depression Flashcards
what are the components of a suicide inquiry
ideation
- frequency, intensity, duration
suicide plan
- timing, location, lethality, access to means, preparatory acts
intent
- extent to which patient expects to carry out the plan and believes to be lethal/ self injurious
explore ambivalence
what are some helplines
- IMH’s mental helpline (6389-2222)
- Samaritan’s of SG (1800-221-4444)
what are the etiology of MDD
biological
- hormonal (increased secretion of stress hormone cortisol)
- monoamine hypothesis (decreased neurotransmitters in brain - NE, 5HT, DA)
psychological
- loss
- negative self-evaluation
psychosocial
- isolation
- lack of social support
genetics
- FMHx
- polymorphism in S allele of SERT gene (S/S more vulnerable)
medical
- medical conditions (endocrine, infection, neurological, CVD, deficiency, metabolic, malignancy)
- psychiatric (alcoholism, anxiety, ED, schizophrenia)
pharmacologicals (drug-induced)
- lipid soluble BB
- psychotropics (BZP, ASMs)
- withdrawal from alcohol
- corticosteroids (systemic)
- interferon beta 1a
- isotretinoin
what is the presentation and diagnostic criteria of MDD based on DSM5
at least 5 of the following over 2w
- In terest loss
- S leep (insomnia/ hypersomnia)
- A ppetite decreased
- D epressed mood (or irritability in children)
- C oncentration difficulties
- A ctivity level decreased
- G uilt/ worthlessness
- E nergy decreased
- S uicidal thoughts
what are the differentials for MDD
- adjustment disorder (within 3m onset of stressor but once stressor terminates, sx does not persist for additional 6m)
- acute stress disorder
(within 1m of traumatic event and last 3d to 1m) - dementia (stepwise/ insidious onset, progressive course, clear consciousness until later stages, poor short and long term memory)
- delirium
(acute onset, variable course, impaired consciousness, poor memory) - substance induced withdrawal/ intoxication (acute onset, rapid course lasting 24-72hrs, continuum of unimpaired to impaired consciousness, intact memory)
comparison to depression - cyclical onset, diurnal variation, generally unimpaired consciousness, intact memory)
what are the general assessments of MDD
- history of presenting illness
- psychiatric hx
- substance use hx
- complete medical and medication hx (drug allergy, s/e, effectiveness, other OTC/ supplements/ non-oral)
- family, social, developmental, occupational hx
- physical and neurological exam
- mental state exam
- labs and other investigations
- labs like vital signs, weight and BMI, U/E/Cr, FBC, LFTs, TFTs, ECG, FBG, lipid, urine toxicology
- other investigations like folate, vitB12 and pregnancy as indicated
identify significance of obtaining a few of the baseline labs
- weight bc extreme weight may indicate fluid congestion
- ECG to rule out cardiac abnorm
- FBG and lipid as some antidepressants and antipsychotics can increase these
- FBC to check for infection
list psychiatric rating scales used for MDD and their scoring
clinician-rated
- hamilton rating scale for depression (HAM-D)
*gold standard
self-rated
- PHQ2
- continue to PHQ9 if any of the two questions is positive response
scoring based on PHQ9
- minimal sx if 1-4
- mild if 5-9
- moderate if 10-14
- moderately-severe if 15-19
- severe if 20 or more
*start antidepressant if score 10 and above
what are the goals of therapy for MDD
symptom free
what are the non-pharmacological management for MDD
lifestyle/ behavioral changes
- good sleep hygiene to improve mood, appetite, energy and concentration
- relaxation techniques
- exercise
nutritional
- vitB12 (meat, poultry, fish, eggs, dairy products)
- L-methylfolate (leafy green vege, legumes, citrus fruits)
- vitD (fatty fish)
- SAMe
- omega-3 fatty acids (fatty fish)
- 5-hydroxytryptophan (lean protein like chicken and tofu, nuts and seeds, legumes, dairy, wholegrains like oats and brownrice)
herbal
- st john’s wort
*significant DDI with antidepressants
neurostimulation
- ECT
- rTMS
psychotherapy
*not as mono therapy in moderate to severe
light therapy for SAD
describe the chemical transmission at the synapse
precursors are transported by blood to the brain –> converted into NT via enzymatic processes –> stored in synaptic vesicles or released on demand –> released into the synaptic cleft in response to an action potential –> diffuse across the synaptic cleft and interact with receptors on the postsynaptic neurons –> induce events relating to downstream signal transduction cascade, leading to various physiological effects –> transmission ends by (i) enzymatic breakdown of NT (ii) NT reuptake (iii) presynaptic autoreceptors that regulate synthesis and release based on a negative feedback mechanism
list the classes of antidepressants and examples in each of the classes
tricyclic antidepressants (TCAs)
- amitriptyline
- nortriptyline
- clomipramine
- imipramine
- dothiepine
selective serotonin reuptake inhibitor (SSRI)
- fluoxetine
- fluvoxamine
- sertraline
- paroxetine
- escitalopram
- citalopram
selective norepinephrine reuptake inhibitor (SNRI)
- duloxetine
- venlafaxine
- desvenlafaxine
Noradrenergic and specific serotoninergic antidepressant (NaSSA)
- mirtazapine
serotonin modulator and stimulators (SMS)
- vortioxetine
reversible inhibitor of monoamine oxidase A (RIMA)
- meclobemide
melatonin receptor agonist
- agomelatine
norepinephrine dopamine reuptake inhibitor (NDRI)
- bupropion
serotonin antagonist and reuptake inhibitor (SARI)
- trazodone
list the additional indications for each antidepressant where relavant
amitriptyline
- depression
- neuropathic pain
- migraine prophylaxis
nortriptyline
- depression
- neuropathic pain
clomipramine
- depression
- OCD
fluoxetine
- depression
- OCD
- bulimia
fluvoxamine
- depression
- OCD
escitalopram
- depression
- anxiety
citalopram
- depression
- PD
sertraline
- depression
- OCD
- PD
paroxetine
- depression
- anxiety
duloxetine
- depression
- GAD
- DM neuropathy
- chronic MSK pain
- stress UI
venlafaxine
- depression
- GAD
bupropion
- depression
- smoking cessation
mirtazapine
- depression
what are the major adverse effects of concern to various antidepressants
- anticholinergic s/e
- sedation
- orthostatic hypotension
- seizures
- cardiac abnormalities
- sexual s/e
which antidepressants are likely to cause anticholinergic s/e
- TCAs (tertiary amines > secondary amines)
- paroxetine (+)
- venlafaxine (+)
- duloxetine (+)
- mirtazapine (+)
- bupropion (+)
