Depression 3 Flashcards
1
Q
Catastrophizing
A
You expect disaster, you filter the decisions through “what if?”. What bad thing can happen? What if it happens to you?
2
Q
Personalization
A
- You think that everything people do or say is some kind of reaction to you
- Constantly compare yourself to others (thinner, smarter, more popular, etch)
3
Q
Polarized thinking
A
Black and white thinking - you are either with or against me
(ex. If you are less than perfect you are a failure, if I don’t get all A’s, I’m a failure)
4
Q
Shoulds: cognitive distortion
A
- List of Ironclad rules
- Angry with people who break them and feel guilty for violating them
5
Q
Overgeneralization
A
Coming to a conclusion based on a single incidence or piece of evidence
(ex: I failed that test, I am a failure as a student. OR I got rejected, I will never reach out again)
6
Q
Cognitive distortion: mental filtering
A
We pick out a negative detail and focus on that thought & filter out all the positive aspects of that situation
7
Q
Cognitive distortion: blaming others
A
You hold of the people responsible for your pain and misfortune
8
Q
Cognitive distortion: Heaven’s reward fallacy
A
- Expect all your self-sacrifice to pay off as if there were some one’s keeping score
- You become bitter or sad when the reward doesn’t come
9
Q
Cognitive distortion: inappropriate expectations of others
A
- You think other people will change if you are convincing her pleasing enough
- You need other people to change because your own happiness is dependent on them
10
Q
Cognitive distortion: ignoring the positives
A
You reject anything positive that does not support your thought (ex: “ that doesn’t count because…”)
11
Q
Cognitive distortions: minimization
A
You undervalue your own positive qualities
12
Q
Advantages to cognitive behavioral therapy compared to medication (6)
A
- Similar efficacy
- Less relapse after discontinuation
- People like it
- Time-limited
- Overall low price
- Few side effects
13
Q
Disadvantages to cognitive behavioral therapy compared to medications
A
- Harder to administer than medication
- Limited availability
- More effort than taking medication
- Not all patients are able (too anxious, severe condition, cognitive impairment)
14
Q
Depression causes people to shut down. They believe that motivation and activty with follow a _______.
A
- “feeling”
(BUT…depressed patients don’t feel like doing anything. aving activity plan helps them recover)
15
Q
Depressed patients don’t feel like doing fun things and have difficulty turning into pleasure. How can you help?
A
- Pleasant events schedule
- You can print out a list of hundreds of things to do that might be fun
16
Q
Medication characteristics to consider when selecting an antidepressant (4)?
A
- Antidepressant class (efficacy)
- Tolerability
- Ease-of-use
- Drug interactions
17
Q
Patient characteristics to consider when selecting antidepressant (5)?
A
- Spectrum symptoms
- Lifestyle and preferences (scared of weight gain or sexual dysfxn)
- Health status: comorbidities, medications
- Hx a response to and or Adverse Events with prior meds
- Cost
18
Q
MC antidepressant class used
A
SSRIs
(little to no effect on NE or D)
19
Q
SSRIs have less side effects such as (4)
A
- anticholinergic
- antihistaminic
- anti-alph1-adrenergic
- cardiotoxic effects
(needs less titration, hard to OD on it)
20
Q
SSRI MOA
A
- Blocking autoreceptor
- Blocking reuptake
- Increased BDNF (brain-derived neurotrophic factor)
(patients with depression have upregulated postsynaptic receptors → SSRIs → down-regulation)
21
Q
Typical antidepressant treatment response takes about ______.
A
3-6 weeks
(longer in anxiety disorders)
22
Q
Depression duration of treatment if they’ve had one episode? Two? Three?
A
- First episode: 6 to 12 months
- Second episode: 1 to 2 years
- Third episode: maintenance
(3rd episode → 90% likely to occur again. Depression causes brain damage, the longer they are depressed, the more likely they are to develop sequelae)
23
Q
SSRI side effects (8)
A
- seuxual dysfunction
- decreased appetite/nausea, weight loss
- sedation
- activation
- headache
- sleep disturbance / vivid dreaming
- hyponatremia
- decreased blood coagulation
(TQ!!)
24
Q
Serotonin syndrome is associated with use of ____ (3)
A
- High doses of or multiple SSRI
- MAOI/SSRI combo
- MAOI/synthetic narcotic pain combo
25
Discontinuation syndrome may occur with \_\_\_\_\_.
This reduction or discontinuation of SSRI or SNRI
(gradual weaning is recommended)
26
Discontinuation syndrome symptoms (6)
1. dizziness
2. shock-like sensations
3. sweating
4. nausea
5. tremor
6. nightmares
27
Cyclic antidepressants CNS effects (7)
1. Insomnia
2. Agitation
3. Drowsiness
4. Disorientation
5. Confusion
6. Headache
7. Fine tremor
28
Cyclic antidepressant cardiovascular effects are MC in the elderly and include _____ (2).
1. Tachycardia
2. Orthostatic postural hypotension
29
What is the only antidepressant that comes in a patch form?
Selegiline
30
Which antidepressant medication has the fewest side effects?
Bupropion
31
Which antidepressant has the greatest incidence of seizures?
Bupropion
(only 2% who were taking it as directed)
32
What is interpersonal therapy?
Psychotherapy focusing on helping patients understand their interpersonal problems & cope with stressors
33
What is cognitive behavioral therapy?
* Focuses on changing negative thinking and behavior patterns
* Assist patients in abandoning negative or self-deprecating attitudes toward their depression
34
What are the nine basic steps of cognitive therapy?
1. What triggered the thought
2. Identify the thought
3. Identify the feeling
4. Identify the response
5. Change the thought
6. Weigh evidence for and against the thought
7. Revised percentage they believe in the thought
8. Restatement of the situation
9. What are the new feelings and responses?
35
Depressed patients may need frequent brief contacts for\_\_\_\_\_\_ (2).
support and medication management
(once or twice-weekly)
36
Most patients with depression require _______ of maintenance medication before considering decreasing or discontinuation.
for months to years
37
What are the five most prescribed antidepressants?
1. Alprazolam (Xanax)
2. Escitalopram (lexapro)
3. Lorazepam (Ativan)
4. Sertraline (Zoloft)
5. Fluoxetine (Prozac)
38
List the SSRIs (8)
1. Fluoxetine (Prozac, Sarafem)
2. Sertraline (Zoloft)
3. Paroxetine (Paxil, Paxil CR, Paxeva)
4. Fluvoxamine (Luvox, Luvox CR)
5. Citalopram (Celexa)
6. Escitalopram (Lexapro)
7. Vilazodone (Vybriid)
8. Vortioxetine (Brintellix)
39
The Black Box warning for suicide on antidepressants typically applies to which age range?
Those 24 years old and younger
40
\_\_\_\_\_\_ is the least sedative SSRI and _____ is the most sedative SSRI.
* Fluoxetine
* Paroxetine
(fluoxetine is also the one the causes the most "activation")
41
Serotonin syndrome symptoms
1. Generalized restlessness
2. Nausea
3. Diarrhea
4. Delirium
5. Diaphoresis
6. Insomnia
7. Cramps/muscle rigidity
42
Treatment for serotonin syndrome (2)?
1. reduce SSRI dose
2. give cyproheptadine
43
List 5 SNRI's
1. **Venlafaxine** (Effexor, Effexor XR)
2. Des**venlafaxine** (Pristiq)
3. Duloxetine (Cymbalta)
4. **Milnacipran** (Savella)
5. Levo**milnacipran** (Fetzima)
44
\_\_\_\_\_\_ may resolve symptoms of Discontinuation Syndrome.
Replacement of short-acting Med with longer acting Med (fluoxetine)
(typically resolves within a week)
45
List 6 cyclic antidepressants
1. Amit**riptyline** (Elavil)
2. Des**ipramine** (Norpramin)
3. Clom**ipramine** (Anafranil)
4. Nor**triptyline** (Pamelor)
5. **Imipramine** (Tofranil)
6. Doxepin (Sinequan, Silenor)
46
Tricyclic antidepressant has 3 major side effects (systems)
1. Anticholinergic
2. CNS
3. Cardiovascular
47
What are the anticholinergic side effects of tricyclic antidepressants?
1. Dry mouth
2. Blurry vision
3. Slows GI motility (constipation, urinary retention)
48
\_\_\_\_\_ is commonly used in combination w/SSRI's and venlafaxine.
Buproprion
(also helpful for smoking cessation)
49
Mirtazapine mechanism of action
5 HT-2A & 2C **antagonist** + alpha 2 **antagonist** = increased 5HT & NE
(without inhibiting 5HT or NE reuptake)
50
Mirazapine adverse effects
* sedation
* weight gain (stim appetite)
(also: dizziness, dry mouth, constipation)
51
Ketamine is mainly used for ________ depression
Treatment-resistant: failed two or more antidepressants and suicidal
52
Ketamine mechanism of action
Blockade of NMDA receptors→ increases glutamate→ activates AMPA receptors
(reduces inflammation too)
53
Ketamine adverse effects
1. Perceptual disturbances / dissociation
2. Elevated blood pressure
3. N/V
4. Potentially addictive
54
How is ketamine administered to treat depression?
1. IV or intranasally
2. 8 treatments
55
Strategies for achieving depression remission (6)?
1. Ensure appropriate diagnosis
2. Psychotherapy
3. Appropriate treatment
4. Manage symptoms and side effects
5. Compliance through education
6. Monitor for compliance
56
Antidepressants must be taken for at least ____ for a *_noticeable effect_* and continued for at least\_\_\_\_\_ *_following remission to prevent relapse._*
* 2 to 4 weeks
* 16 to 20 weeks
## Footnote
***_(maintenance based on risk of recurrence, severity of episode, side effects, patient preference)_***
57
What are the core principles of depression management
1. Aggressive approach
2. Reevaluate frequently
3. Treat to remission
58
How do you take an aggressive approach to managing depression (4)?
1. Actively managed the patient
2. Make treatment plan
3. Set goals
4. Confirm patient adherence to therapy
59
How do you reevaluate an aggressive treatment plan for depression (3)?
1. Reassess for response and adverse effects
2. Consider increasing dose early on, if needed
3. Consider switching to alternate class of antidepressant
60
What are the general guidelines for antidepressant therapy (5)?
1. Patient education
2. Start at lowest dose possible in patients with anxiety
3. Attempt to increase to full therapeutic dose after acute side effects have resolved or are tolerated
4. Target remission of symptoms
5. Manage sustained side effects
61
Educating patients about antidepressant therapy includes (3)
1. Time course of potential effects
2. Short-term vs. long-term side effects
3. Recommended length of therapy
62
Somatic management of depression
1. Electroconvulsive therapy (ECT)
2. Repetitive transcranial magnetic stimulation (rTMS)
3. Vagal nerve stimulator (VNS)
63
Define electroconvulsive therapy
Electric current is passed into the brain to produce grand mal seizure
64
Electroconvulsive therapy effects on the central nervous system (2)?
1. Neurotransmitter changes
2. Neuroendocrine effects and alterations an intracellular signaling pathways
65
ECT indications
1. Acute forms of schizophrenia: mania unresponsive to medication
2. Medication-refractory depression
3. Suicidal depression
4. Depressed & refuses to eat or drink
5. Depression during pregnancy
6. Catatonic syndromes
7. History of positive response to ECT
66
\_\_\_\_\_ % of patients say that they would do electroconvulsive therapy again
80
(80% effective)
67
\_\_\_\_ % of patients respond when ECT is the first line treatment; _____ % respond after failed antidepressants
* 85
* 55
68
ECT is not recommended for\_\_\_\_\_ (2).
* chronic depression
* personality disorder
69
How many treatments are included in electroconvulsive therapy
* 6 to 12 treatments
* 3 per week
(some patients have maintenance ECT)
70
Describe the procedure for electroconvulsive therapy
1. Benzos and anticonvulsant must be stopped
2. Anesthetic, oxygen and muscle relaxant administered
3. Electrodes placed bilaterally over the parietal lobes
4. Electric shocks are administered with increasing amount of electricity until seizure is attained
71
What is stimulus dosing in ECT?
Amount of electricity is minimal amount required to induce a seizure and be therapeutic
(several small doses are given with increasing charge until the patient seizes)
72
With bilateral placement the therapeutic response of ECT is _____ times seizure threshold. Unilateral?
* 2.5
* 6 times threshold
73
ECT adverse effects (during treatment) (7)
1. hypotension or hypertension
2. bradyarrhythmias
3. tachyarrhythmias
4. fractures
5. prolonged seizure
6. laryngospasm
7. prolonged apnea
74
ECT adverse effects immediately after treatment:
1. postictal confusion
2. HA
3. Nausea
4. Muscle pain
75
ECT adverse effects: long term
Memory impairment: retrograde & anterograde
(retrograde may last for months)
76
Transcranial magnetic stimulation uses
1. Major depressive disorder
2. Migraines
3. Parkinson's
4. Dystonia
5. Stroke Rehabilitation
77
How does TMS work?
Magnetic induction of weak electric currents using a rapidly changing magnetic field → depolarization of neurons
78
What is the theoretical goal of TMS?
stimulate brain regions where monoamine deficiency would lead to a boost in monoamine activity.
79
TMS side effects (2)
1. Headache
2. Neck pain
(acute risk of seizure and syncope)
80
Management of depression (outside of meds & therapy)
1. ***_Exercise_***
2. Sleep hygiene
3. Light exposure
4. L-methylfolate (methylfolate reductase insufficiency)
5. OMT
81
Alternative treatments for depression
1. Acupuncture
2. Yoga
3. S-adenyl-L-methionine SAM-e
4. St. John's Wort (300 mg tid)
5. Rhodiola
6. Chocolate
7. Omega-3
82
What is the advantage to using Selegiline as a transdermal patch?
Reduces the risk of tyramine interaction and hypertensive crisis
