Depression

Question 1

what are some risk factors for suicide

Answer 1

see picture

Question 2

what is the diagnostic criteria of major depression

Answer 2

depressed mood

anhedonia

sleep changes - particularly early morning waking

agitation (or psychomotor retardation)

fatigue

appetite changes

concentration

excessive guilt or worthlessness

suicidality

need 5 of 9 for at least 2 weeks

in DSM V, the bereavement exclusion has been removed

Question 3

what are the important differentials between depression and adjustment disorder?

Answer 3

persistence of symptoms is really important

pervasiveness of the symptoms (no positive times at any stage)

Question 4

which anti-depressant class are associated with increased risk of suicide?

Answer 4

TRICK QUESTION

BAHAHAHA SO CLEVER

SSRI can increase anxiety and agitation in the first week of treatment. Due to this, there may be an increased risk of self-harm, however, at a population level there isn’t any evidence that SSRIs lead to increased suicidality.

Question 5

what is the drug side effects particularly noted with:

1. fluoxetine
2. venlafaxine
3. paroxetine

Answer 5

fluoxetine has long half life with active metabolites, making it more of a messy drug

there is also inhibition of the 2d6 (see below)

venlafaxine has been associated with BP elevation

paroxetine is an irreversible inhibitor of CYP2D6, leading to tamoxifen interaction

(tamoxifen is a pro-drug, and is activated by 2D6)

Question 6

what are some side effects of TCAs?

Answer 6

anticholinergic, antiadrenergic and quinidine like effect

there is a significant risk of arrhythmias

postural hypotension

some role in sedation in anxious patients

Question 7

how does St John’s Wort work?

what are the drugs with which it has a major interaction?

Answer 7

it is a plant species that inhibits the uptake of serotonin, NA, dopamine

there is some effectiveness in mild to moderate depression, but often the doses are insufficient

the drugs that you MUST know are:

cyclosporin

indinavir

there is emerging evidence that a few other protease inhibitors are also at risk - saquinavir, ritonavir, nelfinavir

also emerging evidence for:
HIV non-nucleoside reverse transcriptase inhibitors (efavirenz, nevirapine, delavirdine)

Question 8

what’s the risk of depression recurrence?

Answer 8

after one episode it is 50%

after two = 70%

after 3 = 90%

Question 9

which of the SSRI side effects tend to stick around?

which tend to abate?

Answer 9

sexual dysfunction is unfortunately persistent

reduced sleep, dry mouth, headache and nausea tend to abate after 5 days or so

Question 10

if you are going to continue maintenance (after “induction”) of an antidepressant, do you modify the dosing at all?

Answer 10

no. continue on the “induction agent”

Question 11

pall care patient with persistent pain - has become more distressed by loss of independence

mentions thoughts of ending his life by suicide

what’s the chief factor in this patient?

Answer 11

in this setting, this is major depression

while there is significant pain and this will be exacerbating things, the major factor is depression.

saying that any treatment MUST take pain management into account

Question 12

what is the major side effect with interferon?

Answer 12

depression is super important and pre-existing depression is a contraindication to therapy

Question 13

how do the TCAs deliver their antidepressant effect?

Answer 13

it’s via NA reuptake inhibition

the majority of other actions lead to side effect profile