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Pcore Modules > Depression > Flashcards

Depression Flashcards

0
Q

True or false: many ppl suffering from depression dont report depressed mood

A

True!

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1
Q

Some classic signs and symptoms of depression (Mr. George) and appropriate next step if present in patient

A

anhedonia, insomnia, weight gain…

–> perform standardized screening questionnaire for major depression (assist in making diagnosis)

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2
Q

Two most common conditions seen by primary care physicians

A
  1. hypertension

2. depression

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3
Q

Point prevalence of depression in outpatient setting vs. inpatient setting

A

outpatient: 4.8-8.6%
inpatient: 14.6%

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4
Q

% of men predicted to suffer an episode of major depression (at some point in life)

A

7-12%

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5
Q

% of women predicted to suffer an episode of major depression at one point in their lives

A

20-25%

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6
Q

Bipolar disorder lifetime prevalence men vs. women

A

men: 0.4%
women: 1.6%

but has no gender difference?

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7
Q

Peak onset depression

A

age 20-30

high risk for relapse and recurrence (>half of ppl who experience one episode)

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8
Q

Cost of depression in US

A

> 43 billion every year (medical treatments, lost work productivity)

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9
Q

Global disease burden depression

A

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!

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10
Q

Morbidity and mortality of untreated depression: what patients complain of

A

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

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11
Q

Depression is often undiagnosed and untreated

A

even when it is diagnosed it is undertreated!

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12
Q

Barriers to effective depression screening

A

inadequate education and training, limited coordination w mental health resources, time constraints, poor systematic follow up, inadequate reimbursement

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13
Q

Further barriers (demographic) to diagnosis of depression in pri care

A

gender, age, culture, language of patient and physician

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14
Q

Patients with the following dzs with concurrent depression have poorer outcomes than those without depression

A

diabetes, ischemic heart disease, stroke, lung disorders

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15
Q

Depression and higher risk of death from other dzs

A

heart dz, respiratory disorders, stroke, accidents, suicide

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16
Q

% of patients with severe mood disorders who die from suicide

A

15%

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17
Q

% of patients who visited their pri care physician on same day as their suicide

A

20%

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18
Q

Etiology of mood disorders

A

neurotransmitters, genetics, psychosocial stressors all play a part

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19
Q

True or false: same depressed patient may have variable clinical symptoms from one major depressive episode to another

A

True

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20
Q

Neurotransmitter deficiencies

A

serotonin, norepinephrine, dopamine, GABA, peptide neurotransmitters (somatostatin, thyroid-related hormones, brain-derived neurotrophic factors)

all hypothesized to contribute!

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21
Q

Overactivity in neurotransmitters

A

substance P, acetylcholine; elevated cortisol (w lack of diurnal variation) also proposed

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22
Q

Genetics and mood disorders

A

no specific genes found but clear genetic component (depression and bipolar disorder are inheritable)

)

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23
Q

Risk of depression in First degree relatives of patients w recurrent major depression

A

1.5-3 times higher risk of depression compared to gen pop

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24
Q

% children w one parent w mood disorder to develop one themselves

A

27%

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25
Q

% children w 2 parents w mood disorders to develop one themselves

A

50-75%

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26
Q

Bipolar: lifetime prevalence in first degree relatives of pts w bipolar disorder

A

12%

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27
Q

Genetics not enough for mood disorder

A

but genetics not enough (identical twins have incomplete concordance regarding depression, can occur in ppl w out fam hx of mood disorders)

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28
Q

Mxns of depression

A

changes in neurocircuitry, size of neurons, neuronal function, repair capabilities, production of new neurons

elevated cortisol in some may –> reduce hippocampus volume

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29
Q

Primary care: always consider depression in

A
  • 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

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30
Q

Determine baseline mood and function by:

A

asking open ended questions of pt about normal patterns and variations

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31
Q

Mood vs. affect

A

mood: range of emotions a person feels over period of time
affect: how a person displays their mood

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32
Q

Mood disorder may affect in a patient

A

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

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33
Q

Pseudodementia

A
  • severe cognitive impairment due to depression

- may be seen in elder populations or patients with CNS disorders

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34
Q

Psychomotor activity changes

A

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

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35
Q

Good questions for pcp to ask

A

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)

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36
Q

What to think about when screening for depression

A
  • 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
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37
Q

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

A

True

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38
Q

Lack of improvement in depression is more related to inadequate treatment or insufficient case identification?

A

Inadequate treatment

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39
Q

Which formal screening tool is most effective?

A

lots of them are in place but no one shown to be more effective

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40
Q

Recurrent screening for depression in these patients:

A

pts w hx of depression, unexplained somatic sx, substance abuse, chornic pain, comorbid psychological conditions

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41
Q

When to do full diagnostic interview (using standard diagnostic criteria)

A

any screening test that is positive!

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42
Q

Patient Health Questionnaire-2 (PHQ-2)

A

Over the past 2 weeks, have you been bothered by:

  1. little interest or pleasure in doing things?
  2. 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)

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43
Q

Diagnosing major depressive disorder

A

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)

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44
Q

Summary of DSM IV for Major Depressive Episode

going off of PCORE…did not mention DSM V

A

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

  1. depressed mood (or alternatively can be irritable mood in children and adolescents)
  2. marked diminished interest or pleasure in all, or almost all, activities
  3. significant weight loss or weight gain when not dieting
  4. insomnia or hypersomnia
  5. psychomotor retardation or agitation
  6. fatigue or loss of energy
  7. feelings of worthlessness or excessive or inappropriate guilt
  8. diminished ability to think or concentrate
  9. 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)

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45
Q

SIGECAPS

A 
Sleep
Interest (Anhedonia)
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidality
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46
Q

Major depressive episode can be associated with special features

A

melancholic, psychotic, atypical

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47
Q

Depressed patients with melancholic features

A
  • 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

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48
Q

Depressed patients with psychotic features

A
  • hallucinations
  • delusions
  • -> at high risk for suicide even if deny suicidal ideation
  • -> should be sent for hospitalization immediately, should be under care of psychiatrist
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49
Q

Depressed patients with atypical features

A
  • 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

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50
Q

Tips for interviewing patients with depression

A

“patients who’ve had a heart attack sometimes get depressed or down after the event. has this been happening to you recently?”

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51
Q

Depressed mood algorithm

A
  1. 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

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52
Q

Differentiating mild and moderate depression from major depression (linking PHQ9 score and severity of depression)

A

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

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53
Q

Depression due to general medical conditions

cardiac dz

A

ischemic dz, myocardial infarction, heart failure

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54
Q

Depression due to general medical conditions: cancer

A

brain cancer, pancreatic cancer

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55
Q

Depression due to general medical conditions: endocrine disorders

A

hyperthyroidism, hypothyroidism, diabetes, parathyroid dysfunction, cushing’s disease

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56
Q

Depression due to general medical conditions: GI dzs

A

inflammatory bowel disease, irritable bowel syndrome, hepatic encephalopathy, cirrhosis

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57
Q

Depression due to general medical conditions: neurologic dz

A

stroke, chronic headache, dementias, traumatic brain injury, multiple sclerosis, parkinson’s dz, epilepsy

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58
Q

Depression due to general medical conditions: pulmonary dz

A

sleep apnea, reactive airway dz

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59
Q

Depression due to general medical conditions: rheumatologic dz

A

lupus, rheumatoid arthritis, chronic fatigue syndrome, fibromyalgia

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60
Q

Depression due to general medical conditions: metabolic dz

A

renal failure, electrolyte disturbances

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61
Q

Depression due to general medical conditions: Infectious disease

A

HIV, syphilis, hepatitis, lyme dz

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62
Q

Depression due to general medical conditions: hematologic dz

A

severe anemia

63
Q

Lab tests to consider ordering in working up depression

A

TSH, CBC, chemistry panel (chem 7?)

full h&p can give clues as to which additional tests to order

64
Q

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

A

True

65
Q

True statements about depression and mgmt of general medical illness

A
  • 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
66
Q

True or false: presence of chronic medical illness is most prevalent risk factor for devt of depression

A

False!

the presence of chornic med illness alone isnt most prevalent risk factor for depressiond evt

67
Q

substance induced depression

A

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

68
Q

Dysthymic disorder

A

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

69
Q

DSM IV criteria for dysthymic disorder

A

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:

  1. poor appetitie or overeating
  2. insomnia or hypersomnia
  3. low energy or fatigue
  4. low self esteem
  5. poor concentration or difficulty making decisions
  6. 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

70
Q

Bereavement

A
  • 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
71
Q

Adjustment disorder w depressed mood

A

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

72
Q

Seasonal affective disorders

A

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)

73
Q

SSRIs in pregnancy

A

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

74
Q

Medical mgmt depressed pts during pregnancy: agents of choice

A

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%)

75
Q

Teratogenic treatments of depression

A

mood stabilizers (dilantin, valproic acid, carbamazepine)

76
Q

Most important factor in choosing meds during pregnancy

A

–> patients level of functioning in past when she was not taking meds

77
Q

Mild to moderate severity depression during pregnancy

A

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

78
Q

Pregnant patients to definitely treat during pregnancy

A

hx of bipolar dz, suicide attempts, recurrent MDD or psychotic disorders

79
Q

Postpartum depression

A
  • 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

80
Q

Antidepressants in breastfeeding women

A

decision based on severity of depression and need for pharmacotherapy, rather than any known risks to infant

81
Q

Depression in elderly pts

A

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!

82
Q

Common manifestations of depression in elderly pts

A

insomnia, anorexia, fatigue

treatments esp with SSRI can be helpful

83
Q

Pseudodementia

A
  • 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

84
Q

Dementia vs. Depression

A

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

85
Q

Dementia vs. Depression

A

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

86
Q

Manic and hypomanic symptoms: risk in ppl w fam hx

A
  • 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!
87
Q

Treating bipolar disorder as unipolar (mistake)

A

–> only treating depression (antidepressants) can precipitate manic episode

88
Q

Hypomanic vs. manic

A

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

89
Q

Summary of DSM IV criteria for manic episode

A

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

90
Q

Summary of DSM IV criteria for hypomanic episode

A

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

91
Q

Questions in assessing suicidal risk

A
  • 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)
92
Q

Suicidal plan

A

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

93
Q

Antidepressant overdose and suicide

A

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

94
Q

Situations requiring referral to psychiatrist

A
  • 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
95
Q

Onset Beneficial effects of antidepressant treatment

A

2-4 wks

96
Q

Three phases of treating major depression

A
  1. acute phase: remission induced (minimum 6-8wks duration)
  2. continuation phase: remission preserved and relapse prevented (usually 16-20wks )
  3. maintenance phase: susceptible pts protected against recurrence or relpase of subsequent major depressive episodes (duration varies w frequency and severity of previous episodes)
97
Q

Remission (official definition by american psych assoc)

A

return to pts baseline level of sx severity and functioning; should not be confused w significant but incomplete improvement!

98
Q

Relapse (official definition by american psych assoc)

A

re-emergence of significant depressive sx or dysfunction after remission achieved

99
Q

Acute phase of trtmt major depression

A

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)

100
Q

Acute phase treatment: mild to moderate depression

A

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

101
Q

Assessing for adequate response in acute phase

A
  • 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

102
Q

If response inadequate in acute phase

A
  1. increase trtmt dose
  2. if 4-8 wks after inc dose no mod improvement in sx, another review (consider other trtmt options, consulting w psychiatrist)
103
Q

Continuing phase treatment

A

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)

104
Q

Minimum total length of acute and continuation phase treatment

A

6 months

105
Q

Maintenance phase treatment

A

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)

106
Q

Discontinuation of active treatment

A

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

107
Q

True or false: all classes of antidepressants equally effective

A

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)

108
Q

Dosing antidepressants in geriatric population

A

starting dose usually 1/2 recommended starting dose for other adults

109
Q

fluoxetine
selective serotonin reuptake inhibitors
Reuptake inhibitors

A

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

110
Q

paroxetine
SSRI
reuptake inhibitors

A

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

111
Q

sertraline
ssri
reuptake inhibitors

A

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

112
Q

citalopram
ssri
reuptake inhibitors

A

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

113
Q

fluvoxamine
ssri
reuptake inhibitors

A

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

114
Q

escitalopram
ssri
reuptake inhibitors

A

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

115
Q

reboxetine
selective norepinephrine reuptake inhibitors
reuptake inhibitors

A

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

116
Q

desipramine
nonselective norepinephrine reuptake inhibitors
reuptake inhibitors

A

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

117
Q

nortripytline
nonselective norepninephrine reuptake inhibitors
reuptake inhibitors

A

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

118
Q

maprotiline
nonselective norepinephrine reuptake inhibitors
reuptake inhibitors

A

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

119
Q

Amitryptiline
TCAs (older agents)
Mixed or dual action reuptake inhibitors

A 
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
120
Q

Dothiepin
older agents (TCAs)
mixed or dual action reuptake inhibitors

A 
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
121
Q

Clomipramine
older agents (TCA)
mixed or dual action reuptake inhibitors

A 
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
122
Q 
amitryptiline
older agents (tca)
mixed or dual action reuptake inhibitors
A 
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
123
Q

dothiepin
older agent tca
mixed or dual action reuptake inhibitor

A 
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
124
Q

clomipramine
older agent tca
mixed or dual action reuptake inhibitor

A 
lethality in overdose: high
insomnia/agitation: mild
sedation: mod
hypotension: mod
anticholinergic: mod
nausea/gi: mild
sexual dysfunction: mild
wt gain: mod
125
Q

imipramine
older agent tca
mixed or dual action reuptake inhibitor

A 
lethality in overdose: high
insomnia/agitation: mod
sedation:mild
hypotension:mod
anticholinergic: mod
nausea/gi:none or mild
sexual dysfunction:mild
wt gain:mod
126
Q

venlafaxine
new agents non tca
mixed or dual action reuptake inhibitor

A 
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
127
Q

minacipran
new agents non tca
mixed or dual action reuptake inhibitor

A 
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
128
Q

bupropion
new agents non tca
mixed or dual action reuptake inhibitor

A 
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
129
Q

duloxetine
new agents non tca
mixed or dual action reuptake inhibitor

A 
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
130
Q

phenelzine
irreversible agents
MAOIs

A 
lethality in overdose:high
insomnia/agitation: mod
sedation:mild
hypotension:mod
anticholinergic: mild
nausea/gi:mild
sexual dysfunction:mod
wt gain:mild
131
Q

tranylcypromine
irreversible agents
MAOIs

A 
lethality in overdose: high
insomnia/agitation: mod
sedation:mild
hypotension:mod
anticholinergic: mild
nausea/gi:mild
sexual dysfunction:mod
wt gain:mild
132
Q

isocarboxacid
irreversible agents
MAOIs

A 
lethality in overdose:high
insomnia/agitation: mod
sedation:mod
hypotension:mod
anticholinergic: mild
nausea/gi:mild
sexual dysfunction: mod
wt gain:mod
133
Q

selegiline
irreversible agents
MAOIs

A 
lethality in overdose:mod
insomnia/agitation: mild
sedation:none or mild
hypotension:mild
anticholinergic: mild
nausea/gi:mild
sexual dysfunction: mod
wt gain: mild
134
Q

moclobemide
reversible agents
MAOIs

A 
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
135
Q

mirtazapine
mixed action newer agents
MAOIs

A 
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
136
Q

mianserin
mixed action newer agents
MAOIs

A 
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
137
Q

nefazodone
mixed action newer agents
MAOIs

A 
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
138
Q

trazodone
mixed action newer agents
MAOIs

A 
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
139
Q

Possible side effect of all antidepressants

A
  • may induce manic episode in patients susceptible to bipolar disorder
140
Q

SSRI (general info)

A
  • 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
141
Q

Tricyclic antidepressants (TCA) and norepinephrine reuptake inhibitors (NRIs)

A
  • 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
142
Q

dual action antidepressants

serotonin and norepinephrine reuptake

A
  • 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
143
Q

bupropion

dual action antidepressants

A
  • -> 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
144
Q

monoamine oxidase inhibitors (MAOIs)

A
  • 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)
145
Q

newer antidepressant therapies

A
  • 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
146
Q

Considerations before switching antidepressants

A
  • 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
147
Q

Adjunct medications

A
  • 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
148
Q

Anxiety: antidepressants and anxiolytics

A
  • 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

149
Q

Interpersonal therapy

A
  • 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
150
Q

Problem solving therapy

A
  • 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
152
Q

Combo meds and psychotherapy

A
  • 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
153
Q

Electroconvulsive therapy (ECT)

A
  • 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
154
Q

St. John’s Wort

A
  • 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
155
Q

Cognitive Behavioral Therapy

A
  • 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

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