Depression Flashcards
True or false: many ppl suffering from depression dont report depressed mood
True!
Some classic signs and symptoms of depression (Mr. George) and appropriate next step if present in patient
anhedonia, insomnia, weight gain…
–> perform standardized screening questionnaire for major depression (assist in making diagnosis)
Two most common conditions seen by primary care physicians
- hypertension
2. depression
Point prevalence of depression in outpatient setting vs. inpatient setting
outpatient: 4.8-8.6%
inpatient: 14.6%
% of men predicted to suffer an episode of major depression (at some point in life)
7-12%
% of women predicted to suffer an episode of major depression at one point in their lives
20-25%
Bipolar disorder lifetime prevalence men vs. women
men: 0.4%
women: 1.6%
but has no gender difference?
Peak onset depression
age 20-30
high risk for relapse and recurrence (>half of ppl who experience one episode)
Cost of depression in US
> 43 billion every year (medical treatments, lost work productivity)
Global disease burden depression
4.4% of disease burden
(similar to that of diarrheal diseases and ischemic heart disease)
300 mill ppl worldwide, 18 mill of them in US!
Morbidity and mortality of untreated depression: what patients complain of
not nec “feeling depressed”, but rather:
lack of interest or pleasure in activities
somatic complaints
vague unexplained complaints
–> “Unexplained physical symptoms”; more likely to be considered “undifferentiated” patients in primary care settings vs. pts w depression in psychiatric inpatient or outpatient care settings
Depression is often undiagnosed and untreated
even when it is diagnosed it is undertreated!
Barriers to effective depression screening
inadequate education and training, limited coordination w mental health resources, time constraints, poor systematic follow up, inadequate reimbursement
Further barriers (demographic) to diagnosis of depression in pri care
gender, age, culture, language of patient and physician
Patients with the following dzs with concurrent depression have poorer outcomes than those without depression
diabetes, ischemic heart disease, stroke, lung disorders
Depression and higher risk of death from other dzs
heart dz, respiratory disorders, stroke, accidents, suicide
% of patients with severe mood disorders who die from suicide
15%
% of patients who visited their pri care physician on same day as their suicide
20%
Etiology of mood disorders
neurotransmitters, genetics, psychosocial stressors all play a part
True or false: same depressed patient may have variable clinical symptoms from one major depressive episode to another
True
Neurotransmitter deficiencies
serotonin, norepinephrine, dopamine, GABA, peptide neurotransmitters (somatostatin, thyroid-related hormones, brain-derived neurotrophic factors)
all hypothesized to contribute!
Overactivity in neurotransmitters
substance P, acetylcholine; elevated cortisol (w lack of diurnal variation) also proposed
Genetics and mood disorders
no specific genes found but clear genetic component (depression and bipolar disorder are inheritable)
)
Risk of depression in First degree relatives of patients w recurrent major depression
1.5-3 times higher risk of depression compared to gen pop
% children w one parent w mood disorder to develop one themselves
27%
% children w 2 parents w mood disorders to develop one themselves
50-75%
Bipolar: lifetime prevalence in first degree relatives of pts w bipolar disorder
12%
Genetics not enough for mood disorder
but genetics not enough (identical twins have incomplete concordance regarding depression, can occur in ppl w out fam hx of mood disorders)
Mxns of depression
changes in neurocircuitry, size of neurons, neuronal function, repair capabilities, production of new neurons
elevated cortisol in some may –> reduce hippocampus volume
Primary care: always consider depression in
- setting of unexplained physical symptoms or complaints
- persistent worries
- concerns about medical illnesses
- complaints that do not respond to typical interventions
- complaints of outright anxiety or panic attacks
…
also substance abuse disorders
Determine baseline mood and function by:
asking open ended questions of pt about normal patterns and variations
Mood vs. affect
mood: range of emotions a person feels over period of time
affect: how a person displays their mood
Mood disorder may affect in a patient
concentration, attention, motivation, interest, sleep, energy level, hunger, satiety levels, sexual pleasure, pain sensation
lose pleasure and interest (anhedonia) in things, ppl, activities they used to enjoy
cognitive function impaired! (difficulty paying attention/following stories, selective recall, distortion of normal perceptions)
interruption in personal relationships: increased anger and conflicts, lower frustration tolerance, apathy, lack of enthusiastic feelings toward other ppl, emotionally constricted, lose emotional flexibility
Pseudodementia
- severe cognitive impairment due to depression
- may be seen in elder populations or patients with CNS disorders
Psychomotor activity changes
Retardation: thoughts, motor movements, speech slowed down
Agitation: unintentional and purposeless movements (unstoppable crying, pacing room, hand wringing)
may complain of insomnia (hard to fall asleep, wake up in middle of night or early morning w feelings of sadness, anxiety, doom/dread)
sleep excessively, stay in bed
Good questions for pcp to ask
ask about recent bereavement, fam hx depression or bipolar disorder, prior hx of episodes of deporession (determine whether youre observing a relapsing event), ask about hx of bipolar (inapproprpiate treatment of bipolar with antidepressants may precipitate manic episode)
What to think about when screening for depression
- personal previous hx of depresison or bipolar
- first degree biological relative w hx depression or bipolar disorders
- pts w chronic dzs
- obestiy
- chronic pain (back or headache)
- impoverished home envt
- financial strain
- experiencing major life changes
- pregnant or postpartum
- socially isolated
- multiple vague and unexplained symptoms (GI, cardiovascular, neuro)
- fatigue or sleep disturbance
- substance abuse (alcohol, drugs)
- loss of interest in sexual activity
- elderly age
True or false: without post screening followup available within primary care setting, net benefit of screening in all adults for depression likely to be small
True
Lack of improvement in depression is more related to inadequate treatment or insufficient case identification?
Inadequate treatment
Which formal screening tool is most effective?
lots of them are in place but no one shown to be more effective
Recurrent screening for depression in these patients:
pts w hx of depression, unexplained somatic sx, substance abuse, chornic pain, comorbid psychological conditions
When to do full diagnostic interview (using standard diagnostic criteria)
any screening test that is positive!
Patient Health Questionnaire-2 (PHQ-2)
Over the past 2 weeks, have you been bothered by:
- little interest or pleasure in doing things?
- feeling down, depressed, or hopeless?
No response to both: negative screen
Yes response to either OR if doctor is still concerned about depression: ask more thorough assessment (PHQ-9)
Diagnosing major depressive disorder
PHQ 9 > 10 (sensitivity 88%, specificity 88%) in primary care setting where tool was validated
dx of MDD: requires impairment of social, occupational, other important areas of functioning
(rule out: normal bereavement, bipolar disorder, physical disorder, medication, or other drug as biologic cause)
Summary of DSM IV for Major Depressive Episode
going off of PCORE…did not mention DSM V
if depressed mood or loss of interest or pleasure persists for more than at least a 2 week period, consider dx of MDD.
Diagnostic criteria:
A. at least 5 of following symptoms present during same 2-week period, nearly every day, and represent a change from previous functioning.
–> at least one of symptoms must be either (1) depressed mood or (2) loss of interest or pleasure
- depressed mood (or alternatively can be irritable mood in children and adolescents)
- marked diminished interest or pleasure in all, or almost all, activities
- significant weight loss or weight gain when not dieting
- insomnia or hypersomnia
- psychomotor retardation or agitation
- fatigue or loss of energy
- feelings of worthlessness or excessive or inappropriate guilt
- diminished ability to think or concentrate
- recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide
B. symptoms not accounted for by a mood disorder due to general medical condition, a substance-induced mood disorder, or bereavement (normal reaction to death of loved one)
C. symptoms not better accounted for by a psychotic disorder (e.g., schizoaffective disorder)
SIGECAPS
Sleep Interest (Anhedonia) Guilt Energy Concentration Appetite Psychomotor Suicidality
Major depressive episode can be associated with special features
melancholic, psychotic, atypical
Depressed patients with melancholic features
- nearly total anhedonia
- must have 3 of the following:
1) diurnal variation (depression worse in morning)
2) pervasive and irremediable depressed mood
3) marked psychomotor retardation or agitation
4) significant weight loss or anorexia
5) excessive or inappropriate guilt
6) early morning awakening
depressed patients with melancholic features have best response to pharmacotherapy
Depressed patients with psychotic features
- hallucinations
- delusions
- -> at high risk for suicide even if deny suicidal ideation
- -> should be sent for hospitalization immediately, should be under care of psychiatrist
Depressed patients with atypical features
- milder depressed symptoms
- must experience mood reactivity as well as 2 of the following:
1) leaden paralysis (enormous effort to walk or exert)
2) hypersomnia
3) rejection hypersensitivity (even when pt not acutely depressed)
4) overeating or weight gain
–> these pts respond LESS to tricyclic antidepressants
Tips for interviewing patients with depression
“patients who’ve had a heart attack sometimes get depressed or down after the event. has this been happening to you recently?”
Depressed mood algorithm
- Is a general medical condition directly responsible for the symptoms?
Yes –> mood disorder due to general medical condition
No –> Is a substance directly responsible for the symptoms?
- Yes –> substance induced disorder
No–> is depressed mood or anhedonia present for at least 2 weeks?
- Yes–> are associated symptoms present? (if yes, are they explained by bereavement? if yes: bereavement; if no: major depressive disorder; if no associated symptoms, has the depressed mood or anhedonia and milder associated symptoms been present for at least 2 years? if yes: dysthymic disorder; if no: ask about stressor, see below)
No–> are the symptoms due to a stressor?
- Yes –> adjustment disorder with depressed mood
if No –> depressive disorder not otherwise specified or no disorder
Differentiating mild and moderate depression from major depression (linking PHQ9 score and severity of depression)
remember: these symptoms must cause significant distress and/or dysfunction to be considered diagnostic of any depressive disorder
No depression: phq9 0-4; no depression severity
mild to moderate depression: phq 5-9 mild depression severity
major depression:
phq 10-14 moderate
phq 15-19 moderately severe
phq 20-27 severe
Depression due to general medical conditions
cardiac dz
ischemic dz, myocardial infarction, heart failure
Depression due to general medical conditions: cancer
brain cancer, pancreatic cancer
Depression due to general medical conditions: endocrine disorders
hyperthyroidism, hypothyroidism, diabetes, parathyroid dysfunction, cushing’s disease
Depression due to general medical conditions: GI dzs
inflammatory bowel disease, irritable bowel syndrome, hepatic encephalopathy, cirrhosis
Depression due to general medical conditions: neurologic dz
stroke, chronic headache, dementias, traumatic brain injury, multiple sclerosis, parkinson’s dz, epilepsy
Depression due to general medical conditions: pulmonary dz
sleep apnea, reactive airway dz
Depression due to general medical conditions: rheumatologic dz
lupus, rheumatoid arthritis, chronic fatigue syndrome, fibromyalgia
Depression due to general medical conditions: metabolic dz
renal failure, electrolyte disturbances
Depression due to general medical conditions: Infectious disease
HIV, syphilis, hepatitis, lyme dz
Depression due to general medical conditions: hematologic dz
severe anemia
Lab tests to consider ordering in working up depression
TSH, CBC, chemistry panel (chem 7?)
full h&p can give clues as to which additional tests to order
True or false: pts suffering from diabetes, ischemic heart dz, stroke, or lung disorders who have concurrent depression have poorer outcomes than those without depression
True
True statements about depression and mgmt of general medical illness
- pts w depression may exhibit maladaptive interpersonal behaviors that make it hard to collaborate w docs
- pts w depression can have higher rates of adverse health risk behaviors compared to non depressed pts
- pts w aversive symptoms like pain are at increased risk for developing depressive disorders
- importance of screening, diagnosing, and treating depression after an MI has been well documented
True or false: presence of chronic medical illness is most prevalent risk factor for devt of depression
False!
the presence of chornic med illness alone isnt most prevalent risk factor for depressiond evt
substance induced depression
1) substances indicated for recreation or mood alteration, or from withdrawal of these
alcohol, hypnotics, sedatives, opiates, marijuana, amphetamines, cocaine, other designer drugs (ketamine, ectasy)
2) prescirption drugs used for medical treatment: blood pressure meds (reserpine, propanolol), anticholinergics, steroids, oral contraceptives, psychotropic meds, antineoplastic drugs
Dysthymic disorder
chronic form of depression
sx and signs are milder but can –> distress, dysfunction
must have at least 2 yr hx of complaints occurring over half days to make dx
imp to distinguish from mdd bc dysthymic disorder more chronic and unremitting, less responsive to pharmacotherapy
fam and friends may think they’re chronic complainers or pessimists
DSM IV criteria for dysthymic disorder
A. depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years
in children and adolescents: mood can be irritable and duration must be at least one year
B. Presence, while depressed, of 2 or more of following:
- poor appetitie or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness
C. during the 2 yr period (1 yr for children and adolescents) of the distrubrance, the person has never been without the sx in criteria A or B for more than 2 months at a time
D. no major depressive episode has been present during the first 2 yrs of the disturbance (one yr for children and adolescents) ; ie disturbance not better accounted for by chronic major depressive disorder or major depressive disorder in partial remission
E. there has never been a manic episode, mixed episode, or hypomanic episode; and criteria have never been met for cyclothymic disorder
F. disturbance doesnt occur exclusively during course of a chronic psychotic disorder (schizophrenia or delusional disorder)
G. symptoms not due to direct physiologic effects of a substance (drug of abuse, meds) or general medical condition (hypothyroidism)
H. sx cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
Bereavement
- normal rxn to loss of loved one
- accompanied by insomnia, sadness, weight loss, decreased appetitie
- sx: resolve normally within 2 months and do not require psychotherapy or pharmacotherapy
- when sx persist beyond 2 months, possibility of a dx of major depression exists
- pathologic sx: thoughts of death beyond wish to be w loved one, excessive guilt, overwhelming new sense of worthlessness, severe psychomotor retardation, hallucinations (other than transiently hearing voice or seeing image of loved one), inability to perform usual tasks and obligations
Adjustment disorder w depressed mood
dx when pt has depressive sx or complaints within 3 months of an identifiable psychosocial stressor.
stressors may include: academic failure, job loss, divorce.
stressor causes depressed sx that do not meet criteria for major depression or dysthymic disorder
Treatment of choice: psychotherapy over pharmacologic therapy
Seasonal affective disorders
seasonal pattern of major depressive episodes, esp w start of fall or winter, or when natural daylight decreases
dx can be made only if there is clear psychosocial stressor related to change in season
pts respond to standard antidepressants and psychotherapy (in addition to light therapy)
SSRIs in pregnancy
SSRI in 3rd trimester assoc w group of mild symptoms (“poor neonatal adaptation”)
–> irritability, tachypnea, hypoglycemia, thermal instability, a weak or absent cry
(usually mild, transient, lasts no more than 2 wks)
some studies showed small increased absolute risk of persistent pulmonary htn in offspring of women using SSRIs late in pregnancy
Medical mgmt depressed pts during pregnancy: agents of choice
SSRIs;
fluoxetine and tricyclic antidepressants appear to not have teratogenic effects
(FDA: exposure to paroxetine in 1st trimester of pregnancy may increase risk for congenital malformations, esp cardiac malformations but absolute risk is small)
absolute risk increases w 3rd trimester paroxetine use from 1-2/1000 (.1-.2%) to 3-12/1000 (.3-1.2%)
Teratogenic treatments of depression
mood stabilizers (dilantin, valproic acid, carbamazepine)
Most important factor in choosing meds during pregnancy
–> patients level of functioning in past when she was not taking meds
Mild to moderate severity depression during pregnancy
psychotherapy; should be considered 1st line of treatment for pregnant patietns w mild to moderate depression which has been successfully treated in past without meds
Pregnant patients to definitely treat during pregnancy
hx of bipolar dz, suicide attempts, recurrent MDD or psychotic disorders
Postpartum depression
- within 1 month of delivery a baby
- -> normal “baby blues” can begin 24 hours after delivery and last up to 10 days
postpartum depression not diff from a major depressive episode but primary care doc or obstetrician should recognize sx for immediate interventions
challenge: sx often develop before routine 6wk prenatal visit
Antidepressants in breastfeeding women
decision based on severity of depression and need for pharmacotherapy, rather than any known risks to infant
Depression in elderly pts
not normal part of aging
risk factors: hx of depression, chronic medical illness, female sex, being single or divorced, brain dz, alcohol abuse, use of certain meds, stressful life events
–> pts who are elderly when 1st depressive episode occurs have relatively high likelihood of developing recurring chronic depression
treatable and has good prognosis if found!
Common manifestations of depression in elderly pts
insomnia, anorexia, fatigue
treatments esp with SSRI can be helpful
Pseudodementia
- assoc w severe depression , can be easily mistaken for dementia (esp in elderly ppl or ppl w underlying neurologic dz like strokes etc)
sx: marked psychological distress, inability to concentrate or complete daily tasks, marked cognitive dysfunction
differentiate from dementia: these pts exhibit profound concern about their impaired cognitive function in contrast w pts w dementia who may minimize their disability
pharmacotherapy + electroconvulsive therapy
Dementia vs. Depression
Dementia:
onset: insidious, indeterminate;
duration of sx: usually long;
orientation, mood, behavior affect: impaired, inconsistent, fluctuating;
cognitive impairment: consistent, stable or worsening;
neurologic defects: often present (agnosia, dysphasia, apraxia); disabilities: concealed by pt;
depressive sx: present;
memory impairment: doesnt remember recent events, often unaware of memory loss, onset of memory loss occurs before mood change;
psychiatric hx: none;
answers to questions: near answers;
performance: tries hard but unconcerned about losses; associations: unsociability, uncooperativeness, hostility, emotional instability, reduced alertness, confusion, disorientation
Dementia vs. Depression
Onset: relatively rapid, assoc w mood changes;
Duration of sx: usually short;
Orientation, mood, behavior, affect: intact, diurnal variation depressed/anxious, complaints worse than on testing;
Cognitive impairment: inconsistent, fluctuating:
Neurologic deficits: absent;
Disabilities: highlighted by patient;
Depressive sx: present;
Memory impairment: concentration poor, pt complains of memory loss of recent and remote events, follows onset of depressed mood
Psychiatric hx: often, hx of depression
Answers to questions: “dont know” answers
Performance: doesnt try hard but is more distressed by losses
Associations: appetite and sleep disturbances, suicidal thoughts
Manic and hypomanic symptoms: risk in ppl w fam hx
- risk of having bipolar disorder higher in ppl w 1st deg relatives w bipolar disorder
- clues: incidental improvement of sx w lithium
- having hx of hypomanic episode himself!
Treating bipolar disorder as unipolar (mistake)
–> only treating depression (antidepressants) can precipitate manic episode
Hypomanic vs. manic
manic mood: irritability or abnormal euphoria
hypomania: lesser degree of mania that lasts for shorter duration
hypomanic patients: usually can conitineu w normal life and dont require hospitalizations
“mixed state”: must satisfy all criteria of major depressive disorder and mania at same time
Summary of DSM IV criteria for manic episode
A. distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting 1 wk (or any duration if hospitalization necessary)
B. during period of mood disturbance, 3 or more of following sx have persisted (4 if mood is only irritable) and have been present to a significant degree:
1. inflated self esteem or grandiosity
2. decreased need for sleep (feels rested after only 3 hrs for ex)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractability (attn too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal directed activity (either socially, at work or school or sexually) or psychomotor agitation
7. excessive invovlement in pleasurable activities that have high potential for painful consequences (engaging in unrestraind buying sprees, sexual indiscretions, or foolish business investments)
C. sx do not meet criteria for mixed episode
D. mood disturbance sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships w others , or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features
E. sx not due to direct physiologic effectsof substance (drug of abuse, medication, other treatment) or general medical condition (hyperthyroidism)
note: manic like episodes that are clearly caused by somatic antidepressant treatment (medication, electroconvulsive therapy, light therapy) should not count toward dx bipolar I disorder
Summary of DSM IV criteria for hypomanic episode
A. distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least 4 days that is clearly diff from usual non depressed mood
B. during period of mood disturbance, 3 or more of following sx persisted (4 if mood is only irritable) and have been present to a significant degree:
1. inflated self esteem or grandiosity
2. decreased need for sleep (3 hrs)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (attn too easily drawn to unimportant or irrelevant external stimuli)
6. increased goal directed activity (social, work, sexual) or psychomotor agitation
7. excess invovlement in pleasurable activities w high potential for painful consequences
C. episode assoc w unequivocal change in functioning that is uncharacteristic of person when not symptomatic
D. disturbance in mood and change in functioning are observable by others
E. episode not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features
F. sx not due to direct physiologic effects of a substance (drug of abuse, medication, other treatment) or general medical condition (hyperthyroidism)
note: manic like episodes that are clearly caused by somatic antidepressant trtm like medication, ect, light therapy should not count tow dx of bipolar II disorder
Questions in assessing suicidal risk
- current thoughts of harming or killing self
- current plants to harm or kill self
- prior suicide attempts (critical indicator of future suicide risk)
- fam hx mood disorder, alcoholism , suicide
- actions or threats of violence to others
- access to firearms
- male
- elderly
- sig comorbid anxiety or psychotic sx and active substance abuse
- poor social support system or living alone
- recent loss or separation
- hopelessness
- preparatory acts (put affairs in order, suicide notes, give away personal belongings)
Suicidal plan
if suicidal ideation elicited docs should ask if pt has suicidal plan (how, when, where);
a pt that is actively thinking about suicide and has plan for suicide constitutes a medical emergency esp true in pts w previous suicide attempts
911! safe transport to nearest ER
Antidepressant overdose and suicide
tricyclic antidepressants are more lethal in overdose than SSRIs;
risk of suicide in all pts recoveirng from major depression may transiently increase during intiital trtmt;
one possible explanation: more nrg to act on suicidal ideation is only one of possible explanations currently under consideration
fluoxetine: only antidepressant effective in children and adolescents but close surveillance for suicidal ideation warranted
avg risk of suicide in general 4% w antidepressants and 2% on placebo
Situations requiring referral to psychiatrist
- suicide risk
- bipolar disorder or manic episode
-psychotic sx
-severe decrease in level of functioning (unable to care for self) - recurrent deprssion
- chornic depression
-depression refractory to trtmt - cardiac dz requiring TCA trtmt (contraindication)
- need for electroconvulsive therapy (ECT)
- lack of available support system
0 any diagnostic or trtmt questions
Onset Beneficial effects of antidepressant treatment
2-4 wks
Three phases of treating major depression
- acute phase: remission induced (minimum 6-8wks duration)
- continuation phase: remission preserved and relapse prevented (usually 16-20wks )
- maintenance phase: susceptible pts protected against recurrence or relpase of subsequent major depressive episodes (duration varies w frequency and severity of previous episodes)
Remission (official definition by american psych assoc)
return to pts baseline level of sx severity and functioning; should not be confused w significant but incomplete improvement!
Relapse (official definition by american psych assoc)
re-emergence of significant depressive sx or dysfunction after remission achieved
Acute phase of trtmt major depression
goal: induce remission
treatment: pharmacotherapy alone or combo pharmacotherapy + psychotherapy (but not psychotherapy alone as initial therapy choice; insufficient evidence)
see them again in office 1-2wks of starting new antidepressant
if have major depression in setting of psychosocial stressors, interpersonal difficulties, intrapsychic conflict, any axis II comorbidities (do pharmacotherapy + psychotherapy!)
if have depression and psychotic sx, catatonia, or severe impairment consider combo therapy (antidepressants, antipsychotics, and/or ECT)
Acute phase treatment: mild to moderate depression
initital treatment modalities: pharma alone, psychotherapy alone, or both
antidepressant meds: initial trtm if mild to mod depression
clinical features suggesting antidepressants be used: positive response to prior antidepressant trtmt, sig sleep and appetite disturbances, severity of sx, anticipation by physician that maintanence therapy be needed
also if pt prefers it
clinical features suggesting psychotherapy be used: psychosocial stressors, interperonsal difficulties, intrapyschic conflict, axis 2 comorbidiites (personality disorders per dsm4) + pt preference, womans desire to get pregnant or breastfeed
combo may be initial trtmt approach if moderate depression in presence of psychosocial stressors, or pts w only partial remission on one type of trtmt or hx of poor adherence to trtmt
Assessing for adequate response in acute phase
- goal of acute phase: return pt to funcitonal and sx baseline but is common for pts to have substantial but incomplete response to acute phase trtmt
follow up assessment w phq9 or similar tools; dont conclucd etrtmt yet
definitions of response loosely defined:
non response: decrease in baseline sx of 25% or less
partial response: 26-49% decrease in baseline sx
partial remission: 50% or greater w residual sx
remission: complete absence of sx
*if after initial 4-8 wks there is not moderate improvement in baseline sx in acute phase, reassess dx, med regimen and/or psychotherapy, adherence, substance or alcohol use
If response inadequate in acute phase
- increase trtmt dose
- if 4-8 wks after inc dose no mod improvement in sx, another review (consider other trtmt options, consulting w psychiatrist)
Continuing phase treatment
maintain regimen (and dose) to prevent relapse post acute phase
16-20 wks after remission this phase should last
psych mgmt should continue
use of ECT in this phase not researched
frequncy of visits varies in this phase (if stable, every 2-3 months; if in active psychotherapy several times a week may be needed)
if stable throuhgout continuation phase and not candidates for maintenance phase (recurrent relapsing chroinc depression) can be considered candidates for discontinuation of trtmt)
Minimum total length of acute and continuation phase treatment
6 months
Maintenance phase treatment
bw 50-85% ppl w single major depressive episode will have another
maintenance phase trtmt designed to prevent future recurrence
issues to consider: severity of episodes (suicidal ideation or attempts, psychotic sx, functional impairment); risk of recurrence (residual sx bw episodes, # of recurrent episodes), comorbid conditions, side efx of continuous trtmt, or pt preference
the same trtmt that was effective in acute and continuation phase should be continued in maintenance phase; doses usually maintained; type of psychotherapy dictates freq of visits in maintenance phase (cognitive behavioral therapy, interpersonal therapy decrease to 1x/month while psychodynamic psychoterhapy maintains same previous freq)
combo therapy: may be beneficial for some though not well studied
pts w recurrent mod or severe dep episodes who dont respond well to pharm may be candidates for periodic ECT
freq of visits can vary asin continuation phase
length of maintenance trtmt may be influenced by: freq and severity of recurrent episodes, persistence of sx after period of recovery, tolerability of trtmt, pt preference (some pts need maintnence indefinitely)
Discontinuation of active treatment
freq amd severity of recurrent episodes, dysthymic sx bw episodes, presence of other psychiatric disorders, presence of chronic general med disorders, pt preference
if maintenance pharm d/c, recommended to taper meds over weeks (slow tapering allow you to monitor for emerging sx and restor to full dose )
d/c syndromes: mood disturbances, sleep, energy, appetitie) can appear much like in relapses but are due to lack of tapering of meds in reality! (or can be)
pts on short acting agents more likely to d/c syndromes and should be tapered over longer periods
signs and sx of relapse: review once d/c hapens
True or false: all classes of antidepressants equally effective
True but you may have class consideratiosn based on pts needs/situation
meds differ in side effect profiles, drug-drug interactions, cost
SSRI is first line! however
dual action reputake inhibitors venlafaxine and bupropion are 2nd line!
Tricyclics and other mixed or dual action inhibitors 3rd line
MAOis usually last resort (low tolerability, dietary restrictions, drug-drug interactions)
Dosing antidepressants in geriatric population
starting dose usually 1/2 recommended starting dose for other adults
fluoxetine
selective serotonin reuptake inhibitors
Reuptake inhibitors
Mxn of actions and functional classification: ssri
lethality in overdose: low
side effects: moderate insomnia and agitation, none or mild sedation, none or mild hypotension, none or mild anticholinergic effect, moderate GI side effects/nausea, moderate sexual dysfunction, mild wt gain
paroxetine
SSRI
reuptake inhibitors
Mxn of actions and functional classification: ssri
lethality in overdose: low
side effects: moderate insomnia and agitation, none or mild sedation, mild anticholinergic effect, moderate nausea/gi effects, moderate sexual dysfunction, mild weight gain
sertraline
ssri
reuptake inhibitors
Mxn of actions and functional classification: ssri
lethality in overdose: low
side effects: moderate insomnia and agitation, none or mild sedation, none or mild hypotension, none or mild anticholinergic effect, moderate nausea/gi side efx, mod sexual dysfunction, mild weight gain
citalopram
ssri
reuptake inhibitors
Mxn of actions and functional classification: ssri
lethality in overdose: low
side effects: mod insomnia and agitation, none or mild sedation, none or mild hypotension, none or mild anticholinergic effect, mod nausea/gi side efx , mod sexual dysfunction, wt gain mild
fluvoxamine
ssri
reuptake inhibitors
Mxn of actions and functional classification: ssri
lethality in overdose: low
side effects: moderate insomnia and agitation, mild sedation, none or mild hypotension, none or mild anticholinergic, mod nausea/gi , mod sexual dysfunction, mild wt gain
escitalopram
ssri
reuptake inhibitors
Mxn of actions and functional classification: ssri
lethality in overdose: low
side effects: mod insomnia and agitation, none or mild sedation, none or mild hypotension, none or mild anticholinergic effect, moderate nause/gi , mod sexual dysfunction, mild wt gain
reboxetine
selective norepinephrine reuptake inhibitors
reuptake inhibitors
Mxn of actions and functional classification: snri
lethality in overdose: low
side effects: mild insomnia and agitation, none or mild sedation, none or mild hypotension, none or mild anticholinergic, mild naus/gi, mild sexual dysufnction, none or mild wt gain
desipramine
nonselective norepinephrine reuptake inhibitors
reuptake inhibitors
Mxn of actions and functional classification: nnri
lethality in overdose: high
side effects: none or mild insominia/agitation, none or mild sedation, mild hypotension, mild anticholinergic, none or mild naus/gi, mild sexual dysfunction, mild wt gain
nortripytline
nonselective norepninephrine reuptake inhibitors
reuptake inhibitors
Mxn of actions and functional classification: nnri
lethality in overdose: high
side effects: none or mild insomnia/agitation, mild sedation, mild hypotension, mild anticholinergic effect, none or mild naus/gi, mild sexual dysfunction, mild wt gain
maprotiline
nonselective norepinephrine reuptake inhibitors
reuptake inhibitors
Mxn of actions and functional classification: nnri
lethality in overdose: high
side effects: mild insominia and agitation, none or mild sedation, mild hypotension, mild anticholinergic, none or mild naus/gi, mild sexual dysufnction, mod wt gain
Amitryptiline
TCAs (older agents)
Mixed or dual action reuptake inhibitors
Lethality in overdose: high Insomnia and agitation: none or mild sedation: severe hypotension: moderate anticholinergic effect: none or mild nausea/GI effects: none or mild sexual dysfunction: mild weight gain: moderate
Dothiepin
older agents (TCAs)
mixed or dual action reuptake inhibitors
Lethality in overdose:high Insomnia and agitation:none or mild sedation: moderate hypotension: moderate anticholinergic effect: moderate nausea/GI effects: none or mild sexual dysfunction: mild weight gain: moderate
Clomipramine
older agents (TCA)
mixed or dual action reuptake inhibitors
lethality in overdose: high insomnia and agitation: mild sedation: moderate hypotension: moderate anticholinergic effect: moderate nausea/GI side effects: mild sexual dysfunction: mild weight gain: moderate
amitryptiline older agents (tca) mixed or dual action reuptake inhibitors
mxn of action: older agent tca lethality in overdose: high insomnia or agitation: none or mild sedation: severe hypotension: moderate anticholinergic effect: none or mild nausea/gi: none or mild sexual dysfunction: mild weight gain: moderate
dothiepin
older agent tca
mixed or dual action reuptake inhibitor
lethality in overdose: high insomnia/agitation: none or mild sedation: moderate hypotension: moderate anticholinergic: moderate nausea/gi: none or mild sexual dysfunction: mild wt gain: moderate
clomipramine
older agent tca
mixed or dual action reuptake inhibitor
lethality in overdose: high insomnia/agitation: mild sedation: mod hypotension: mod anticholinergic: mod nausea/gi: mild sexual dysfunction: mild wt gain: mod
imipramine
older agent tca
mixed or dual action reuptake inhibitor
lethality in overdose: high insomnia/agitation: mod sedation:mild hypotension:mod anticholinergic: mod nausea/gi:none or mild sexual dysfunction:mild wt gain:mod
venlafaxine
new agents non tca
mixed or dual action reuptake inhibitor
lethality in overdose: mod insomnia/agitation:mod sedation:none or mild hypotension:none or mild anticholinergic: none or mild nausea/gi:mod sexual dysfunction: mod wt gain:none or mild
minacipran
new agents non tca
mixed or dual action reuptake inhibitor
lethality in overdose: low insomnia/agitation: mod sedation:none or mild hypotension:none or mild anticholinergic: none or mild nausea/gi:mod sexual dysfunction: mod wt gain: none or mild
bupropion
new agents non tca
mixed or dual action reuptake inhibitor
lethality in overdose:low insomnia/agitation: mod sedation:none or mild hypotension:mild anticholinergic: mild nausea/gi:mild sexual dysfunction: none or mild wt gain:none or mild
duloxetine
new agents non tca
mixed or dual action reuptake inhibitor
lethality in overdose:low insomnia/agitation: none or mild sedation:mild hypotension:mild anticholinergic: mild nausea/gi:mild sexual dysfunction: none or mild wt gain:none or mild
phenelzine
irreversible agents
MAOIs
lethality in overdose:high insomnia/agitation: mod sedation:mild hypotension:mod anticholinergic: mild nausea/gi:mild sexual dysfunction:mod wt gain:mild
tranylcypromine
irreversible agents
MAOIs
lethality in overdose: high insomnia/agitation: mod sedation:mild hypotension:mod anticholinergic: mild nausea/gi:mild sexual dysfunction:mod wt gain:mild
isocarboxacid
irreversible agents
MAOIs
lethality in overdose:high insomnia/agitation: mod sedation:mod hypotension:mod anticholinergic: mild nausea/gi:mild sexual dysfunction: mod wt gain:mod
selegiline
irreversible agents
MAOIs
lethality in overdose:mod insomnia/agitation: mild sedation:none or mild hypotension:mild anticholinergic: mild nausea/gi:mild sexual dysfunction: mod wt gain: mild
moclobemide
reversible agents
MAOIs
lethality in overdose:low insomnia/agitation: mild sedation:none or mild hypotension:none or mild anticholinergic: mild nausea/gi:mild sexual dysfunction: none or mild wt gain:none or mild
mirtazapine
mixed action newer agents
MAOIs
lethality in overdose:low insomnia/agitation:none or mild sedation:severe hypotension:mild anticholinergic: none or mild nausea/gi:none or mild sexual dysfunction:none or mild wt gain:severe
mianserin
mixed action newer agents
MAOIs
lethality in overdose: low insomnia/agitation: none or mild sedation:mod hypotension:mild anticholinergic: mild nausea/gi:none or mild sexual dysfunction:none or mild wt gain:mild
nefazodone
mixed action newer agents
MAOIs
lethality in overdose:low insomnia/agitation: none or mild sedation:mod hypotension:mild anticholinergic: mild nausea/gi:mild sexual dysfunction: none or mild wt gain:mild
trazodone
mixed action newer agents
MAOIs
lethality in overdose: low insomnia/agitation:none or mild sedation:severe hypotension:mild anticholinergic: none or mild nausea/gi:mild sexual dysfunction: none or mild wt gain:mild
Possible side effect of all antidepressants
- may induce manic episode in patients susceptible to bipolar disorder
SSRI (general info)
- little diff in efficacy and tolerability among ssri’s
- well tolerated compared to other classes of antidepressants
- half life long enought for once a day doseing (improves pt adherence)
- fluoxetine and escitalopram: effective in controlled trials for adolescents age 12-17
- fluoxetine also fda approved for use in children starting age 8
- SSRI have fewer cardiovascular effects than TCAs
Tricyclic antidepressants (TCA) and norepinephrine reuptake inhibitors (NRIs)
- older than ssri
- may be more effective in severe depression or depression w melancholic features
- may be better than ssri for depression that has predominant physical symptoms or pain
- tca and nri tend to have cardiac conduction effects; not drug of choice in pts w cardiovascular conditions esp conduction defects
- contraindicated in ppl w bph, urinary retention, closed angle glaucoma
dual action antidepressants
serotonin and norepinephrine reuptake
- venlafaxine, milnacipran, duloxetine are serotonin norepinephrine reuptake inhibitors
- block monoamine transporters more selectively than tca and nri
- less cardiac conduction effects
- duloxetine as effective as ssri paroxetine
- both duloxetine and paroxetine are effective in treating chronic pain and diabetic neuropathy
bupropion
dual action antidepressants
- -> buproprion: norepinephrine and dopamine, but not serotonin, reuptake
- similar efficacy to tca and ssri but less diarrhea, nausea, somnolence, and sexual side effects than ssri
- can also be used as adjunct in smoking cessation tho some health insurance wont pay forsmoking cessation purpsoe
monoamine oxidase inhibitors (MAOIs)
- nonselectively block mao a and b isoenzymes
- similar efficacy to tca
- maoi not considered 1st line due to side effect profile, drug drug interaxn, need to adhere to low tyramine diet to prevent hypertensive crisis
- maybe more effective than tca for atypical depression characterized by extreme fatigue, sensitivity to rejection, or troubled relationships (under care of psychiatrist)
newer antidepressant therapies
- nefazodone: blocks 5HT serotonin receptors thus enahcing serotonin in synaptic clefts; efficacy similar to ssri, tends to be sedating
- mirtazapine blocks alpha2 adrenergic receptors specific serotonin recpetors and histamine receptors to enhance norepinephrine in synaptic cleft; as effective as ssri and tca; tends to be sedating and cause sig wt gain
Considerations before switching antidepressants
- consider having antidepressant dose increased before changing med altogether if pt not acheiving response
- pcp shoudl reassess dx, consider increaseing dose, assess pt adherence, consider alcoholism or substance abuse, reevaluate for coexisting med conditions and use of non psychiatric drugs that may contribute to treatment failure
- -> in general pts who dont respond to ssri shoudl be switched to antideprssant in antoehr class
- if a dual action antidepressant has been used first switch to ssri
- for pts w partial response to one antidepressant, 2nd antidepressant from antoehr class can be added for augmentation
Adjunct medications
- in conjunction w antidepressants to augment effects
- mood stabilizers: lithium can prevent manic and depressive episodes in bipolar pts, effective augmenting agent in pts who dont have effective response to antidepressants alone
- antipsychotic meds can be added to antidepressants to treat depression w psychotic features
Anxiety: antidepressants and anxiolytics
- in major depression w comorbid anxiety or panic disorder (15-30% of cases) depression and anxiety sx resolve w antidepressant treatment;
- ssri and tca may initially worsen anxiety, avoid this by stasrting at low dose and titrating up slowly
benzodiazepenes: used as adjuvant in 30-60% of cases of depression w anxiety or insomnia; improve antidepressant response but can cause sedation memory loss and dependence and withdrawal sx; benzos should be used on limited basis to avoid dependency and avoid in ppl w hx of alcohol or drug abuse
use benzos w extreme caution in geriatric pop who dont metabolize drugs well and can cause increased cognitive dysfunction, falls, death
in gneeral: benzos shouldnt be used as primary pharm agent in any pt w major depression and anxiety disorders
Interpersonal therapy
- based on belief that depression is caused by problems in important interpersonal relationships
- focus on teaching about connection bw interpersonal problems and depression
- depression viewed as arising out of conflict or loss in interpersonal relationships
- key feature: compile interpersonal inventory that lists and examines all the pts relationships
- # of sessions limited over period of several moths
- treatment divided into 3 stages:
1 assessment
2 practice
3 termination
–> emphasis on relapse prevention skills and techniques
focus: present events rather than past hx, learning ways to improve imp relationship in present and to have more + interaxns
pts taught to id and deliberately tolerate feelings
- this model says: as relationships improve, so should pts mood*
- incorporates psychoeducation, is “medication friendly”, agrees w a medical model of depression
- -> unlike cbt, interpersonal therapy doesnt involve formal hw or rely on extensive paperwork tho pts encouraged to develop skills, experiment bw sessions
- -> useful for pts who find psychodynamic approaches mystifying and has been modified for use with adolescents
Problem solving therapy
- brief, focused form of cognitive therapy
- focus on problems person currently faces
- help find solutions to probs
- links bw poor problem solving abilities and etiology and maintanence of psych disorders
- used in treatment of depression
- involve changing situation itself vs emotion focused strategies which involve changing ones rxn to a sitch
- prob solving strategies: work well in addressing and solving problems encountered in everyday situations where change in behavior can have + results
- ppl taught to identify, discover, and invent effective responses for specific problematic sitautions
- goal: provide clients w set of tools on how to effectively manage life stress to decrease distress, enahnce sense of control, improve quality of life
- interventions: didactic explanations, trianing exercises, practice opportunities, hw bw sessions
- prob solving therapy sessions often conducted in groups as well as individual
- often < expensive than other forms of trmt can be easily performed by health professionals
- shown to be effective in treating depression in adults of all ages, esp for treating older adults
Combo meds and psychotherapy
- few clinical trials to guide what best combo is
- same considerations in selecting monotherapy of antidepressants or psychotherapy apply
- side effects, efficacy, adherence, safety must all be monitored
- if after 4-8 wks no moderate improvement in baseline sx, then reassess dx, med regimen, adherence, substance or alcohol use
- change in treatment can be considred
- if after 4-8 wks after change in treatment there is no mod improvement of sx, another review should occur
- other trt options: consider, + consult a psych specialist if pt fails to respond
Electroconvulsive therapy (ECT)
- exclusively available thru experienced psych specialist
- remission rates: 60-80% in severe major depressive disorder
- max response usually 3 wks after treatment
- ECT is first line trtmt when there is severe depression w psychotic features, psychomotor retardation, or resistance to meds
- suicidal pts and pregnant pts may also have rapid benefits from ECT
- ect consists of 6-12 treatments (2-3x/week)
- -> bc relapse rate after ECT is >50%, most psychiatrists start prophylactic treatment w antidepressants and adjuvant meds such as lithium
- postictal confusion, retrograde and anterograde memory impairment usually improves in a few days
St. John’s Wort
- not an effective trtmt of major depression
- info on combo w SSRIs or TCAs unknown
- combo with MAOIs contraindicated
- ppl w HIV on ARTs should be told it is contraindicated bc it lowers serum levels of antiretrovirals
Cognitive Behavioral Therapy
- targets thoughts and behaviors that need to be changed
- based on premise that behaviors have their roots in thoughts;
assumes depression is rooted in pessimistic thoughts and excessive self-criticism - goal: recognize what triggers certain thoughts and behavrios and alter your routines thru direction and action
- learning to substitute healthy thoughts for negative thoughts –> improve mood, self concept, behavior, physical state
primary goal: behavior change - internal change is byproduct
inititally in treating depression: behavioral principels used to overcome pts inertia and reinforce + activities
imp part of cbt: schedule pleasurable activities, esp with others to give + reinforcement
other methods: graded tasks, hw assignments, acting out difficult behavioral situations
emphasis; on present rathe rthan past
combo of cbt and antidepressants shown to effectively manage severe or chronic depression and for adolescents w depression’
–> reduce relapse rates, effectively manage residual sx
