depression Flashcards
suicide risk assessment
- 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)
primary causes of MDD
- 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)
secondary causes of MDD
- 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
medical causes of MDD
- 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
DSM5 dx criteria for MDD
- 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)
In SAD CAGES
○ 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
types of depressive d/o
- 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
differential dx
- 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
dx assessments (general evaluation)
- 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
labs
○ 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
rule out other med conditions (not assoc w/ dep)
- Delirium
- Psychosis
- Mania
- ANX
- Insomnia
- Thyroid dysfunction
- DM
pgx relevance
2C19, 2D6 ultra-rapid, intermediate status
may affect dosing and tolerability of escitalopram/ sertraline (2C19), paroxetine/ fluoxetine (2D6)
delirium
- fast onset
- impaired consciousness
- poor memory
dementia
- insidious, step wise change (progressive)
- clear consciousness until later stages
- poor ST & LT memory
w/d or intoxication
- acute onset, rapid (24-72hr)
- unimpaired –> impaired consciousness
- intact memory
psychiatric rating scales
- 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
HAM-D score
remission, response monitor
- 10-13: mild
- 14-17: moderate (start antidep)
- > 17: moderate-severe
response: 50% improvement
remission: =/< 7 (goal, sx free)
tx plan
1) non-pharm
2) pharm
3) adjuncts
phases of tx
- acute phase (adequate trial: dose + duration 4-8wks)
- continuous phase (total 6-12mnths)
* continue for at least 4-9 mnths after acute
acute phase to ensure adequate trial
- 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
continuous phase
- 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
non-pharm therapy
- 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
non-pharm CAM
- 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)
pharm tx
- 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
adjunct meds
- PRN, short course
- hypnotics, anxiolytics
approach: switch atidep when
- If ineffective/ intolerable to adequate dose in 2-4wk
○ SSRI –> SNRI/ MIRTA/ BUP/ AGOME/ VORTIO - If cross titration
○ Serotonin syndrome if combining serotonergic agents
direct switch (others –> SSRI)
except RIMA, fluoxetine)
1 SSRI can be stopped abruptly. Next serotonergic agent initiated
gradual cross tapering
(serotonergic daily 2mnths –> non-serotonergic: BUP, MRA)
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
wash out period
switch TO MAOi: washout at least 1wk
* 5wks if fluoxetine
switch FROM moclobemide (RIMA): 24hr washout
approach: augmenting tx if
- partial response
* combine 2nd antidep (diff MOA) to existing antidep (mirtazapine, BUP, nortriptyline TCA, Li, T3) - adjunct SGAs: quetiapine XR, aripiprazole, brexipiprazole
approach: tx resistant dep
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
dep in preg
consider nortriptyline in late preg
avoid paroxetine, BUP
breast feeding
consider sertraline (SSRI), mirtazapine
postpartum dep
brexanolone (GABA-A modulator: allosteric)
bipolar depression
Li
lamo, lurasidone, cariprazine
antipsychotics (quetiapine, olanzapine + fluoxetine ssri) QORA
hepatic insufficiency
avoid duloxetine (SNRI), agomelatine
caution: paroxetin, escitalopram
consider vortioxetine (mild-mod hep, no adj needed)
renal insuff
avoid: duloxetine
caution: paroxetine, vortioxetine (may consider)
post MI depression
may consider sertraline (antiplt effect)
avoid: TCA (ECG changes), escitalopram/ citalopram (QTc), trazodone ( QTc)
CBS accident
SSRI (fluoxetine)
caution with antiplt, anticoag
elderly
- 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
anticholinergic SE
avoid: TCA (duloxetine), paroxetine (SSRI)
- BPH, narrow angle glaucoma, urinary retention
- trazodone (priapism but no anticholinergic effect)
obese
consider: bupropion, SSRI (except paroxetine), SNRI
avoid: mirtazapine, TCA, MAOi
underweight/ eating d/o
consider: mirtazapine, fluoxetine
avoidL bupropion (seizure risk with electrolytes imbalance)
chronic pain/ neuropathy
consider: SNRI, TCA
- duloxetine: for diabetic peripheral neuropathy, chronic MSK pain
DM
avoid TCA, some SSRI (esp paroxetine)
* worsens glycemic control
consider: citalopram, Duloxetine (DM neuropathy)
seizure
consider: SSRI, SNRI
avoid: BUP, TCA,
hypertension
avoid: TCA, SNRI
(incr sympathetic tone)
(venlafaxine incr BP)
tamoxifen therapy (requires CYP2D6 conversion to active form)
avoid: paroxetine, fluoxetine, BUP (CYP2D6i)
consider: venlafaxine, desvenla, excitalopram
smoking
bupropion (smoking cessation too)
Suicidality
- Esp with <24yo (counselling pt, monitor by caregiver, regular review)
- Medication guide provided with dispensing, documented in med records
DDI
- serotonin syndrome
- risk of bleeing (serotonergic drugs)
- CNS depressant effect
- anticholinergic agents
- CYP
- serotonin syndrome
caused by?
onset?
- serotonergic agent + serotonergic agent
*triptans, ergots, opioids, linezolid, ritonavir, MAOi (if never wash out), subtramine (weight loss SNRI) - acute onset (6-8hrs)
degree of serotonin syndrome
- 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
- bleeding risk DDI
- 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)
- incr CNS depressant effects DDI
- alcohol (space 4-6hrs apart from meds)
- APS, H1 antagonist, opioids
- anticholinergics DDI
- excessive anticholinergics effect
* esp with TCA, paroxetine
* oxybutynin, Hyoscyamine, scopolamine
- CYP DDI
- fewer CYP int: mirt, escitalopram, venlafaxine, desvenlafaxine, vortioxetine
- fluvoxamine (ssri): inhbits CYP1A2, 2C19
- fluoxetine, paroxetine (ssri), BUP: inhibits CYP2D6
CYP3A4 i
clarithromycin, azoles (ketoconzaole), ritonavir
grapefruit juice
CYP3A4 inducers
CBP, PT, rifampicin, st john’s wort
antidep discontinuation sx
- 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)
FINISH sx
○ 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)
avoid antidep discontinuation sx by
- avoided by gradual tapering
* decr by half tab of lowest strength every 1-2wks. - unless fluoxetine, BUP (long t1/2 = no taper)
possible SE and management
- Drowsy = ON
- Insomnia = OM
- dizzy/ light headedness = rise slowly
- stomach upset = take after food
- sexual dysfunction = can be tx, less with MIRTA, BUP, AGOM
