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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
what level of evidence is required for a treatment to be first line in the CANMAT Depression Guidelines
level 1 or 2 evidence, plus clinical support
26
what level of evidence is required for a treatment to be second line in the CANMAT Depression Guidelines
level 3 evidence plus clinical support
27
what level of evidence is required for a treatment to be third line in the CANMAT Depression Guidelines
level 4 evidence plus clinical support
28
what constitutes level 1 evidence in the CANMAT Depression Guidelines
meta-analysis with narrow confidence interval and/or 2 or more RCTs with adequate sample size, preferably placebo controlled
29
what constitutes level 2 evidence in the CANMAT Depression Guidelines
meta-analysis with wide confidence intervals and/or 1 or more RCTs with adequate sample size
30
what constitutes level 3 evidence CANMAT Depression Guidelines
small sample RCTs or nonrandomized, controlled prospective studies or case series or high quality retrospective studies
31
what constitutes level 4 evidence in the CANMAT Depression Guidelines
expert opinion/consensus
32
where does depression rank in terms of causes of global disability
it is the SECOND leading cause of global disability
33
mixed features are found in what % of those diagnosed with MDE
up to 1/3
34
mixed depressive episodes are more common in what population
younger people
35
why do we care about indicating whether someone has a mixed depressive episode
tend to be more severe carry higher risk for suicide *specifier is controversial
36
what is the relationship between sleep disturbance and depression
bidirectional depression can cause sleep disturbance and sleep disturbance is an independent risk factor for onset of an MDE
37
how does perinatal maternal depression affect children
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
38
are there adverse outcomes in offspring of fathers with depression
yes--> adverse outcomes in offspring are also observed with paternal depression
39
depression is an independent risk factor for what medical condition(s)
ischemic heart disease CV mortality *this is bidirectional as well--> vascular risk factors are associated with onset of depression later in life
40
the CANMAT Depression Guidelines recommends screening for depression under what circumstances?
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
41
what are some of the cognitive deficits that can be found in MDE
attention memory processing speed executive function *common residual symptom--> may continue after mood sx remitted
42
list common somatic complaints found in depression
headaches body aches fatigue anergia
43
what % of people presenting with MDD in a given year also have GAD
25%
44
what % of people with MDE have a chronic episode that has lasted over 2 years
26.5% (and 15.1% have chronic course during 3 year follow up)
45
what % of global DALYs can be attributed to depression
2.5% of global DALYs
46
what part of the depression syndrome is most strongly associated with productivity loss
the cognitive symptoms *depression treatment has a significantly positive effect on productivity
47
why is it important to treat maternal depression
improved parenting + reduced psychiatric symptoms in offspring
48
describe the relationship between obesity/metabolic problems and MDD
bidirectional immune-inflammatory dysfunction neural plasticity, neuroprogression
49
are suicide risk assessment tools particularly reliable in predicting future suicide attempts
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
50
list 4 strategies to help improve treatment adherence in those with MDD
patient education supported self management collaborative care discuss early and monitor frequently
51
list clinical factors that may be considered risk factors for depression and thus prompt screening for depression
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
52
list system factors that may be considered risk factors for depression and thus prompt screening for depression
unexplained physical symptoms chronic pain fatigue insomnia anxiety substance use
53
what are the benefits of supported self management
increases empowerment and self efficacy decreases reliance on HCPs
54
list the 9 "principles of clinical management" given in the CANMAT Depression Guidelines for approaching assessment and treatment for depression
*dont forget the last one, which is "monitor outcomes with measurement based care"
55
what is the strongest risk factor for future suicide attempt
history of suicide attempt
56
list the non modifiable risk factors for suicide during an MDE
past suicide attempt family hx suicide hx self harm hx legal problems older men sexual minority
57
list modifiable risk factors for suicide during an MDE
active SI psychotic symptoms hopelessness anxiety impulsivity stressful life events comorbidities--> SUD, PTSD, personality disorders esp. cluster B, chronic pain conditions, cancer
58
are patient rated questionnaires as "good" as clinician rated scales for monitoring depression sx
they are highly correlated with clinician rated scales and are often simpler to use and more efficient
59
name 3 clinician rated scales that look at depression SYMPTOMS
HAM-D (hamilton depression rating scale) MADRS (montgomery-asberg depression rating scale) IDS (inventory for depressive symptomatology)
60
name 3 patient rated scales that look at depression SYMPTOMS
PHQ-9 QIDS-SR (quick inventory for depressive symptomatology, self rated) CUDOS (clinically useful depression outcome scale)
61
name 3 clinician rated scales that look at depression FUNCTIONING
MSIF (multidimensional scale of independent functioning) WHO-DAS (WHO disability assessment scale) SOFAS (social and occupational functioning assessment scale)
62
name 3 patient rated scales that look at depression FUNCTIONING
SDS (sheehan disability scale) WHO-DAS, self rated LEAPS (lam employment absence and productivity scale)
63
name 1 clinician rated scales that look at depression side effects
UKU side effect rating scale
64
name 1 patient rated scales that look at depression side effects
FIBSER (frequency, intensity, and burden of side effects rating)
65
name 1 clinician rated scales that look at depression quality of life
QOLI (quality of life index)
66
name 1 patient rated scales that look at depression quality of life
QLESQ (quality of life, enjoyment and satisfaction questionnaire)
67
what are the two phases of treatment addressed by the CANMAT Depression Guidelines
acute and maintenance
68
what timeframe is the "acute" phase of depression treatment
8-12 weeks
69
what are the goals of treatment in the acute phase of depression treatment
REMISSION of symptoms --> so no longer meeting criteria RESTORATION of functioning
70
what are 5 activities to perform during the acute phase of depression treatment according to the CANMAT guidelines
establish therapeutic alliance psychoeducation support self management deliver evidence based treatment monitor progress
71
what timeframe is considered the "maintenance" phase of depression treatment
6-24 months, or longer
72
what are the goals of maintenance treatment phase of depression treatment
RETURN to FULL FUNCTIONING and quality of life PREVENTION of recurrence
73
what are 5 activities to perform during the maintenance phase of depression treatment according to the CANMAT guidelines
psychoeducation support self management rehabilitate treat comorbidities monitor for recurrence
74
in what case would psychological treatments for depression NOT be indicated
in psychotic depression *this requires pharmacotherapy and/or ECT
75
in what cases would may you preferentially consider psychological treatment for depression
in the case of pregnancy or wanting to conceive
76
what is a particular treatment consideration in the case of the more severe and high risk cases of depression
SPEED and accessibility imperative to start a treatment that is IMMEDIATELY AVAILABLE and to consider ALL treatment modalities including NEUROSTIMULATION
77
how might you decide between psychological treatments and antidepressants in moderately severe or low risk cases of depression
consider the balance of patient preferences and availability of each treatment
78
do psychological treatments benefit one gender more than the other
no--> benefit both genders equally
79
are psychological treatments only beneficial for certain subtypes of depression?
no--> particularly CBT appears to be EQUALLY effective for different subtypes such as atypical, melancholic and anxious depression
80
is CBT or pharmacotherapy superior in most cases of depression?
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
does severity of depression differentially predict outcomes of treatment with CBT and antidepressants
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
how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment: ADHD
CBT can improve BOTH depression and ADHD symptoms
83
how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment: personality disorder
negative prognostic impact of personality disorder on treatment outcomes, including psychological treatment
84
how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment: SUDs
CBT is effective for depressive symptoms in SUDs **level 2 evidence supports integrated psychosocial treatment of AUD and depression
85
how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment: anxiety symptoms or disorders
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
is there evidence of effectiveness for psychological treatments for depression co occurring with CV disease
yes-->evidence for CBT, IPT and problem solving therapy (level 2)
87
is there evidence of effectiveness for psychological treatments for depression co occurring with cancer
yes--> but are studied by type of intervention and phase of cancer treatment--> a variety have evidence however
88
is there evidence of effectiveness for psychological treatments for depression co occurring with HIV
yes--> LEVEL 1--> variety of psychological treatments including CBT--> showed improvement in both depression sx as well as adherence to medical treatment
89
is there evidence of effectiveness for psychological treatments for depression co occurring with MS
yes--> mostly CBT level 2
90
is there evidence of effectiveness for psychological treatments for depression co occurring with parkinsons
yes--> mostly CBT level 2
91
what medical illness was noted to have "strikingly high" rates of depression accompanying it in the CANMAT depression guidelines
hepatitis C
92
what level of evidence is there to support psychological treatment at FIRST LINE for perinatal women with mild to moderate depressive illness
level 1 evidence supports psychological treatments as first line for perinatal women with mild to moderate depressive illness
93
list 3 common factors in therapy relationships that were demonstrably effective in increasing positive outcomes in psychological treatments
establishing strong therapeutic alliance using empathy collecting client feedback (with standardized scales)
94
what factors to do with the therapist themselves are associated with better outcomes in psychological treatments for depression
therapist experience, adherence and ability to be responsive to individual patient differences
95
how do you decide on a particular psychological treatment for depression
consider treatment efficacy, quality and availability *start with first line then move to second line
96
is supportive therapy as effective as other types of therapy
no, is LESS effective than other types
97
list the 3 psychological therapies listed as FIRST LINE treatment in the ACUTE phase of MDD the CANMAT depression guidelines
CBT (level 1) IPT (level 2) BA --behavioral activation (level 2)
98
list the 2 psychological therapies listed as FIRST LINE treatment in the MAINTENANCE phase of MDD the CANMAT depression guidelines
CBT MBCT (mindfulness based cognitive therapy)
99
list the 6 psychological therapies listed as SECOND LINE treatment in the ACUTE phase of MDD the CANMAT depression guidelines
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
list the 3 psychological therapies listed as SECOND LINE treatment in the MAINTENANCE phase of MDD the CANMAT depression guidelines
IPT BA CBASP (cognitive behavioural analysis system of psychotherapy)
101
list the 4 psychological therapies listed as THIRD LINE treatment in the ACUTE phase of MDD the CANMAT depression guidelines
long term psychodynamic psychotherapy acceptance and committment therapy videoconferences psychotherapy motivational interviewing
102
list the 1 psychological therapy listed as THIRD LINE treatment in the MAINTENANCE phase of MDD the CANMAT depression guidelines
long term psychodynamic psychotherapy
103
what is the most established evidence based, first line treatment for depression, both acute and maintenance?
CBT **substantial evidence of efficacy even in those with severe depression or who had FAILED antidepressant therapy
104
how does MBCT compare to medication treatment in terms of effectiveness
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
is IPT first line for maintenance treatment of MDD
no, second line
106
how does group vs individual therapy settings affect outcome
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
is # sessions or frequency of sessions more important to the outcome of psychological treatments
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
what element of CBT is crucial for effectiveness
homework
109
how would you describe the approach of CBT
intensive time limited symptom focused *idea is that depression is maintained by unhelpful behaviours + inaccurate thoughts/beliefs about oneself, others and the future
110
do the effects of CBT last
yes--> sustained effects shown at 3 year follow up
111
by how much does CBT reduce relapse risk in the first year after tx?
by 21% (and by 28% in the second year)
112
was there a difference in effectiveness between IPT and CBT in acute MDD
no difference in acute
113
long term psychodynamic psychotherapy may be useful in cases where MDD is comorbid with what condition
personality disorder
114
motivational interviewing may be more appropriate for patients with MDD comorbid with waht condition
SUDs
115
what is cognitive behavioural analysis system of psychotherapy
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
list the three first line interventions for MILD depression
psychoeducation self management psychological treatments consider pharmacotherapy IF certain conditions are met (next flashcard)
117
when should you consider pharmacotherapy for MILD depression
patient preference previous response to ADs lack of response to non-pharmacological interventions
118
what is first line treatment for moderate to severe depression
most 2nd generation antidepressants (and psychological treatments like CBT)
119
what are the three "newly approved antidepressants" listen in the CANMAT guidelines
levomilnacipran vilazodone vortioxetine
120
what is the mechanism of action of levomilnacipran
SNRI is the active enantiomer of milnacipran has greater selectivity for NE reuptake inhibition compared to other SNRIs
121
does levomilnacipran have evidence for response, remission and relapse prevention in MDD?
has evidence from RCTs for response and remission but did not yet show benefit over placebo for relapse prevention
122
what is the mechanism of action of vilazodone
multimodal AD--> serotonin reuptake inhibitor, 5HT1A partial agonist
123
is there evidence for vilazodone in response, remission and relapse prevention
lacking meta-analyses, mixed results
124
what is a consideration when prescribing vilazodone in terms of dosing timing
must be taken with food and do a slow titration to avoid GI side effects
125
what is the mechanism of action of vortioxetine
multimodal AD serotonin reuptake inhibition 5HT1A agonist 5HT2a partial agonist 5HT1D/3A/7 antagonist
126
is there evidence for response, remission and relapse for vortioxetine
yes--> superior to placebo in all of these phases
127
in what area of MDD symptomatology does vortioxetine show particular benefit
neuropsychological/ cognitive effects in multiple domains
128
how soon should you follow up after starting an AD
no more than 2 weeks after starting then 2-4 weeks thereafter
129
what is FIRST LINE pharmacotherapy for MDD
the SSRIs the SNRIs buproprion vortioxetine mirtazapine agomelatine
130
what is the mechanism of buprioprion
NDRI
131
what is the mechanism of mirtazapine
alpha2 agonist 5HT2 antagonist
132
what is the mechanism of action of agomelatine
MT1/MT2 agonist 5HT2 antagonist
133
what is the mechanism of milnacipran
SNRI
134
what is the mechanism of trazodone
SRI 5HT2 antagonist
135
what is the mechanism of vilazodone
SRI 5HT1A partial agonist
136
what is the mechanism of moclobemide
MAO-A inhibitor (reversible)
137
what is the mechanism of selegiline (transdermal)
MAO-B inhibitor (irreversible)
138
what is the mechanism of phenelzine
MAOi (irreversible)
139
what is the mechanism of reboxetine
NRI
140
what are the SECOND LINE options for pharmacotherapy for MDD
levomilnacepran TCAs (amitriptyline, clomipramine) quetiapine trazodone vilazodone moclobemide selegiline
141
what are the THIRD LINE options for pharmacotherapy for MDD
phenelzine tranylcypromine reboxetine
142
why are TCAs, quetiapine and trazodone second line for MDD
higher side effect burden
143
why are moclobemide and selegiline second line for MDD
potential serious drug interactions
144
why is levomilacipran second line for MDD
lack of comparative/relapse prevention data
145
why is vilazodone second line for MDD
lack kof comparative/relapse prevention data need to titrate and take with food
146
why are the MAOis third line for MDD
higher SE burden drug interactions diet issues
147
why is reboxetine third line for MDD
lower efficacy
148
list the 4 SNRIs
venlafaxine desvenlafaxine duloxetine milnacipran
149
list the 6 SSRIs
citalopram escitalopram fluoxetine fluvoxamine paroxetine sertraline
150
list the 5 ADs that are first line for MDD with "other" mechanisms
buproprion mirtazapine mianserin vortioxetine agomelatine
151
what is the mechanism of mianserin
alpha 2 agonist 5HT2 antagonist (like mirtazapine)

4. Mood Disorders (17 decks)

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