Depression Flashcards
What are general risk factors for suicide? (6)
o Poor
o Elderly
o Lonely
o Male
o Physical/mental comorbidities
o Previous suicide attempt
What are key steps in managing suicide risk? (5)
1) Identifying and managing underlying disorders
2) Identifying risk factors
3) Identifying protective factors (or lack thereof)
4) Removing means of suicide
5) Activating support system (with patient consent)
State the medical disorders associated with Depression (7)
1) Endocrine (Hypothyroidism, Cushing Syndrome, T2DM in women)
2) CVS: CAD, MI, CHF
3) Nutritional Deficiency: Anemia, Wernicke’s Encephalopathy
4) Infections: CNS infections, HIV/STD, TB
5) Neurological insults: Stroke, Alzheimer, Parkinsons, Epilepsy, Pain
6) Malignancy
7) Metabolic disorders: electrolyte imbalance, hepatic encephalopathy
State the DSM-5 criteria for MDD (3)
1) At least 5 symptoms (In.SAD.CAGES) have been present during the same 2-week period and represent a change from previous functioning. 1 symptom must be loss of interest or feeling depressed
2) Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.
3) Symptoms are not caused by an underlying medical condition or substance (reversible causes).
What is the clinical presentation of Depression? (InSADCAGES)
1) Interest: Decreased interest and pleasure in normal activities
2) Sleep: Insomnia or hypersomnia
- Insomnia = want to sleep but cannot sleep
- Hypersomnia = sleep a lot
3) Appetite: Decreased appetite, weight loss (from loss of interest)
4) Depressed: Depressed mood (adults); may be irritable mood in children
5) Concentration: Impaired concentration and decision making
6) Activity: Psychomotor retardation or agitation
7) Guilt: Feelings of guilt or worthlessness (that is excessive and inappropriate)
8) Energy: Decreased energy or fatigue
- Be sure to check for DM, thyroid disorders, anemia or bleeds
9) Suicidal thoughts or attempts
Define Adjustment Disorder and Acute Stress Disorder
o Adjustment Disorder: Symptoms occur within 3 months of onset of a stressor; but once the stressor is terminated, symptoms do not persist for additional 6 months
o Acute Stress Disorder: Symptoms occur within 1 month of a traumatic event and lasts 3 days to 1 month. Symptoms include intense fear, helplessness, horror, with dissociation, re-experiencing, avoidance, increased arousal
o If persist for more than 1 month then is PTSD
State 2 important things to be done during General Assessment for Depression (history taking)
Ask for history of manic/hypomanic episodes
Assess for suicidal ideation and risks
Differentiate Depression from other conditions (Delirium, Dementia, Withdrawal/ intoxication) with respect to Onset, Consciousness and Memory
Onset of Depression is cyclical, Consciousness is generally unimpaired and memory is intact
State the PHQ-9 score above which, treatment of MDD with antidepressant is indicated and the severity of depression that corresponds to the score
Score 10 and above (moderate depression)
Name examples of SSRIs (5)
Fluoxetine, Fluvoxamine, Escitalopram, Paroxetine, Setraline
Name examples of SNRIs (3)
Duloxetine, Venlafaxine, Desvenlafaxine
What drug class does Mirtazapine belong to?
Noradrenergic and Specific Serotonergic antidepressant
Explain why a 5 week washout period is required before switching from fluoxetine to Moclobemide, while other antidepressants generally only require 1 week washout
Fluoxetine has long half life of 4-6 days and active metabolite Norfluoxetine with longer half life of (4-16 days)
State the half life of Vortioxetine
66 hours
State the cause of GI and Sexual dysfunction ADRs
- GI side effects (N/V/D) are due to activation of 5HT3 receptor
- Sexual dysfunction side effects are due to activation of 5HT2 receptor
Which SSRI has the most anticholinergic side effects: most sedating, most weight gain, shortest t1/2 + have withdrawal effect and should not be used in elderly?
Paroxetine
What is the maximum daily dose of Amitriptyline?
300mg/day
What is the maximum daily dose of Clomipramine?
300mg/day
State usual starting dose of Fluoxetine and the maximum daily dose
Starting dose: 20mg OM
Max dose: 80mg
State the usual adult dose of Desvenlafaxine ER
50mg/day
State the usual dosing range of Mirtazapine
15-45mg/day
What are the symptoms of antidepressant discontinuation syndrome? (FINISH)
1) Flu like symptoms (lethargy, fatigue, headache, achiness, sweating)
2) Insomnia (with vivid dreams or nightmares)
3) Nausea (sometimes vomiting),
4) Imbalance (dizziness, vertigo, light headedness),
5) Sensory disturbances (“burning,” “tingling,” “electric like” sensations)
6) Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness).
Which antidepressant is DOC for those with insomnia or cannot eat (underweight)?
Mirtazapine (sedating + appetite stimulating)
Which antidepressant is DOC for those feeling tired/no energy?
Buproprion (stimulating antidepressant)
Which antidepressant is DOC for those with concomitant chronic pain/ neuropathy? (e.g diabetic peripheral neuropathy , fibromyalgia and chronic MSK pain)
Duloxetine
Which antidepressant should be avoided in those with eating disorders/ risk of seizures?
Buproprion
State drugs that can be used if patients get sexual dysfunction upon using SSRI/SNRI
Mirtazapine, Buproprion
State 1st line antidepressants for those with no other comorbidities
First Line (antidepressant monotherapy): Mirtazapine, SSRI, SNRI, or Bupropion
State what is considered an adequate trial of antidepressant
Adequate Trial = adequate dose + duration (4-8 weeks).
State time course of treatment response to antidepressant treatment
o Physical symptoms may improve in 1-2 weeks (e.g. sleep, appetite)
o Mood symptoms may take longer time to improve, e.g. 4-8 weeks
State duration of treatment of the 1st episode of uncomplicated MDD
Continue treatment for at least another 4-9 months after acute phase treatment (i.e. Total treatment duration = 6-12 months at least)
State the respective ways to manage MDD treatment for the various scenarios:
a) No response or intolerable to adequate dose in 2-4 weeks
b) Partial response
c) Treatment Resistant
a) Switch
- Either cross titrate or direct switch (cross-taper recommended if switching from serotonergic to non-serotonergic agent; if serotonergic agent being used for past 2 months)
- Washout required for MAOi to avoid Serotonin syndrome (If switching from Moclobemide to other antidepressant, washout 24hrs; if switching from other antidepressant to Moclobemide, washout for at least 1 wk, if fluoxetine then 5 wk)
b) Add on 2nd antidepressant with different MOA OR add on SGA (Quetiapine XR, Aripiprazole or Brexpiprazole)
c)
* Neurostimulation: Electroconvulsive Therapy, repetitive Transcranial Magnetic Stimulation
* Symbyax® Oral Capsule (Olanzapine 6mg + Fluoxetine 25mg per Cap)
* Spravato® Nasal Spray (Esketamine 28mg per vial), as adjunct to SSRI/SNRI treatment.
What is the remission rate with first antidepressant use?
~30%
Which SGAs can be used as adjuncts for MDD? (3)
Aripiprazole
Brexpiprazole
Quetiapine XR
Which herb has significant DDI with antidepressants
St. John’s Wort
What DDI is SPECIFICALLY associated with SSRI and how to manage?
Increase risk of bleeds if used in elderly on NSAIDs, Warfarin, Steroids, Anticoagulant, Antiplatelet (Note that any drug with serotonergic properties has inc bleed risk)
Consider adding PPI.
What is the key thing to note with antidepressant use in young patients?
Risk of suicide increase for those 24 y.o or younger; counselling required
Which class of antidepressant most associated with hyponatremia?
State possible antidepressants to switch to should this ADR occur.
SSRI.
Switch to: Agomelatine, Buproprion, Mirtazapine (low dose Mirtazapine recommended by NBT)
Which SNRI may worsen/ cause hypertension?
Venlafaxine (technically all but idk why NBT only put this)
What are the goals of therapy for MDD treatment?
Goal of Therapy = Remission of symptoms; treatment adherence; Suicide Prevention.
List the non-pharmacological management of depression (4)
Sleep Hygiene; Psychotherapy, Counselling.
ECT reserved for severe depression
State the counselling points for Antidepressants (5)
1) Antidepressants may take at least a couple of weeks to help with symptoms of low mood, poor sleep and appetite, may need at least a couple of months to help with anxiety. Do not stop medication without informing doctor
2) Do not take at same time as alcohol (space 4-6 hours apart)
3) Tell your Drs & nurses what other medicines you are using
4) If your condition is worsening , or if you feel suicidal or bothered by side effects, contact Dr. (Suicide risk highest for children & adolescents ≤ 24 years old, hence need to monitor closely)
5) Possible Side Effects (but not everybody will experience these
* DROWSY –“take at bedtime”
* INSOMNIA –“take in the morning”
* DIZZY/ LIGHT HEADEDNESS –“rise up slowly”
* STOMACH UPSET take after food”
* CHANGES in SEXUAL FUNCTION –“may cause CHANGES in sexual functioning in some people. Tell your doctor if you notice any changes since this can be treated and reversible ” (This side effect is less likely with Mirtazapine, Bupropion or Agomelatine)
* Persistently ELEVATED/ EXPANSIVE MOOD (DIGFAST) – Seek medical attention immediately
What are examples of drug classes that are serotonergic causing increase risk of Serotonin syndrome? (8)
- SSRI, SNRI, SMS (serotonin modulator and stimulator)
- Opioid (e.g Tramadol, Fentanyl, Pethidine, Hydromorphone), Dextromethorphan
- Ritonavir, Linezolid
- Triptans
- MAOi
State how to avoid antidepressant discontinuation syndrome and how to manage if it occurs. Also state the antidepressants that do not require tapering
Avoid by gradual taper (not necessary for Buproprion and Fluoxetine due to long t1/2 and active metabolites)
If occurs, no need to treat, self-resolving in 1-2 weeks
State the MOA by which SNRI and TCAs may cause Hypertension
Both inhibit the reuptake of norepinephrine, resulting in increase activation of sympathetic nervous system, which increases the HR, which contributes to increase in BP.
What is the safest antidepressant for patients with high bleed risk?
Agomelatine
State the antidepressant that is a CYP1A2 substrate and what monitoring needs to be done. Also state which drugs it should NOT be used with.
Agomelatine (monitor LFTs).
Fluvoxamine, Macrolides, FQs (potent CYP1A2 inhibitors)
State which drugs are substrates of CYP2D6 and which antidepressants may worsen their ADR if used.
Substrates:
- Opioid agonists (Codeine, Tramadol, hydrocodone, oxycodone)
- BB (e.g Metoprolol)
Antidepressants that inhibit CYP2D6:
- Buproprion
- Paroxetine
- Fluoxetine
State which drugs are substrates of CYP3A4.
Statins (except Rosuva)
CCBs
State the drugs that may be affected by CYP1A2 inhibition.
Agomelatine, Theophylline, Warfarin-R, Amiodarone
State possible antidepressant options for person aged < 18 years old (3 classes, 9 drugs total)
1) SSRI (Setraline, Fluvoxamine, Fluoxetine, Escitalopram)
2) SNRI (only Duloxetine)
3) TCA (Amitriptyline, Nortriptyline, Imipramine, Clomipramine)
Which SNRI may cause urinary retention?
Duloxetine
Appetite stimulating and sedating properties of Mirtazapine is due to?
H1 antagonism
Which antidepressant is less associated with CYP interactions and is also not a substrate of liver enzymes?
Desvenlafaxine
