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3153 psych > depression > Flashcards

depression Flashcards

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1
Q

suicide risk assessment

A
  • suicide inquiry
    • ideation
    • suicide plan
    • intent (extent to carry out)
    • protective factors
  • identify and manage underlying factors
  • risk factors
    • prior attempts/ psych d/o, alc/sub use
    • fam hx, stressors (triggers/ med condition)

(any YES = seek health)
(YES for intent, ideation, preparatory acts = IMMEDIATE)

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2
Q

primary causes of MDD

A
  • Biological
    • Hormonal influence: secretion of cortisol (stress hormone)
    • Monoamine hypothesis: neurotransmitter in brain (NE, 5HT, DA)
  • Psychological
    • Loss, negative self evaluation
  • Psychosocial
    • Isolation, lack of social support
  • Genetics
    • polymorphism in 5HTT SERT gene (S/S > L/L)
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3
Q

secondary causes of MDD

A
  • medical
  • Psychiatric disorders
    • Alcoholism
    • ANX
    • SCHIZO
    • Eating disorders
  • Pharmacological - Drug induced
    • Lipid-soluble BB
    • Psychotropics: CNS depressants (BZP, opioids, barbiturates) anticonvulsants, tetrabenazine
    • w/d from alcohol, stimulants
    • CS (systemic, LT use)
    • Isotretinoin
    • Interferon-B-1a
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4
Q

medical causes of MDD

A
  • 2nd to medical disorders (DM, CVA, cancer)
  • Endocrine disorder: HypoTHY, Cushing, bidirectional assoc (Dep & T2DM)
  • Deficiency states: anemia, Wernicke’s encephalopathy (vit B1)
  • Infections: CNS infections, STD/HIV, TB
  • Metabolic disorders: electrolyte imbalance (K, Na), hepatic encephalopathy
  • Cardiovascular: CAD, CHF, MI
  • Neurological: Alzheimer’s, epilepsy, pain, Parkinson’s post-stroke
  • Malignancy
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5
Q

DSM5 dx criteria for MDD

A
  • At least 5 sx present during the same 2 wk period and represent a change from previous functioning.
    SADCAGES (dep mood/ loss of interest)
  • Sx cause significant distress or impairment in social, occupational, other areas of functioning
  • Sx are not caused by an underlying medical condition or substance use (withdrawal, abuse, DDI)
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6
Q

In SAD CAGES

A

○ Interest: decr interest and pleasure in normal activities
○ Sleep: insomnia (3hr sleep), hypersomnia (excessively sleep)
○ Appetite: decr appetite, weight loss
○ Depressed: irritable mood in children
○ Concentration, decision making
○ Activity: psychomotor retardation, agitation
○ Guilt: feeling guilty, worthlessness
○ Energy: decr energy or fatigue
○ Suicidal thoughts or attempts

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7
Q

types of depressive d/o

A
  • MDD (=/>5/9 sx)
  • persistent MDD (dep mood + 2sx) 2yrs
  • Disruptive mood dysregulation disorder (child up to 18yo)
  • Premenstrual dysphoric disorder
  • Substance/ medication- induced depressive disorder
  • Depressive/ disorder due to another medical condition (hypoTHY)
  • Other specified depressive disorder
  • Unspecified depressive disorder
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8
Q

differential dx

A
  • Adjustment disorder (ANX &/or Depressed mood)
    ○ Sx occur within 3mnths of onset of stressor
    ○ Once stressor terminated, sx do not persist for additional 6 mnths
  • Acute stress disorder
    ○ Sx occur within 1 mnth of traumatic event, lasts 3 days – 1mnth
    ○ Intense fear, helplessness, horror (dissociation), re-exp, avoidance, incr arousal
  • Seasonal affective disorder
  • Substance-induced disorder
  • (mood d/o) Bipolar affective disorder — depressive episodes
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9
Q

dx assessments (general evaluation)

A
  • HPI
  • psych hx
  • sub use hx
  • med hx
  • fam, social, forensic, developmental, occupational hx
    * SERT gene/ fam responses to what drugs
  • physical, neurologic exam
  • MSE!!!
  • labs
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10
Q

labs

A

○ Vital signs, weight BMI, FBC
○ Renal: urea, electrolytes, Cr
○ Na (SIADH SE: base, 2w, 4w, 3mly)
○ LFT, ECG, BGL, lipid panel
○ Urine toxicology
○ Rule out anemia (folate, vit B12), preg, other investigations, infection

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11
Q

rule out other med conditions (not assoc w/ dep)

A
  • Delirium
  • Psychosis
  • Mania
  • ANX
  • Insomnia
  • Thyroid dysfunction
  • DM
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12
Q

pgx relevance

A

2C19, 2D6 ultra-rapid, intermediate status

may affect dosing and tolerability of escitalopram/ sertraline (2C19), paroxetine/ fluoxetine (2D6)

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13
Q

delirium

A
  • fast onset
  • impaired consciousness
  • poor memory
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14
Q

dementia

A
  • insidious, step wise change (progressive)
  • clear consciousness until later stages
  • poor ST & LT memory
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15
Q

w/d or intoxication

A
  • acute onset, rapid (24-72hr)
  • unimpaired –> impaired consciousness
  • intact memory
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16
Q

psychiatric rating scales

A
  • clinician
    * HAM-D
    * clinical global-impression severity scale
    * montgomery-asberg depression rating scale
  • self-rated
    * screening (pt health questionnaire) (2qns)
    * pt health qustionnaire (9 qns) = Mod dep: > 5-9 points (start antidep)
    * quick inventory for depressive sx
    * back depression inventory
    * geriatric depression scale
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17
Q

HAM-D score
remission, response monitor

A
  • 10-13: mild
  • 14-17: moderate (start antidep)
  • > 17: moderate-severe

response: 50% improvement
remission: =/< 7 (goal, sx free)

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18
Q

tx plan

A

1) non-pharm
2) pharm
3) adjuncts

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19
Q

phases of tx

A
  • acute phase (adequate trial: dose + duration 4-8wks)
  • continuous phase (total 6-12mnths)
    * continue for at least 4-9 mnths after acute
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20
Q

acute phase to ensure adequate trial

A
  • delayed onset of effectiveness
    * gradual regulation of pre-synaptic autoreceptors, release of neurotransmitters
  • time course of tx response
    * physical sx (sleep, appetite): improve 1-2wks
    * mood sx: improve at 4-8wks
  • switch only if ineffective after adequate trial
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21
Q

continuous phase

A
  • 1st ep of uncomplicated MDD (total 6-12 mnths)
    * after 4-8wks of acute
  • 4-9mnths of continuous
  • Longer term if:
    * high risks
    * =/> 2 ep MDD
    * Geriatric MDD
    * Likely relapse if stop meds
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22
Q

non-pharm therapy

A
  • Sleep hygiene – improve sleep habits (affect appetite, energy, concentration lvl)
  • Psychotherapy – insuff in mod~severe depression
    ○ Combi with antidep
  • Neurostimulation (high risk pt: PREG refuse to eat)
    ○ Electroconvulsive treatment: severe/ refractory tx
    ○ Repetitive transcranial magnetic stimulation (rTMS)
  • Light therapy
    ○ For seasonal affective disorder
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23
Q

non-pharm CAM

A
  • Therapeutic lifestyle/ behavioural changes
    • Sleep hygiene
    • Exercise
    • Relaxation technique
  • Nutritional
    • Vit B12
    • L-methylfolate
    • Vit D
    • S-adenosylmethionine (SAMe)
    • Omega 3 FA
    • 5-hydroxytrytophan (5-HTP)
  • Herbal
    • St John’s wort (inducer)
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24
Q

pharm tx

A
  • indicated for: mod-severe, ANX, PDD (persistent)
  • effectiveness: respone 60-70%, remission 30%
  • choice: mirtazapine, SSRI, SNRI, bupropion
    * selection based on: target sx, DDI, prior response, pt preference
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25
Q

adjunct meds

A
  • PRN, short course
  • hypnotics, anxiolytics
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26
Q

approach: switch atidep when

A
  • If ineffective/ intolerable to adequate dose in 2-4wk
    ○ SSRI –> SNRI/ MIRTA/ BUP/ AGOME/ VORTIO
  • If cross titration
    ○ Serotonin syndrome if combining serotonergic agents
27
Q

direct switch (others –> SSRI)
except RIMA, fluoxetine)

A

1 SSRI can be stopped abruptly. Next serotonergic agent initiated

28
Q

gradual cross tapering
(serotonergic daily 2mnths –> non-serotonergic: BUP, MRA)

A

taper the first antidepressant (usually over 1-2 week or longer), and build up the dose of the new antidepressant simultaneously.

reduce risk of antidep discontinuation syndrome
watch for serotonin syndrome (combine serotonergic agents)

fluoxetine 5wks

29
Q

wash out period

A

switch TO MAOi: washout at least 1wk
* 5wks if fluoxetine

switch FROM moclobemide (RIMA): 24hr washout

30
Q

approach: augmenting tx if

A
  • partial response
    * combine 2nd antidep (diff MOA) to existing antidep (mirtazapine, BUP, nortriptyline TCA, Li, T3)
  • adjunct SGAs: quetiapine XR, aripiprazole, brexipiprazole
31
Q

approach: tx resistant dep

A

No response to =/> 2 adequate trials of antidep

  • neurostimulation: ECT, rTMS (magnetic)
  • combi: olanzapine + fluoxetine
  • rapid onset nasal spray: ketamine (glutamate NMDA RA) & adjunct to SSRI/ SNRI
32
Q

dep in preg

A

consider nortriptyline in late preg

avoid paroxetine, BUP

33
Q

breast feeding

A

consider sertraline (SSRI), mirtazapine

34
Q

postpartum dep

A

brexanolone (GABA-A modulator: allosteric)

35
Q

bipolar depression

A

Li
lamo, lurasidone, cariprazine
antipsychotics (quetiapine, olanzapine + fluoxetine ssri) QORA

36
Q

hepatic insufficiency

A

avoid duloxetine (SNRI), agomelatine
caution: paroxetin, escitalopram

consider vortioxetine (mild-mod hep, no adj needed)

37
Q

renal insuff

A

avoid: duloxetine
caution: paroxetine, vortioxetine (may consider)

38
Q

post MI depression

A

may consider sertraline (antiplt effect)

avoid: TCA (ECG changes), escitalopram/ citalopram (QTc), trazodone ( QTc)

39
Q

CBS accident

A

SSRI (fluoxetine)

caution with antiplt, anticoag

40
Q

elderly

A
  • avoid TCA: anticholinergics, CNS, hypoTENsive, cardiac SE
  • monitor hypoNa, SIADH (in all antidep)
    * more in SSRI
    * monitor at baseline, 2nd, 4th wk, 3mnthly
  • consider (less risk): mirtazapine, agomelatine, bupropion
41
Q

anticholinergic SE

A

avoid: TCA (duloxetine), paroxetine (SSRI)

  • BPH, narrow angle glaucoma, urinary retention
  • trazodone (priapism but no anticholinergic effect)
42
Q

obese

A

consider: bupropion, SSRI (except paroxetine), SNRI

avoid: mirtazapine, TCA, MAOi

43
Q

underweight/ eating d/o

A

consider: mirtazapine, fluoxetine

avoidL bupropion (seizure risk with electrolytes imbalance)

44
Q

chronic pain/ neuropathy

A

consider: SNRI, TCA

  • duloxetine: for diabetic peripheral neuropathy, chronic MSK pain
45
Q

DM

A

avoid TCA, some SSRI (esp paroxetine)
* worsens glycemic control

consider: citalopram, Duloxetine (DM neuropathy)

46
Q

seizure

A

consider: SSRI, SNRI
avoid: BUP, TCA,

47
Q

hypertension

A

avoid: TCA, SNRI

(incr sympathetic tone)
(venlafaxine incr BP)

48
Q

tamoxifen therapy (requires CYP2D6 conversion to active form)

A

avoid: paroxetine, fluoxetine, BUP (CYP2D6i)

consider: venlafaxine, desvenla, excitalopram

49
Q

smoking

A

bupropion (smoking cessation too)

50
Q

Suicidality

A
  • Esp with <24yo (counselling pt, monitor by caregiver, regular review)
  • Medication guide provided with dispensing, documented in med records
51
Q

DDI

A
  • serotonin syndrome
  • risk of bleeing (serotonergic drugs)
  • CNS depressant effect
  • anticholinergic agents
  • CYP
52
Q
  1. serotonin syndrome

caused by?
onset?

A
  • serotonergic agent + serotonergic agent
    *triptans, ergots, opioids, linezolid, ritonavir, MAOi (if never wash out), subtramine (weight loss SNRI)
  • acute onset (6-8hrs)
53
Q

degree of serotonin syndrome

A
  • mild: insomnia, ANX, ND, HTN, tachy, hyper-reflexia
  • mod: agitation, myoclonus, tremor, mydriasis (dilate), flush, diaphoresis (sweat), fever
  • severe: HIGH hyperthermia, confusion, rigid, resp failure, coma, DEATH
54
Q
  1. bleeding risk DDI
A
  • serotonergic antidep + NSAID/ warfarin/ steroids
    * higher risk in elderly
    * add PPI
    * stop serotonergic antidep 2 wks before surgery (if high bleeding risk)

agomelatine, BUP/ MIRTZ (safer)

55
Q
  1. incr CNS depressant effects DDI
A
  • alcohol (space 4-6hrs apart from meds)
  • APS, H1 antagonist, opioids
56
Q
  1. anticholinergics DDI
A
  • excessive anticholinergics effect
    * esp with TCA, paroxetine
    * oxybutynin, Hyoscyamine, scopolamine
57
Q
  1. CYP DDI
A
  • fewer CYP int: mirt, escitalopram, venlafaxine, desvenlafaxine, vortioxetine
  • fluvoxamine (ssri): inhbits CYP1A2, 2C19
  • fluoxetine, paroxetine (ssri), BUP: inhibits CYP2D6
58
Q

CYP3A4 i

A

clarithromycin, azoles (ketoconzaole), ritonavir
grapefruit juice

59
Q

CYP3A4 inducers

A

CBP, PT, rifampicin, st john’s wort

60
Q

antidep discontinuation sx

A
  • Esp with abrupt stopping of regular tx
    * (SSRI: paroxetine, SNRI: venlafaxine) except fluoxetine (long t1/2)
  • Sx: FINISH (discomfort but not life-threatening)
  • onset: 36-72hrs, duration: 3-7d
  • resolves: 1-2wks (w/o tx)
61
Q

FINISH sx

A

○ Flu-like sx (lethargy, fatigue, headache, achiness, sweating)
○ Insomnia (vivid dreams or nightmares)
○ NV
○ Imbalance (dizzy, vertigo, light headed)
○ Sensory disturbances (burn, tingle, electric-like sensation)
○ Hyperarousal (ANX, irritable, agitation, aggression, mania, jerkiness)

62
Q

avoid antidep discontinuation sx by

A
  • avoided by gradual tapering
    * decr by half tab of lowest strength every 1-2wks.
  • unless fluoxetine, BUP (long t1/2 = no taper)
63
Q

possible SE and management

A
  1. Drowsy = ON
  2. Insomnia = OM
  3. dizzy/ light headedness = rise slowly
  4. stomach upset = take after food
  5. sexual dysfunction = can be tx, less with MIRTA, BUP, AGOM

3153 psych (11 decks)

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