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Royal College 2023 > Depression > Flashcards

Depression Flashcards

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1
Q

What is the age cut off for late life depression?

A

60 years and older

It is different than recurrence of early onset adult depression

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2
Q

Late onset depression vs. early onset depression outcomes

A

Worse prognosis
More chronic course
Higher relapse rate
More medical comorbidity
Higher mortality
More cognitive impairment (need to monitor)

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3
Q

What is social isolation?

A

Objective lack of/limited social contact with others

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4
Q

What is loneliness?

A

Subjective feeling of being lonely or perception of social isolation

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5
Q

What are features of geriatric depression that are different than early onset depression?

A

More somatic symptoms (loss of appetite, insomnia, lack of energy, cognitive deficits, GI complaints, psychomotor retardation)
More anxiety
More withdrawal and lack of vigor
Less depressed mood
More anhedonia
Feelings of dysphoria or sadness frequently absent

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6
Q

What are risk factors for depression in older adults?

A
  1. Female
  2. Widowed/divorced
  3. Hx of depression
  4. Cerebrovascular changes
  5. Personality type (avoidant, dependent)
  6. Disabling illness
  7. Medications
  8. Excess alcohol
  9. Social factors
  10. Caregiver for ill person
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7
Q

What are 11 risk factors for suicide?

A

Non mod
1. Male
2. Older age
3. Widowed/divorce
4. Hx self harm
5. Losses
Modifiable
6. Social isolation
7. Chronic painful conditions
8. Abuse alcohol/meds
9. Presence and severity of depression
10. Presence of hopelessness and SI
11. Access to means

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8
Q

Methods to prevent depression

A
  1. Reminiscence
  2. Horticultural
  3. Physical exercise
  4. Videoconference with family
  5. Gender based social groups
  6. Social prescribing
  7. Watchful waiting
  8. CBT based bibliotherapy
  9. Problem solving therapy
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9
Q

What are the general treatment recommendations for unipolar depression?

A
  1. Antidepressants AND
  2. Psychotherapy AND
  3. ECT if:
    - Previous good response OR
    - Failed response to 1 or more antidepressant trial plus therapy
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10
Q

What are indications for ECT?

A
  1. Psychotic features
  2. Catatonic features
  3. Tx resistant depression
  4. Can’t tolerate medications
  5. Urgent response needed (suicidal, malnutrition/dehydration)
  6. Significant functional impairment
  7. Schizoaffective disorder
  8. Mania
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11
Q

What conditions are at risk with ECT?

A
  1. CV disease - arrhythmia, systolic, HTN
  2. Lesion with inc ICP
  3. Recent hemorrhage/stroke
  4. Bleeding or unstable vascular aneurysm
  5. Severe pulmonary condition
  6. ASA 4/5
  7. Transient memory loss, delirium
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12
Q

What is the general treatment recommendation for unipolar depression with psychotic features?

A

Combined antidepressant and antipsychotic

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13
Q

What are non pharmacologic treatment options for depression?

A
  1. Exercise and mind body interventions
  2. Psychotherapy
    a. CBT
    b. Problem solving therapy
    c. Interpersonal therapy
    d. Behaviour therapy
    e. Reminiscence therapy
  3. ECT
  4. rTMS
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14
Q

What are the two first line medications for acute episode of MDD? And two alternatives?

A
  1. Sertraline
  2. Duloxetine
  3. Escitalopram
  4. Citalopram
    *Limited by QTc (cit>esc)
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15
Q

What treatment to be used for depression in Parkinson’s disease?

A
  1. SSRI
  2. SNRI
  3. CBT
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16
Q

What treatment for depression post stroke?

A
  1. SSRI (inc risk bleeding with NSAID)
  2. SNRI, mirtazapine
  3. Methylphenidate
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17
Q

What are second and third line options for treatment of depression?

A
  1. Venlafaxine
  2. Mirtazapine
  3. Bupropion
  4. Vortioxetine
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18
Q

What medications should NOT be used to treat depression?

A

Fluoxetine (long t 1/2)
Paroxetine (high anticholinergic)
1st gen MAOi (selegiline, phenelzine, high risk drug drug/food)
TCAs (amitriptyline, clomipramine, doxepin - many sfx)

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19
Q

How should you monitor after starting patient on treatment for depression?

A

Every 1-2 weeks for response and dose
If SSRI/SNRI ask for hx of hypoNa, get baseline Na if pos hx
Na within 2-4 weeks of starting

20
Q

When should you consider augmentation for depression tx?

A

Significant improvement occurred but recovery not complete
Either:
1. Another 4 weeks of monotherapy
2. Augment with another antidepressant or Li or antipsychotic or specific psychotherapy

21
Q

Why is depression under diagnosed in older patients?

A
  1. 2 core symptoms of depressed mood and anhedonia not major features/manifest differently
  2. Feelings of dysphoria/sadness often absent
  3. Shift towards somatic symptoms
  4. Overlap of symptoms with other physical or neurologic conditions and frailty
22
Q

Loneliness is associated with what % increase in mortality in older adults?

A

26%

23
Q

What are seven comorbidities associated with loneliness?

A
  1. Cognitive impairment
  2. Depression, anxiety, suicide
  3. Cardio and cerebrovascular
  4. Mortality
  5. Elder abuse
  6. Smoking, substance, sleep
  7. Poor function/ADLs
24
Q

What are risk of bupropion?

A
  1. Lowers seizure threshold
  2. CYP2D6 inhibitor - substrates include donepezil, oxycodone, metoprolol
25
Q

What is the minimum amount of time SSRI needs to be taken for risk of withdrawal? What are symptoms of withdrawal?

A

At least 1 month

FINISH
Flu like
Insomnia
Nausea
Imbalance
Sensory disturbances
Hyperarousal

26
Q

What are concerns with paroxetine?

A

CYP2D6 inhibitor
Tramadol is a substrate and inhibits reuptake of NE and serotonin

27
Q

What are symptoms of serotonin syndrome?

A

Shivering
Hyperreflexia, myoclonus
Inc temp
Vital signs inc HR, inc RR, inc/dec BP
Encephalopathy
Restlessness
Sweating

28
Q

What are some common CYP2D6 substrates?

A

Tramadol
Dextromethorphan
Sertraline
Duloxetine
Donepezil
Oxycodone
Metoprolol

29
Q

What scale can you use to screen for depression in patients with dementia? What is it’s sensitivity?

A

Cornell scale for depression in dementia
Sn 0.84 Sp 0.8
Improve Sn by changing cut off from 8 to 6

30
Q

What scale can you use to screen for depression in those without dementia?

A

GDS
PHQ-9

31
Q

How long should you treat first episode of depression?

A

Minimum 1 year, up to 2 years
Indefinite if severe, hard to treat, required ECT or >2 episodes

32
Q

What are 8 important things to ask on social history for person with depression?

A
  1. Bereavement recent
  2. Adverse life events
  3. Institutionalized setting
  4. Chronic stress
  5. Widowed/divorced
  6. Low social supports
  7. Role of caregiver
  8. Alcohol/substance misuse
33
Q

What are 4 reasons for neuropsychiatric testing in clinic?

A
  1. Distinguish between different types of dementias (AD vs. other)
  2. Differentiate neurologic vs. psychiatric conditions
  3. Help determine capacity
  4. Patient with early changes
34
Q

What are precipitating factors for depression?

A
  1. Recent bereavement
  2. Moved to institution
  3. Adverse life events
  4. Chronic stress
  5. Persistent sleep difficulties
35
Q

What are next steps for patient on tx but resistant to tx?

A
  1. Augment with: additional AD, Li, antipsychotic
  2. Switch to another antidepressant
  3. ECT
  4. rTMS
  5. Increase dose
  6. Pharmacogenetic testing
36
Q

What are 6 risk factors for hoarding in older adults?

A
  1. Executive dysfunction
  2. Excess emotional attachment to possessions
  3. avoidance of stressful situations
  4. Personality traits of perfectionism
  5. History of trauma
  6. Genetics
37
Q

What are reasons to refer to geri psych?

A
  1. Bipolar disorder
  2. Psychotic depression
  3. Suicidal ideation/intent

Other
1. Depression + substance use
2. Severe depression
3. Depression + dementia

38
Q

What percentage of older adults achieve remission with tx of depression?

A

1/3

39
Q

PHQ-9 cut off

A

10+
Good response/remission rate

40
Q

What are three first line treatments for depression suggested by CANMAT 2016?

A

Duloxetine
Mirtazapine
Nortriptyline

41
Q

Examples of SSRIs and side effects

A

Sertraline
Citalopram
Escitalopram

Falls, QT prolong, hypoNa, weight gain, drowsiness, nausea, dry mouth, HA, insomnia, diarrhea, sexual dysfunction

42
Q

Examples of SNRIs and side effects

A

Duloxetine
Venlafaxine

Falls, urinary retention (D), HTN (V), bleeding, constipation, hypoNa

43
Q

What are atypical antidepressants and side effects?

A

Mirtazapine - dry mouth, weight gain, sedation, hypoNa, anticholinergic
Bupropion - insomnia, anxiety, vivid dreams, weight loss, reduced seizure threshold

44
Q

What are TCA examples and side effects?

A

Amitriptyline
Nortriptyline

Anticholinergic, OH
Dizzy, drowsy, memory, weight gain, falls, QT, seizures

45
Q

Meta-analysis JAGS 2011 of depression in dementia showed disappointing results. Which two antidepressants showed positive outcomes in this meta-analysis?
What are three questions to be able to implement this meta-analysis in an evidence-based medicine practice?

A

Two antidepressants showing positive efficacy: clomipramine, sertraline

  1. Who was the study population
  2. What dose of drug did they use
  3. What was the duration of drug
  4. What was the clinical outcome

Royal College 2023 (79 decks)

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