CANMAT Guidelines: Depression (+trials + DSM general section) Flashcards
list the possible depressive disorders in the DSM
DMDD
MDD/MDE
PDD
premenstrual dysphoric disorder (PMDD)
sub/med induced
due to another medical condition
other/unspecified depressive disorders
what is the common feature in the depressive disorders? what differs between them?
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
why was disruptive mood regulation disorder (DMDD) added to the DSM
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
why is DMDD in the depressive disorders chapter
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
does bereavement typically induce an episode of MDD
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
What was the name of the STAR*D trial
“sequenced treatment alternatives to relieve depression”
what was the research question in the STAR*D trial
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?
when was the STAR*D trial published
2006
what was the study design/algorithm in the STAR*D trial
what was the study design in the STAR*D trial
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
what was the primary endpoint of the STAR*D trial
“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
what were the results of the STAR*D trial
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
why do we care about the STAR*D trial
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
what was the title of the TORDIA trial
treatment of resistant depression in adolescents
what was the structure of the TORDIA trial
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.
what were the results of the 12week acute phase of the TORDIA trial
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).
what % of teens in the TORDIA trial achieved remission at the 6 month mark
40% (lower than the 60% reported in the TADS trial)
what was the title of the TADS trial
treatment for adolescents with depression study
what did the TADS trial look at
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.
what were the results of the TADS trial
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)
what was the title of the SADHART trial
safety and efficacy of sertraline for depression in patients with heart failure
what was the objective of the SADHART trial
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
why did they bother looking at treatment of depression in heart failure in the SADHART trial
depression is common amongst HF patients and is associated with hospitalization and mortality
what were the results of the SADHART trial
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.
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
what level of evidence is required for a treatment to be second line in the CANMAT Depression Guidelines
level 3 evidence plus clinical support
what level of evidence is required for a treatment to be third line in the CANMAT Depression Guidelines
level 4 evidence plus clinical support
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
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
what constitutes level 3 evidence CANMAT Depression Guidelines
small sample RCTs or nonrandomized, controlled prospective studies or case series or high quality retrospective studies
what constitutes level 4 evidence in the CANMAT Depression Guidelines
expert opinion/consensus
where does depression rank in terms of causes of global disability
it is the SECOND leading cause of global disability
mixed features are found in what % of those diagnosed with MDE
up to 1/3
mixed depressive episodes are more common in what population
younger people
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
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
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
are there adverse outcomes in offspring of fathers with depression
yes–> adverse outcomes in offspring are also observed with paternal depression
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
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
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
list common somatic complaints found in depression
headaches
body aches
fatigue
anergia
what % of people presenting with MDD in a given year also have GAD
25%
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)
what % of global DALYs can be attributed to depression
2.5% of global DALYs
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
why is it important to treat maternal depression
improved parenting
+
reduced psychiatric symptoms in offspring
describe the relationship between obesity/metabolic problems and MDD
bidirectional
immune-inflammatory dysfunction
neural plasticity, neuroprogression
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
list 4 strategies to help improve treatment adherence in those with MDD
patient education
supported self management
collaborative care
discuss early and monitor frequently
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
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
what are the benefits of supported self management
increases empowerment and self efficacy
decreases reliance on HCPs
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”
what is the strongest risk factor for future suicide attempt
history of suicide attempt
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
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
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
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)
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)
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)
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)
name 1 clinician rated scales that look at depression side effects
UKU side effect rating scale
name 1 patient rated scales that look at depression side effects
FIBSER (frequency, intensity, and burden of side effects rating)
name 1 clinician rated scales that look at depression quality of life
QOLI (quality of life index)
name 1 patient rated scales that look at depression quality of life
QLESQ (quality of life, enjoyment and satisfaction questionnaire)
what are the two phases of treatment addressed by the CANMAT Depression Guidelines
acute and maintenance
what timeframe is the “acute” phase of depression treatment
8-12 weeks
what are the goals of treatment in the acute phase of depression treatment
REMISSION of symptoms
–> so no longer meeting criteria
RESTORATION of functioning
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
what timeframe is considered the “maintenance” phase of depression treatment
6-24 months, or longer
what are the goals of maintenance treatment phase of depression treatment
RETURN to FULL FUNCTIONING and quality of life
PREVENTION of recurrence
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
in what case would psychological treatments for depression NOT be indicated
in psychotic depression
*this requires pharmacotherapy and/or ECT
in what cases would may you preferentially consider psychological treatment for depression
in the case of pregnancy or wanting to conceive
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
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
do psychological treatments benefit one gender more than the other
no–> benefit both genders equally
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
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
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
how does the following comorbidity affect psychological treatment outcomes (like CBT) in depression treatment:
ADHD
CBT can improve BOTH depression and ADHD symptoms
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
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
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
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)
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
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
is there evidence of effectiveness for psychological treatments for depression co occurring with MS
yes–> mostly CBT
level 2
is there evidence of effectiveness for psychological treatments for depression co occurring with parkinsons
yes–> mostly CBT
level 2
what medical illness was noted to have “strikingly high” rates of depression accompanying it in the CANMAT depression guidelines
hepatitis C
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
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)
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
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
is supportive therapy as effective as other types of therapy
no, is LESS effective than other types
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)
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)
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
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)
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
list the 1 psychological therapy listed as THIRD LINE treatment in the MAINTENANCE phase of MDD the CANMAT depression guidelines
long term psychodynamic psychotherapy
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
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
is IPT first line for maintenance treatment of MDD
no, second line
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
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
what element of CBT is crucial for effectiveness
homework
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
do the effects of CBT last
yes–> sustained effects shown at 3 year follow up
by how much does CBT reduce relapse risk in the first year after tx?
by 21%
(and by 28% in the second year)
was there a difference in effectiveness between IPT and CBT in acute MDD
no difference in acute
long term psychodynamic psychotherapy may be useful in cases where MDD is comorbid with what condition
personality disorder
motivational interviewing may be more appropriate for patients with MDD comorbid with waht condition
SUDs
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
list the three first line interventions for MILD depression
psychoeducation
self management
psychological treatments
consider pharmacotherapy IF certain conditions are met (next flashcard)
when should you consider pharmacotherapy for MILD depression
patient preference
previous response to ADs
lack of response to non-pharmacological interventions
what is first line treatment for moderate to severe depression
most 2nd generation antidepressants
(and psychological treatments like CBT)
what are the three “newly approved antidepressants” listen in the CANMAT guidelines
levomilnacipran
vilazodone
vortioxetine
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
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
what is the mechanism of action of vilazodone
multimodal AD–> serotonin reuptake inhibitor, 5HT1A partial agonist
is there evidence for vilazodone in response, remission and relapse prevention
lacking meta-analyses, mixed results
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
what is the mechanism of action of vortioxetine
multimodal AD
serotonin reuptake inhibition
5HT1A agonist
5HT2a partial agonist
5HT1D/3A/7 antagonist
is there evidence for response, remission and relapse for vortioxetine
yes–> superior to placebo in all of these phases
in what area of MDD symptomatology does vortioxetine show particular benefit
neuropsychological/ cognitive effects in multiple domains
how soon should you follow up after starting an AD
no more than 2 weeks after starting
then 2-4 weeks thereafter
what is FIRST LINE pharmacotherapy for MDD
the SSRIs
the SNRIs
buproprion
vortioxetine
mirtazapine
agomelatine
what is the mechanism of buprioprion
NDRI
what is the mechanism of mirtazapine
alpha2 agonist
5HT2 antagonist
what is the mechanism of action of agomelatine
MT1/MT2 agonist
5HT2 antagonist
what is the mechanism of milnacipran
SNRI
what is the mechanism of trazodone
SRI
5HT2 antagonist
what is the mechanism of vilazodone
SRI
5HT1A partial agonist
what is the mechanism of moclobemide
MAO-A inhibitor (reversible)
what is the mechanism of selegiline (transdermal)
MAO-B inhibitor (irreversible)
what is the mechanism of phenelzine
MAOi (irreversible)
what is the mechanism of reboxetine
NRI
what are the SECOND LINE options for pharmacotherapy for MDD
levomilnacepran
TCAs (amitriptyline, clomipramine)
quetiapine
trazodone
vilazodone
moclobemide
selegiline
what are the THIRD LINE options for pharmacotherapy for MDD
phenelzine
tranylcypromine
reboxetine
why are TCAs, quetiapine and trazodone second line for MDD
higher side effect burden
why are moclobemide and selegiline second line for MDD
potential serious drug interactions
why is levomilacipran second line for MDD
lack of comparative/relapse prevention data
why is vilazodone second line for MDD
lack kof comparative/relapse prevention data
need to titrate and take with food
why are the MAOis third line for MDD
higher SE burden
drug interactions
diet issues
why is reboxetine third line for MDD
lower efficacy
list the 4 SNRIs
venlafaxine
desvenlafaxine
duloxetine
milnacipran
list the 6 SSRIs
citalopram
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
list the 5 ADs that are first line for MDD with “other” mechanisms
buproprion
mirtazapine
mianserin
vortioxetine
agomelatine
what is the mechanism of mianserin
alpha 2 agonist
5HT2 antagonist
(like mirtazapine)
