

A

up to 1/3

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34
Q

mixed depressive episodes are more common in what population

A

younger people

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35
Q

why do we care about indicating whether someone has a mixed depressive episode

A

tend to be more severe

carry higher risk for suicide

*specifier is controversial

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36
Q

what is the relationship between sleep disturbance and depression

A

bidirectional

depression can cause sleep disturbance and sleep disturbance is an independent risk factor for onset of an MDE

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37
Q

how does perinatal maternal depression affect children

A

associated with multiple adverse outcomes in children i.e:

increased problems with emotional regulation

internalizing disorders

behavioural disorders

hyperactivity

reduced social competence

insecure attachment

adolescent depression

negative effects on cognitive development

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38
Q

are there adverse outcomes in offspring of fathers with depression

A

yes–> adverse outcomes in offspring are also observed with paternal depression

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39
Q

depression is an independent risk factor for what medical condition(s)

A

ischemic heart disease

CV mortality

*this is bidirectional as well–> vascular risk factors are associated with onset of depression later in life

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40
Q

the CANMAT Depression Guidelines recommends screening for depression under what circumstances?

A

do it in primary and secondary care settings in individuals with risk factors when there are available resources and services for subsequent diagnostic assessment and management

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41
Q

what are some of the cognitive deficits that can be found in MDE

A

attention

memory

processing speed

executive function

*common residual symptom–> may continue after mood sx remitted

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42
Q

list common somatic complaints found in depression

A

headaches

body aches

fatigue

anergia

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43
Q

what % of people presenting with MDD in a given year also have GAD

A

25%

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44
Q

what % of people with MDE have a chronic episode that has lasted over 2 years

A

26.5%

(and 15.1% have chronic course during 3 year follow up)

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45
Q

what % of global DALYs can be attributed to depression

A

2.5% of global DALYs

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46
Q

what part of the depression syndrome is most strongly associated with productivity loss

A

the cognitive symptoms

*depression treatment has a significantly positive effect on productivity

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47
Q

why is it important to treat maternal depression

A

improved parenting
+
reduced psychiatric symptoms in offspring

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48
Q

describe the relationship between obesity/metabolic problems and MDD

A

bidirectional

immune-inflammatory dysfunction

neural plasticity, neuroprogression

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49
Q

are suicide risk assessment tools particularly reliable in predicting future suicide attempts

A

no, NOT PARTICULARLY RELIABLE

but can aide in assessment and documentation in clinical practice

i.e SADPERSONS, columbia suicide severity rating scale, chronological assessment of suicide risk interview guide

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50
Q

list 4 strategies to help improve treatment adherence in those with MDD

A

patient education

supported self management

collaborative care

discuss early and monitor frequently

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51
Q

list clinical factors that may be considered risk factors for depression and thus prompt screening for depression

A

hx of depression

family history of depression

psychosocial adversity

high users of the medical system

chronic medical conditions

other psych conditions

times of hormonal change

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52
Q

list system factors that may be considered risk factors for depression and thus prompt screening for depression

A

unexplained physical symptoms

chronic pain

fatigue

insomnia

anxiety

substance use

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53
Q

what are the benefits of supported self management

A

increases empowerment and self efficacy

decreases reliance on HCPs

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54
Q

list the 9 “principles of clinical management” given in the CANMAT Depression Guidelines for approaching assessment and treatment for depression

A

*dont forget the last one, which is “monitor outcomes with measurement based care”

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55
Q

what is the strongest risk factor for future suicide attempt

A

history of suicide attempt

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56
Q

list the non modifiable risk factors for suicide during an MDE

A

past suicide attempt

family hx suicide

hx self harm

hx legal problems

older men

sexual minority

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57
Q

list modifiable risk factors for suicide during an MDE

A

active SI

psychotic symptoms

hopelessness

anxiety

impulsivity

stressful life events

comorbidities–> SUD, PTSD, personality disorders esp. cluster B, chronic pain conditions, cancer

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58
Q

are patient rated questionnaires as “good” as clinician rated scales for monitoring depression sx

A

they are highly correlated with clinician rated scales and are often simpler to use and more efficient

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59
Q

name 3 clinician rated scales that look at depression SYMPTOMS

A

HAM-D (hamilton depression rating scale)

MADRS (montgomery-asberg depression rating scale)

IDS (inventory for depressive symptomatology)

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60
Q

name 3 patient rated scales that look at depression SYMPTOMS

A

PHQ-9

QIDS-SR (quick inventory for depressive symptomatology, self rated)

CUDOS (clinically useful depression outcome scale)

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61
Q

name 3 clinician rated scales that look at depression FUNCTIONING

A

MSIF (multidimensional scale of independent functioning)

WHO-DAS (WHO disability assessment scale)

SOFAS (social and occupational functioning assessment scale)

62
Q

name 3 patient rated scales that look at depression FUNCTIONING

A

SDS (sheehan disability scale)

WHO-DAS, self rated

LEAPS (lam employment absence and productivity scale)

63
Q

name 1 clinician rated scales that look at depression side effects

A

UKU side effect rating scale

64
Q

name 1 patient rated scales that look at depression side effects

A

FIBSER (frequency, intensity, and burden of side effects rating)

65
Q

name 1 clinician rated scales that look at depression quality of life

A

QOLI (quality of life index)

66
Q

name 1 patient rated scales that look at depression quality of life

A

QLESQ (quality of life, enjoyment and satisfaction questionnaire)

67
Q

what are the two phases of treatment addressed by the CANMAT Depression Guidelines

A

acute and maintenance

68
Q

what timeframe is the “acute” phase of depression treatment

A

8-12 weeks

69
Q

what are the goals of treatment in the acute phase of depression treatment

A

REMISSION of symptoms
–> so no longer meeting criteria

RESTORATION of functioning

70
Q

what are 5 activities to perform during the acute phase of depression treatment according to the CANMAT guidelines

A

establish therapeutic alliance

psychoeducation

support self management

deliver evidence based treatment

monitor progress

71
Q

what timeframe is considered the “maintenance” phase of depression treatment

A

6-24 months, or longer

72
Q

what are the goals of maintenance treatment phase of depression treatment

A

RETURN to FULL FUNCTIONING and quality of life

PREVENTION of recurrence

73
Q

what are 5 activities to perform during the maintenance phase of depression treatment according to the CANMAT guidelines

A

psychoeducation

support self management

rehabilitate

treat comorbidities

monitor for recurrence

74
Q

in what case would psychological treatments for depression NOT be indicated

A

in psychotic depression

*this requires pharmacotherapy and/or ECT

75
Q

in what cases would may you preferentially consider psychological treatment for depression

A

in the case of pregnancy or wanting to conceive

76
Q

what is a particular treatment consideration in the case of the more severe and high risk cases of depression

A

SPEED and accessibility

imperative to start a treatment that is IMMEDIATELY AVAILABLE and to consider ALL treatment modalities including NEUROSTIMULATION

77
Q

how might you decide between psychological treatments and antidepressants in moderately severe or low risk cases of depression

A

consider the balance of patient preferences and availability of each treatment

78
Q

do psychological treatments benefit one gender more than the other

A

no–> benefit both genders equally

79
Q

are psychological treatments only beneficial for certain subtypes of depression?

A

no–> particularly CBT appears to be EQUALLY effective for different subtypes such as atypical, melancholic and anxious depression

80
Q

is CBT or pharmacotherapy superior in most cases of depression?

A

meta-analysis: men and women derive similar benefits from CBT and from antidepressants

in PDD–> medication treatment or combo of meds + psychological treatment was better than psychological treatment alone

81
Q

does severity of depression differentially predict outcomes of treatment with CBT and antidepressants

A

no–> there is evidence of comparable efficacy for CBT and meds even in severe depression

BUT timecourse of improvement is typically faster with antidepressants and thus this may be preferred in severe depression

82
Q

how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment:

ADHD

A

CBT can improve BOTH depression and ADHD symptoms

83
Q

how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment:

personality disorder

A

negative prognostic impact of personality disorder on treatment outcomes, including psychological treatment

84
Q

how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment:

SUDs

A

CBT is effective for depressive symptoms in SUDs

**level 2 evidence supports integrated psychosocial treatment of AUD and depression

85
Q

how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment:

anxiety symptoms or disorders

A

insufficient evidence to support positive or negative effect of anxiety symptoms or disorders on depression outcomes but CBT may be MORE effective than other treatments

86
Q

is there evidence of effectiveness for psychological treatments for depression co occurring with CV disease

A

yes–>evidence for CBT, IPT and problem solving therapy

(level 2)

87
Q

is there evidence of effectiveness for psychological treatments for depression co occurring with cancer

A

yes–> but are studied by type of intervention and phase of cancer treatment–> a variety have evidence however

88
Q

is there evidence of effectiveness for psychological treatments for depression co occurring with HIV

A

yes–> LEVEL 1–> variety of psychological treatments including CBT–> showed improvement in both depression sx as well as adherence to medical treatment

89
Q

is there evidence of effectiveness for psychological treatments for depression co occurring with MS

A

yes–> mostly CBT

level 2

90
Q

is there evidence of effectiveness for psychological treatments for depression co occurring with parkinsons

A

yes–> mostly CBT

level 2

91
Q

what medical illness was noted to have “strikingly high” rates of depression accompanying it in the CANMAT depression guidelines

A

hepatitis C

92
Q

what level of evidence is there to support psychological treatment at FIRST LINE for perinatal women with mild to moderate depressive illness

A

level 1 evidence supports psychological treatments as first line for perinatal women with mild to moderate depressive illness

93
Q

list 3 common factors in therapy relationships that were demonstrably effective in increasing positive outcomes in psychological treatments

A

establishing strong therapeutic alliance

using empathy

collecting client feedback (with standardized scales)

94
Q

what factors to do with the therapist themselves are associated with better outcomes in psychological treatments for depression

A

therapist experience, adherence and ability to be responsive to individual patient differences

95
Q

how do you decide on a particular psychological treatment for depression

A

consider treatment efficacy, quality and availability

*start with first line then move to second line

96
Q

is supportive therapy as effective as other types of therapy

A

no, is LESS effective than other types

97
Q

list the 3 psychological therapies listed as FIRST LINE treatment in the ACUTE phase of MDD the CANMAT depression guidelines

A

CBT (level 1)

IPT (level 2)

BA –behavioral activation (level 2)

98
Q

list the 2 psychological therapies listed as FIRST LINE treatment in the MAINTENANCE phase of MDD the CANMAT depression guidelines

A

CBT

MBCT (mindfulness based cognitive therapy)

99
Q

list the 6 psychological therapies listed as SECOND LINE treatment in the ACUTE phase of MDD the CANMAT depression guidelines

A

MBCT

CBASP
(cognitive behavioural analysis system of psychotherapy)

PST
(problem solving therapy)

STPP
(short term psychodynanic psychotherapy)

telephone delivered CBT and IPT

internet and computer assisted therapy

100
Q

list the 3 psychological therapies listed as SECOND LINE treatment in the MAINTENANCE phase of MDD the CANMAT depression guidelines

A

IPT

BA

CBASP
(cognitive behavioural analysis system of psychotherapy)

101
Q

list the 4 psychological therapies listed as THIRD LINE treatment in the ACUTE phase of MDD the CANMAT depression guidelines

A

long term psychodynamic psychotherapy

acceptance and committment therapy

videoconferences psychotherapy

motivational interviewing

102
Q

list the 1 psychological therapy listed as THIRD LINE treatment in the MAINTENANCE phase of MDD the CANMAT depression guidelines

A

long term psychodynamic psychotherapy

103
Q

what is the most established evidence based, first line treatment for depression, both acute and maintenance?

A

CBT

**substantial evidence of efficacy even in those with severe depression or who had FAILED antidepressant therapy

104
Q

how does MBCT compare to medication treatment in terms of effectiveness

A

EQUAL efficacy of MBCT to medication as maintenance treatment for recurrent MDD in a large high quality RCT

*MBCT is second line for acute and first line for maintenance based on this evidence

105
Q

is IPT first line for maintenance treatment of MDD

A

no, second line

106
Q

how does group vs individual therapy settings affect outcome

A

less effective at end of treatment with higher dropout
BUT
NO difference found at follow up

*there may be a slight preference towards individual therapy but this must be weight against access etc

107
Q

is # sessions or frequency of sessions more important to the outcome of psychological treatments

A

FREQUENCY has strong positive assoc. with clinical improvement

(no association between number of sessions and clinical improvement)

*recommend more frequent sessions, especially early on in course of tx

108
Q

what element of CBT is crucial for effectiveness

A

homework

109
Q

how would you describe the approach of CBT

A

intensive

time limited

symptom focused

*idea is that depression is maintained by unhelpful behaviours + inaccurate thoughts/beliefs about oneself, others and the future

110
Q

do the effects of CBT last

A

yes–> sustained effects shown at 3 year follow up

111
Q

by how much does CBT reduce relapse risk in the first year after tx?

A

by 21%

(and by 28% in the second year)

112
Q

was there a difference in effectiveness between IPT and CBT in acute MDD

A

no difference in acute

113
Q

long term psychodynamic psychotherapy may be useful in cases where MDD is comorbid with what condition

A

personality disorder

114
Q

motivational interviewing may be more appropriate for patients with MDD comorbid with waht condition

A

SUDs

115
Q

what is cognitive behavioural analysis system of psychotherapy

A

specifically developed for the treatment of chronic depression

involves cognitive, behavioural, and interpersonal strategies

how maladaptive cognitions and behaviours influence each other and lead to and perpetuate negative outcomes

116
Q

list the three first line interventions for MILD depression

A

psychoeducation

self management

psychological treatments

consider pharmacotherapy IF certain conditions are met (next flashcard)

117
Q

when should you consider pharmacotherapy for MILD depression

A

patient preference

previous response to ADs

lack of response to non-pharmacological interventions

118
Q

what is first line treatment for moderate to severe depression

A

most 2nd generation antidepressants

(and psychological treatments like CBT)

119
Q

what are the three “newly approved antidepressants” listen in the CANMAT guidelines

A

levomilnacipran

vilazodone

vortioxetine

120
Q

what is the mechanism of action of levomilnacipran

A

SNRI

is the active enantiomer of milnacipran

has greater selectivity for NE reuptake inhibition compared to other SNRIs

121
Q

does levomilnacipran have evidence for response, remission and relapse prevention in MDD?

A

has evidence from RCTs for response and remission but did not yet show benefit over placebo for relapse prevention

122
Q

what is the mechanism of action of vilazodone

A

multimodal AD–> serotonin reuptake inhibitor, 5HT1A partial agonist

123
Q

is there evidence for vilazodone in response, remission and relapse prevention

A

lacking meta-analyses, mixed results

124
Q

what is a consideration when prescribing vilazodone in terms of dosing timing

A

must be taken with food and do a slow titration to avoid GI side effects

125
Q

what is the mechanism of action of vortioxetine

A

multimodal AD

serotonin reuptake inhibition
5HT1A agonist
5HT2a partial agonist
5HT1D/3A/7 antagonist

126
Q

is there evidence for response, remission and relapse for vortioxetine

A

yes–> superior to placebo in all of these phases

127
Q

in what area of MDD symptomatology does vortioxetine show particular benefit

A

neuropsychological/ cognitive effects in multiple domains

128
Q

how soon should you follow up after starting an AD

A

no more than 2 weeks after starting

then 2-4 weeks thereafter

129
Q

what is FIRST LINE pharmacotherapy for MDD

A

the SSRIs

the SNRIs

buproprion

vortioxetine

mirtazapine

agomelatine

130
Q

what is the mechanism of buprioprion

A

NDRI

131
Q

what is the mechanism of mirtazapine

A

alpha2 agonist

5HT2 antagonist

132
Q

what is the mechanism of action of agomelatine

A

MT1/MT2 agonist

5HT2 antagonist

133
Q

what is the mechanism of milnacipran

A

SNRI

134
Q

what is the mechanism of trazodone

A

SRI

5HT2 antagonist

135
Q

what is the mechanism of vilazodone

A

SRI

5HT1A partial agonist

136
Q

what is the mechanism of moclobemide

A

MAO-A inhibitor (reversible)

137
Q

what is the mechanism of selegiline (transdermal)

A

MAO-B inhibitor (irreversible)

138
Q

what is the mechanism of phenelzine

A

MAOi (irreversible)

139
Q

what is the mechanism of reboxetine

A

NRI

140
Q

what are the SECOND LINE options for pharmacotherapy for MDD

A

levomilnacepran

TCAs (amitriptyline, clomipramine)

quetiapine

trazodone

vilazodone

moclobemide

selegiline

141
Q

what are the THIRD LINE options for pharmacotherapy for MDD

A

phenelzine

tranylcypromine

reboxetine

142
Q

why are TCAs, quetiapine and trazodone second line for MDD

A

higher side effect burden

143
Q

why are moclobemide and selegiline second line for MDD

A

potential serious drug interactions

144
Q

why is levomilacipran second line for MDD

A

lack of comparative/relapse prevention data

145
Q

why is vilazodone second line for MDD

A

lack kof comparative/relapse prevention data

need to titrate and take with food

146
Q

why are the MAOis third line for MDD

A

higher SE burden

drug interactions

diet issues

147
Q

why is reboxetine third line for MDD

A

lower efficacy

148
Q

list the 4 SNRIs

A

venlafaxine

desvenlafaxine

duloxetine

milnacipran

149
Q

list the 6 SSRIs

A

citalopram

escitalopram

fluoxetine

fluvoxamine

paroxetine

sertraline

150
Q

list the 5 ADs that are first line for MDD with “other” mechanisms

A

buproprion

mirtazapine

mianserin

vortioxetine

agomelatine

151
Q

what is the mechanism of mianserin

A

alpha 2 agonist

5HT2 antagonist

(like mirtazapine)

4. Mood Disorders (17 decks)

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