Chapter 63 - Depression Flashcards
Neurotransmitters believed to be involved in depression include:
- serotonin (5-HT)
- norepinephrine (NE)
- epinephrine (Epi)
- dopamine (DA)
- glutamate
- acetylcholine (ACh)
Diagnosis:
- Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
- The Hamilton Depression Rating Scale (HDRS, Ham-D)
DSM-5 Criteria
At least 5 of the following symptoms present during the same two week period (must include depressed mood or diminished interest/ pleasure):
-Mood - depressed
- Sleep - increased/decreased
- Interest/pleasure - diminished
- Guilt or feelings of worthlessness
- Energy - decreased
- Concentration - decreased
- Appetite - increased/decreased
- Psychomotor agitation or retardation
- Suicidal ideation
Remember: M SIG E CAPS
Prior to initiating antidepressant therapy, it is necessary to rule out:
Why?
- Bipolar disorder
- To avoid inducing mania or causing rapid-cycling (cycling rapidly between bipolar depression and mania).
What is a drug used in anxiety but should not be used alone in case the patient has depression and why?
Benzodiazepines (BZDs) are often used to treat anxiety, though they are not first-line.
When depression and anxiety occur together, BZDs should not be used alone; they can worsen and/or mask depression and can be problematic in patients with concurrent substance abuse disorders (called Dual Diagnosis).
SELECT DRUGS THAT CAUSE OR WORSEN DEPRESSION
- Atomoxetine (Strattera) (ADHD medications)
- lndomethacin (Analgesics)
- Efavirenz (in Atripla) (Antiretrovirals (NNRTls))
- Rilpivirine (in Complera, Odefsey) (Antiretrovirals)
- Beta-blockers (especially propranolol) (CV meds)
- Hormonal contraceptives (Hormones)
- Anabolic steroids (Hormones)
- Systemic steroids
- Interferons
- Varenicline
- Ethanol
-Methylphenidate and other stimulants
- Methadone, and possibly other chronic opioid use that can lower testosterone or estrogen levels
- Clonidine
- Methyldopa
- Procainamide
- Cyclosporine
- Isotretinoin
Medical conditions that can cause or worsen depression:
- stroke,
- Parkinson disease,
- dementia,
- multiple sclerosis,
- hypothyroidism,
- low vitamin D levels,
- metabolic conditions (e.g., hypercalcemia),
- malignancy,
- overactive bladder
- infectious diseases
Natural products that may be helpful in treating depression:
notes on each?
- St. John’s wort,
- SAMe (S-adenosyl-L-methionine),
- valerian
- 5-HTP (5-hydroxytryptophan)
- st john wort: only if pregnant or breastfeeding and prefer herbal treatment.
- St. John’s wort, SAMe and 5-HTP can increase the risk of serotonin syndrome and should not be used with other serotonergic agents.
- St. John’s wort is a broad-spectrum CYP450 enzyme inducer with many significant drug interactions, and it can cause phototoxicity.
- Valerian can cause sedation.
The patient should stay on the drug for … before assessing if the treatment is working or not
4 - 8 weeks
- How much do antidepressants vary in effectiveness?
- what should the initial choice of medication be based on?
- What are the preferred ttmt? and in case of special concurrent conditions?
- The effectiveness of the different antidepressant classes is generally comparable.
- The initial choice of medication should be based on the side effect profile, safety concerns and patient-specific symptoms.
- For most patients an SSRI or SNRI is preferred, or (with specific concurrent conditions) mirtazapine or bupropion.
- How much do antidepressants vary in effectiveness?
- what should the initial choice of medication be based on?
- What are the preferred ttmt? and in case of special concurrent conditions?
- The effectiveness of the different antidepressant classes is generally comparable.
- The initial choice of medication should be based on the side effect profile, safety concerns and patient-specific symptoms.
- For most patients an SSRI or SNRI is preferred, or (with specific concurrent conditions) mirtazapine or bupropion.
Can you continue antidepressants if the woman wishes to become pregnant?
It may be possible to taper the drug if the depression is mild and she has been symptom-free for the previous six months.
In more severe cases, medications may need to be continued.
Untreated depression, especially in the late second or early third trimesters, is associated with:
Increased rates of adverse outcomes; e.g.
- Premature birth
- Low birth weight
- Postnatal complications
The American College of Obstetricians and Gynecologists (ACOG) guidelines for mild depression in pregnancy recommend:
psychotherapy first, followed by drug treatment if needed
What is the preferred drug in pregnancy?
What is the warning regarding its use?
- SSRis are often used initially, with the exception of paroxetine, due to potential cardiac effects.
- Although preferred, there is a warning regarding SSRI use during pregnancy and the potential risk of persistent pulmonary hypertension of the newborn (PPHN).
