Depression Flashcards
[Pathophysiology] Depression
Increased cortisol (stress)
Decreased neurotransmitters (NE, 5-HT, Dopamine)
Loss, Isolation, lack of social support
Genetics
Medical: DM, CVA, cancer
Secondary Causes of Depression
Endocrine (Hypothyroidism, Cushing)
Cardiovascular: CAD, CHF, MI
Infections, Alzheimer’s, Epilepsy
Malignancy
Clinical Presentation of Depression
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
DDx for Depression
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
2 impt symptoms for assessing Depression:
Interest
Feeling down
1st-line agent for Depression:
SSRI, SNRI, Mirtazapine, Bupropion, Agomelatine (?)
Characteristics of the TRIO (Mirt, Bup, Ago)
Less GI and sexual dysfunction
Less bleeding risk
Less hyponatremia risk
To further decide using weight, hepatic characteristics.
Rule OUTs: Bupropion
Patient has eating disorders,
Seizures
CYP2D6 interactions (eg. Opioids, ROBA)
Pregnancy
Rule OUTs: Agomelatine
Hepatic impaired
BUT has sleep improvement w/o day time sedation.
Rule INs and OUTs of Paroxetine:
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
Key points for Sertraline:
- Take w/ food for better absorption.
- Suitable for Breastfeeding
- Post-MI Depression (has antiplatelet effect)
- Less QTc prolongation compared to Escitalopram.
- Suitable for Dementia BPSD.
Unique point about Clomipramine.
Is a TCA used as 2nd-line for OCD, after SSRIs, before SNRIs.
Hepatic and Renal impaired:
Vortioxetine
compare SSRI and Mirtazapine:
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.
Wash-out how long for MAOIs (both changing to and from):
Changing from Moclobemide - 24hr
Changing to Moclobemide - 1 week (5 weeks for Fluoxetine)
Suicidality risk is higher in:
<= 24 years old.
Which agent would you use for chronic pain / neuropathy?
Duloxetine
use of Fluoxetine should be cautioned with coadministration of which drugs?
CYP2D6 inhibition:
- Tamoxifen therapy
- Opioids (Codeine, Hydrocodone, Oxycodone, Tramadol)
- ROBA (risp, olan, brex, arip)
use of Fluvoxamine should be cautioned with coadministration of which drugs?
CYP1A2 inhibition:
- Theophylline
- Amiodarone
- Warfarin-R
- Agomelatine
- Clozapine
- Phenothiazines
CYP2C19 inhibition:
- Warfarin-R
- Omeprazole
- Sulphonylurea: tolbutamide
List the S&S of Antidepressant Discontinuation Syndrome:
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.
Counselling points of Antidepressants:
- will take a few weeks to help;
- Alcohol (space 4-6 hrs apart);
- If condition worsens, or if feel suicidal, contact Dr. (esp. <= 24 yo)
- Side effects
- Drowsy
- Insomnia
- Dizzy / light-headed
- Stomach upset
- Changes in sexual dysfunction
[Side Effects] Antidepressants
Drowsy
Insomnia
Dizzy / light-headed
Stomach upset
Changes in sexual function
how long will the treatment be?
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
[Side Effects] SSRIs, SNRIs
GI and sexual dysfunction
Fluoxetine - Insomnia
Headache
Transient nervousness
Bleeding risk
Hyponatremia
EPSE
SNRI (Venlafaxine) - increased BP
