depression Flashcards
suicide inquiry
1) ideation: frequency, intensity, duration
2) suicide plan
3) intent
4) explore ambivalence
suicide risk factors
1) prior attempt of suicide/self harm
2) past/current psychiatric diagnosis
3) ley symptoms
4) family history
5) Stressors
6) Access
aetiology for depression
1) biological: neuroendocrine theories
- hormonal influences: increases cortisol
- monoamine hypothesis: decrease neurotransmitters in brain (norepinephrine, serotonin, dopamine)
2) psychological
3) psychosocial
secondary causes for depression tldr
1) medical
2) psychiatric
3) drug-induced
medical secondary cause for depression
1) endocrine disorder
- hyperthyroidism
- Cushing’s syndrome
- bidirectional association between depression and T2DM in women
2) deficiency states
- anemia
- Wernicke’s encephalopathy
3) metabolic disorders
- electrolyte imbalance
- hepatic encephalopathy
4) cardiovascular
- CAD, CHF, MI
- depression risk factors for poor diagnosis among patients w ACS
5) neurological
6) malignancy
psychiatric secondary causes for depression
alcoholism, anxiety, eating, Schizophrenia
drug-induced secondary cause for depression
1) lipid soluble BB
2) psychotropic: CNS depressant
3) withdrawal
4) systemic corticosteroids
5) isotretinoin
6) interferon beta-1a
DSM-5 criteria for depression
1) depressed mood or loss of interest and at least 5 symptoms present during the same 2 week period and is change from previous functioning (In.SAD.CAGES)
- Interest: decreased interest and pleasure from normal activities
- sleep: insomnia or hypersomia
- Appetite: decreased appetite, weight loss
- Depressed: depressed mood, maybe irritable mood in children
- Concentration: impaired concentration and decision making
- Activity: psychomotor retardation or agitation
- Guilt: feelings of guilt and worthlessness
- Energy: decreased energy or fatigue
- Suicidal thoughts or attempts
2) Symptoms cause significant distress or impairment in functioning
3) symptoms not caused by underlying medical condition or substance
common characteristics of depression
- cyclical onset
- unimpaired consciousness
- intact memory
classifications of depression
1) major depressive disorder (MDD)
- single and recurrent episode
- ≥ 5 symptoms including depressive mood and loss of interest
2) persistent depressive disorder (dysthymia)
- depressed mood + ≥ 2 symptoms for 2 years but not fulfilling MDD diagnosis
3) disruptive mood dysregulation
- children up to 18 yo
4) unipolar depression
- reactive depression: non-familial, associated with life events, + anxiety and agitation
- endogenous depression: familial pattern, not directly related to external stress
general assessment of depression
- same as Schizophrenia but psychiatric assessment assess for history of maniac/hypomanic episodes
differential diagnosis for depression
1) adjustment disorder
- with anxiety and/or depressive mood
- symptoms occur within 3 months of onset of a stressor but once stressor is terminated, symptoms do not persist for additional 6 months
2) acute stress disorder
- symptoms occur within 1 month of traumatic event and last 3 days - 1 month
- intense fear, helplessness, horror, with dissociation, re-experiencing, avoidance, increased arousal
3) bipolar
4) delirium
- acute onset, impaired consciousness, poor memory
5) dementia
- insidious, step-wise change
- clear consciousness until later stage
- poor short and long term memory
6) withdrawal/intoxication
- acute onset
- continuum of unimpaired to impaired consciousness
- intact memory
assessments for depression
1) psychiatric rating scales
- HAM-D
** goal: HAM-D score ≤ 7
** response = 50% improvement
2) self-related
- PHQ-9 (start antidepressant if ≥ 10
** 1-4: minimal symptoms
** 5-9: mild depression
** 10-14: moderate depression
**15-19: moderately severe depression
** ≥ 20: severe depression
non-pharmaco for depression
1) therapeutic lifestyle/behavioural change
- sleep hygiene, exercise, relaxation techniques
2) nutritional
- Vit B12, L-methylfolate, Vit D, omega-3
3) Herbal
- St John’s Wort
principles of pharmaco therapy for depression
- indication: moderate - severe depression
- which to consider first
** mirtazapine, SSRI, SNRI, bupropion, agomelatine > TCA > MAOi
phases of depression therapy
1) acute phase treatment
- adequate trial = adequate dose + duration (4-8 wks)
- delayed onset of effectiveness
** physical symptoms improve 1-2 wks
** mood symptoms improve 4-8 wks
** if patient feel good right after meds then bipolar mania
2) continuation phase
- continue for at least another 4-9 months after acute phase treatment
Selective serotonin reuptake inhibitors (SSRI) - types
1) fluoxetine -> norfluoxetine
2) fluvoxamine
3) escitalopram
4) paroxetine
Selective serotonin reuptake inhibitors (SSRI) - MOA
block reuptake of 5-HT selectively
Selective serotonin reuptake inhibitors (SSRI) - SE
1) GI, sexual dysfunction
2) initiation: headache, transient nervousness
3) hyponatremia, bleeding risk, EPSE
4) N, insomnia
- discontinuation/rebound symptoms of withdrawal when plasma levels of drug drop between doses
5) serotonin syndrome
Selective serotonin reuptake inhibitors (SSRI) - PGx testing
for CYP2D6 and CYP2C19
- why?
** poor metaboliser -> reduced SSRI metabolism -> more exposure to SSRI -> increased AE risk - who?
** experience inadequate response or AE from SSRI
** before initiation for high toxicity risk patients - actions to take after testing
** intermediate metaboliser = reduce dose
** poor metaboliser/ultrarapid metaboliser = alternative therapy or adjust dose
Selective serotonin reuptake inhibitors (SSRI) - notes
- fluoxetine long t1/2
- paroxetine most anticholinergic, sedating, increase weight and short t1/2
- escitalopram QTc prolongation if high dose in elderly
serotonin norepinephrine reuptake inhibitors (SNRI) - types
1) Venlafaxine -> desvenlafaxine
2) duloxetine
serotonin norepinephrine reuptake inhibitors (SNRI) - MOA
block reuptake of NE and 5HT
serotonin norepinephrine reuptake inhibitors (SNRI) - SE
- same as SSRI
- venlafaxine: increase BP
- duloxetine: urinary hesitation
- withdrawal effect stronger and more common
