Depression Flashcards
Initial workup of suspected new onset depression
- Complete medical history, H&P
- Routine labs
- Thyroid studies
Weight gain without increase in appetite in association with new onset depression
Highly suggestive of a secondary etiology, especially hypothyroidism or Cushing syndrome
Depression episode following stroke
The incidence of secondary depression induced by stroke is quite high
Depression secondary to stimulant withdrawal
Education and substance abuse treatment aresthe most imporant things
Antidepressant is generally not needed initially, but if depressive symptoms continue an antidepressant is indicated.
If there is suicidal intent with plan, the patient should be hospitalized on an inpatient psychiatric unit until withdrawal-induced depression improves.
Cocaine “crash”
Withdrawal from cocaine is known to produce a severely dysphoric mood, which may manifest with suicidal ideation/intent/plan
There is some evidence to suggest that patients with co-occurring depression and cocaine use may respond to ___ better than to ___
There is some evidence to suggest that patients with co-occurring depression and cocaine use may respond to tricyclic antidepressants better than to SSRIs
___ are probably the most common chronic medication which may induce depression
Beta blockers are probably the most common chronic medication which may induce depression
Used for cardiac care, hypertension, essential tremor, etc.
If patients undergoing severe depression do not quite meet criteria for involuntary admission, it is often a good idea to. . .
. . . offer voluntary psychiatric admission just in case
Even if a minor does not meet criteria for involuntary admission, their parents may. . .
. . . choose to admit them as the patient’s guardian
“Vegetative” symptom
- Describes a symptom of depression that is physiologic or related to body functions. Examples include:
- Loss of apetite
- Insomnia
- Decrease in energy levels
- Decrease in sex drive
For a patient to be diagnosed with a depressive episode, at least one symptom must be either:
Anhedonia
OR
Depressed mood
When you diagnose a patient with x mood disorder with psychotic features, you should specify whether the psychotic features are. . .
. . . mood congruent or mood incongruent
Somatic delusion
False belief about one’s body.
In depression, these are usually beliefs regarding illness: for example, that a patient has undiagnosed cancer and is on the verge of death.
Risk factors for MDD
- Genetics/Family history
- Loss of a parent before age 11
- ACEs
Suicide in males vs females
Females attempt more often
Males complete more often (since they use more lethal means)
Can you make the diagnosis of major depressive episode in a period of bereavement?
Yes, if the person meets criteria AND it causes considerable impairment in function
Hallucinatory phenomena in adolescents undergoing bereavement
Children and adolescents with normal bereavement often have hallucinatory phenomena where they will see or hear the deceased loved one, often with messages that are comforting or reassuring.
This is usually NOT a sign of psychotic depression.
However, hostile accusatory hallucinations may represent a major depressive episode with psychotic features.
Treating depression
- Try an SSRI
- If this fails, try another SSRI
- If this fails, try a different class
If a child is suffering from an MDE with psychotic features and responds to a combination of antidepressant and atypical antipsychotic. . .
. . . the antipsychotic should be continued for 3 months, then tapered off.
Similarly, the antidepressant should be continued for 6-12 months, then tapered off over 2-3 months.
Children and adolescents with MDD often self-describe their mood as. . .
. . . angry or mad rather than sad or depressed
Whenever a patient with MDD has psychotic features, this should prompt. . .
. . . antipsychotic therapy and strong consideration for hospitalization
In the diagnosis of MDD with psychotic features, the psychotic features. . .
. . . must have appeared after the onset of mood symptoms
If they pre-dated the mood symptoms, an alternative diagnosis such as schizoaffective disorder is more likely.
Current medications considered equivalent first-line options for MDD
SSRIs
SNRIs
Buproprion (weak inhibitor of dopamine and norepinephrine reuptake)
Mirtazapine (alpha-2 receptor antagonist)
Best option for a patient with MDD who wants to avoid sexual side effects
Buproprion
Depressive disorder with postpartum onset
- Occurs in as many as 20-40% of women in the US
- “Peripartum” since 50% begin prior to delivery
- Must be dinstinguished from “baby blues”, which are mild postpartum depressive symptoms that do not constitute a major depressive episode
- Baby blues last <1 week
- Once the diagnosis is made, treatment is the same as for any other MDD diagnosis
- However, they should be educated that breastfeeding may be contraindicated as the antidepressant can appear in breastmilk
1 year and lifetime recurrence risk of major depressive episode
1 year: ~40%
Lifetime: ~80%
Treatment of uncomplicated recurrent episodes of major depression
- Not significantly different from treating the first episode
- If medication is poorly tolerated, rTMS is a good option for outpatients
- If severe or psychotic and rapid response is required, ECT should be strongly considered
If a patient is going to develop GI side effects on an SSRI, it will be ___.
If a patient is going to develop sexual dysfunction on an SSRI, it will be ___.
If a patient is going to develop GI side effects on an SSRI, it will be early in the treatment course.
If a patient is going to develop sexual dysfunction on an SSRI, it will be late in the treatment course.
Discontinuing antidepressant therapy
Can be considered in patients with one episode of major depression after a period of time, however the lifetime risk of another episode is high off of therapy (~85%)
Diagnostic criteria for persistent depressive disorder
- Patient has a depressed mood that occurs almost all the time and has done so for at least 2 years
- No gaps in depression lasting longer than 2 months
- Can be 1 year for children and adolescents
- As opposed to the ‘episodic’ major depression of MDD.
- Need 2 or more SIGECAPS symptoms
“Double depression”
When a patient with PDD also has an MDD depressive episode
Worse prognosis than either diagnosis alone
How is persistent depressive disorder treated?
Just like MDD
rTMS is contraindicated in patients with. . .
. . . pacemakers
___ are safe antidepressants for women who are breastfeeding and are often used for postpartum depression.
SSRIs are safe antidepressants for women who are breastfeeding and are often used for postpartum depression.
Therapy for trichotillomania
CBT and SSRIs
