Depression

Question 1

[Pathophysiology] Depression

Answer 1

Increased cortisol (stress)
Decreased neurotransmitters (NE, 5-HT, Dopamine)
Loss, Isolation, lack of social support
Genetics
Medical: DM, CVA, cancer

Question 2

Secondary Causes of Depression

Answer 2

Endocrine (Hypothyroidism, Cushing)
Cardiovascular: CAD, CHF, MI
Infections, Alzheimer’s, Epilepsy
Malignancy

Question 3

Clinical Presentation of Depression

Answer 3

In. SAD.CAGES (>= 5 of 9 sx over 2 weeks), including depressed mood / loss of interest.

Interest (decreased)

Sleep (insomnia, or hypersomnia)
Appetite (decreased)
Depressed mood

Concentration (impaired)
Activity - psychomotor retardation, agitation
Guilt
Energy (decreased, fatigue)
Suicidal thoughts or attempts

Question 4

DDx for Depression

Answer 4

Adjustment Disorder - within 3 mo of stressor
Acute Stress Disorder - within 1 mo of traumatic event.

<- Has trigger / stressor / traumatic event.

Bipolar Disorder -> Hx of mania / hypomanic episodes;
Delirium -> acute onset, impaired consciousness poor memory;
Dementia -> poor short and long-term memory;
Withdrawal -> acute onset, visual and tactile hallucinations

Question 5

2 impt symptoms for assessing Depression:

Answer 5

Interest
Feeling down

Question 6

1st-line agent for Depression:

Answer 6

SSRI, SNRI, Mirtazapine, Bupropion, Agomelatine (?)

Question 7

Characteristics of the TRIO (Mirt, Bup, Ago)

Answer 7

Less GI and sexual dysfunction
Less bleeding risk
Less hyponatremia risk

To further decide using weight, hepatic characteristics.

Question 8

Rule OUTs: Bupropion

Answer 8

Patient has eating disorders,
Seizures
CYP2D6 interactions (eg. Opioids, ROBA)
Pregnancy

Question 9

Rule OUTs: Agomelatine

Answer 9

Hepatic impaired
BUT has sleep improvement w/o day time sedation.

Question 10

Rule INs and OUTs of Paroxetine:

Answer 10

INs
1. All Anxiety disorders (GAD, PD, SAD, OCD, PTSD)

OUTs
1. Anticholinergic: BPH, acute angle glaucoma
2. Pregnancy
3. CYP2D6 Substrates: Metoprolol, Opioids, ROBA
4. Discontinuation syndrome

Question 11

Key points for Sertraline:

Answer 11

1. Take w/ food for better absorption.
2. Suitable for Breastfeeding
3. Post-MI Depression (has antiplatelet effect)
4. Less QTc prolongation compared to Escitalopram.
5. Suitable for Dementia BPSD.

Question 12

Unique point about Clomipramine.

Answer 12

Is a TCA used as 2nd-line for OCD, after SSRIs, before SNRIs.

Question 13

Hepatic and Renal impaired:

Answer 13

Vortioxetine

Question 14

compare SSRI and Mirtazapine:

Answer 14

SSRI - has GI and sexual dysfunction, Fluoxetine causes insomnia. Has higher bleeding risk.
Mirtazapine - less GI and sexual dysfunction, somnolence, weight gain. Has less bleeding risk.

Question 15

Wash-out how long for MAOIs (both changing to and from):

Answer 15

Changing from Moclobemide - 24hr
Changing to Moclobemide - 1 week (5 weeks for Fluoxetine)

Question 16

Suicidality risk is higher in:

Answer 16

<= 24 years old.

Question 17

Which agent would you use for chronic pain / neuropathy?

Answer 17

Duloxetine

Question 18

use of Fluoxetine should be cautioned with coadministration of which drugs?

Answer 18

CYP2D6 inhibition:
- Tamoxifen therapy
- Opioids (Codeine, Hydrocodone, Oxycodone, Tramadol)
- ROBA (risp, olan, brex, arip)

Question 19

use of Fluvoxamine should be cautioned with coadministration of which drugs?

Answer 19

CYP1A2 inhibition:
- Theophylline
- Amiodarone
- Warfarin-R
- Agomelatine
- Clozapine
- Phenothiazines

CYP2C19 inhibition:
- Warfarin-R
- Omeprazole
- Sulphonylurea: tolbutamide

Question 20

List the S&S of Antidepressant Discontinuation Syndrome:

Answer 20

Flu-like sx (lethargy, fatigue, sweating, achiness, headache)
Insomnia (vivid dreams or nightmares)
Nausea / vomiting
Imbalance (dizziness, vertigo, light-headedness)
Sensory disturbances (“burning”, “tingling”)
Hyperarousal (anxiety, irritability, aggression, mania)

Can be avoided w gradual tapering.

Question 21

Counselling points of Antidepressants:

Answer 21

1. will take a few weeks to help;
2. Alcohol (space 4-6 hrs apart);
3. If condition worsens, or if feel suicidal, contact Dr. (esp. <= 24 yo)
4. Side effects
   - Drowsy
   - Insomnia
   - Dizzy / light-headed
   - Stomach upset
   - Changes in sexual dysfunction

Question 22

[Side Effects] Antidepressants

Answer 22

Drowsy
Insomnia
Dizzy / light-headed
Stomach upset
Changes in sexual function

Question 23

how long will the treatment be?

Answer 23

Physical sx improve in 1-2 wk
Mood sx improve in 4-8 wk
————————————-
Total duration = 6-12 mo
Acute phase - 4-8 wk (max trial period = 12wks)
Continuation phase - 4-9 mo

Question 24

[Side Effects] SSRIs, SNRIs

Answer 24

GI and sexual dysfunction
Fluoxetine - Insomnia
Headache
Transient nervousness

Bleeding risk
Hyponatremia
EPSE

SNRI (Venlafaxine) - increased BP