Depression Flashcards
What are the diagnostic criteria of MDD?
More or equal to 5 of the following nearly every day for more than 2 weeks or more and equal to one of: depressed mood + Decreased interest.
Depressed mood most of the day
Sleep- insomnia or hypersomnia
Interest- Diminished in almost all activities most of the day
Guilt- Feelings of worthlessness or inappropriate guilt
Energy- Fatigue or loss of energy
Concentration- Diminished ability to think/concentrate, indecisiveness
Appetite- Decreased or increased appetite, significant wt loss/gain
Psychomotor agitation or retardation
Suicidal ideation-recurrent thoughts of death, ideation or attempts
What are the subtypes of depression?
- Melancholic (nonreactive mood, anhedonia, weight loss, guilt, psychomotor retardation, worse in am)
- Atypical (reactive mood, over sleeping, over eating, leaden paralysis, interpersonal rejection, sensitivity)
- Psychotic (delusional, hallucination)
- Catatonic (catalepsy, catatonic excitement, negativism)
- Anxious (feeling keyed up/tense/ restless/worried)
- Mixed state (elevated mood, inflated self-esteem, increased activity and thoughts)
- Seasonal (regular + seasonal onset + remission)
- Postpartum + Antepartum (onset within 4 weeks of postpartum)
- Cognitive dysfunction (disturbance in attention/processing/memory)
- Sleep disturbance (Circadian rhythm disturbance)
- Somatic (headaches, body ache, fatigue, anergia)
DDx of depression
- Persistent depressive disorder
- Adjustment disorder (stressor < 3months, resolves in <6 months)
- Grief reaction (loss, usually < 3 months)
- Bipolar
- Schizoaffective disorder
- Organic (substance abuse, DM, thyroid, pituitary, decreased B12, anemia, dementia, Parkinson’s, MS, CVA, hepatitis, OCP, BZD, Betablockers)
CBC, lytes, creat, TSH, folate, B12, LFTs, consider drug screen
ECG for prolonged QT if starting meds
What are the screening tools for depression?
- Patient Health Questionnaire (96% sensitive, 57% specific for MDD)
- Hamilton Rating Scale, Beck fast scan, Quick inventory of depressive symptomatology self-report, Patient Health Questionnaire-9
Other things to screen for:
- Suicide Risk
- Substance Abuse
What is the risk of recurrence?
85%- more common if complete remission not achieved
Risk factors for recurrence/chronic:
- Earlier age of onset
- Previous episodes
- Severity ( more symptoms, psychotic features), disruption in sleep-wake cycle, co-morbid psychopathology, family hx of psychiatric illness, high neuroticism, poor social support, stressful life events.
Complementary and Alternative therapy for MDD
Mild to moderate MDD:
1- St John’s Wort 200-600 mg TID (Monotherapy)
2- Exercise (30 minutes 3 x per week for 2-3 months)
3- Omega 3 SAM 800-1600 mg per day (adjunct)
4- Light therapy
5- Acetyl-L-Carnitine (monotherapy)
6- DHEA (monotherapy)
7- Folate (adjunct)
8- Lavender (adjunct)
9- Acupuncture (adjunct)
Moderate to Severe MDD:
St John’s wort (adjunct)
Omega 3
Exercise
sleep deprivation up to 40 hours several times per week.
Seasonal Affective Disorder:
Light therapy (monotherapy) 10.000 Lux x 30 minutes per day during early morning for 6 weeks and up to 3 weeks for a response
Benefits of Therapy
Equal efficacy across age groups, genders and ethnic backgrounds
Individual more effective than group therapy
Efficacy equal to meds but superior in combination with meds
Decreased relapse by 20% when used AFTER meds
1- CBT effective for most subtypes
2- Interpersonal psychotherapy
3- Behavioural activation
4- Mindfulness based cognitive therapy
5- Problem solving (PST)
Neurostimulation therapy
1- Repetitive Transcranial magnetiv stimulation for patients that have failed more than 1 antidepressant (26-28 sessions, requires maintenance)
Electro convulsant therapy
Transcranial direct current stimulation
Vagus nerve stimulation
What is the approach to pharmacotherapy in the acute phase?
Step 1: Choose 1st line medication based on comorbid conditions, reponse s/e of previously used antidepressants, patient preference, potential interactions, simplicity and cost
Step 2: Use measurement based care
Step 3: Reassess after 2-4 weeks for 20% improvement
If more than 20% improvement: continue Tx and reassess after 6-8 weeks
If less than 20% improvement: if med tolerable: increase the dose and reassess for 20% improvement in 2-4 weeks
If Med NOT tolerable: switch to another 1st line med or add adjunct and reassess for 20% improvement in 2-4 weeks
Switch: this is 1st antidepressant trial, poorly tolerated side effects, no response < 25% to initial antidepressant, there is more time to wait for a response (less severe, less functional impairment)
Controversial whether to switch within the same class or between classes of drugs
Failure of more than 1 antidepressant consider switch to second line
Step 4: once symptoms are in remission, assess for maintenance phase
For chronic and resistant depression consider a chronic disease management approach with less emphasis on symptoms remission and more emphasis on improved QoL
Approach to pharmacotherapy- Maintenance Phase
Goal is to prevent relapse and recurrence
For average patient: after achieving symptomatic remission, remain on stable dose for 6-9 months (Level I)
For high risk patients: after achieving symptomatic remission, remain on stable dose for a minimum of 2 years (Level 3-4)
High risk includes:
- Frequent or recurrent episodes
- Severe episodes (psychosis, severe impairment, suicidality)
- Chronic episodes
- Presence of co-morbid psychiatric or medical conditions
- Presence of residual symptoms
- Difficult to treat episode
Discontinuation of Meds
Taper over several weeks
Symptoms: FINISH
Flu-like
Insomnia
Nausea
Imbalance
Sensory disturbance
Hyperarousal
Symptoms more common with paroxetine and venlafaxine, least common with fluoxetine and vortioxetine
Definition of Pregnancy and postpartum Depression
Major depressive episode during pregnancy or 4 weeks after delivery (6.5% will develop in the first 3 months)
Must balance the small risk of exposing the fetus or neonate to an antidepressant against the benefit of treating MDD
Risk of not treating: poor nutrition + Prenatal care, substance misuse
SSRI risk: pregnancy: spontaneous abortion (OR: 1.5), BW decreased by 74 g, newborn irritability
Breastfeeding irritability, insomnia
Antidepressants Level 1 in children and adolescents
Fluoxetine
ATD for perimenopausal
Desvenlafaxine
