Depression Flashcards
1
Q
Pathogenesis of Depression
5 factors that contribute?
A
- Genetics
- Early Life Adversity
- Social Factors
- Psychological Factors
- Secondary Depression (general medical disorders/medications/substance of abuse)
2
Q
How does ealry life adversity predispose pts to major depression?
A
by altering sensitivity to stress and response to negative stimuli
3
Q
- Pathologically how does early life stress affect the stress response?
- How can this affect the child for life?
A
- hyperactive corticotropin releasing factor cells in hypothalamus – increased stress response. (HPA axis)
- Stress responses can be set for life and modify the activation of certain genes (epigenetics!) and transmitted to offspring
4
Q
WHat are epigenetics?
A
Epigenetics – changes in expression of genes caused by early life experiences or chronic stress.
genes + environment + environmentally altered gene expression
5
Q
Social Factors- May lead to depression onset or lead to depressive episodes. What are some examples of this?
4
How can this affect behavior about medical care and their own symtpoms?
A
- Isolation
- Poor social relationships
- Criticism from family members (expressed emotion)
- Depression in social networks
Influence symptoms expressed and willingness/ability to access care.
6
Q
How can Cognitive/Behavioral factors lead to depression?
A
Negative/distorted patterns of thinking predispose to depression
- These patterns worsen in the depressed person
7
Q
Describe Neuroticism (personality trait)
A
anxiety, moodiness, envy, frustration, loneliness – respond poorly to stressors, interpret ordinary situations as threatening, and minor frustrations as hopelessly difficult.
8
Q
Pathogenesis - Secondary Depression
can be caused by?
3
A
- General Medical Conditions
- Medications
- Drugs of Abuse
9
Q
Medical conditions that can lead to depression?
Top 5
Other?
A
- Sleep Apnea
- Hypothyroidism/Vitamin D deficiency/Diabetes
- Chronic Pain
- Stroke
- Heart Disease – ischemic, HF, cardiomyopathy
Parkinson's MS Epilepsy Head injury Cancer COPD Dementia HIV/Neurosyphilis
10
Q
Medications that may cause depresison?
5
A
- Interferon
- Corticosteroids
- Benzodiazepines/Opiods
- Varenicline (Chantix)/
- Beta-Blockers
11
Q
Drugs of abuse that may cause depression? 8
A
- PCP
- Amphetamines
- Cocaine
- Marijuana
- Sedative-hypnotics
- Alcohol
- Opiates
- Steroids
12
Q
Neurobiology of Depression
Structural abnormalities that may cause this?
4
A
- increased ventricular-brain ratio
- smaller frontal lobe volumes
- smaller hippocampal volumes
- number/density/size of neurons and glial cells are abnormal
13
Q
Hypothalamic-pituitary-adrenal axis (HPA axis) excess excretion of glucorticoids may lead to what?
A
suppression of neurogenesis and hippocampal atrophy
14
Q
Sleep/Circadian rhythms – leads to decreased?
A
REM latency and slow wave sleep Inflammation – higher levels of inflammatory markers
15
Q
Symptoms of Major Depression
three categories?
A
- Psychological
- Neurovegetative
- Psychomotor/physical
16
Q
Psychological symptoms?
7
A
- Depressed Mood (Dysphoria)
- Numbness
- Anhedonia (inability to experience joy)
- Decreased Interest
- Irritability/Anxiety
- Guilt/worthlessness
- Suicidal Ideation
17
Q
Neurovegetative symtpoms?
4
A
- Appetite
- Sleep
- Energy
- Concentration
18
Q
Psychomotor symptoms? 2
Phsyical symptoms? 3
A
Psychomotor
- retardation (walking through mud or having bricks tied to feet)
- agitation
Physical
- aches/pain
- weakness/malaise
- GI distress
19
Q
Qualifiers for Dx of depression?
55
A
- Symptoms occur in the same two weeks
- Most of the day nearly every day
- Distress or impairment
- R/O substances/general medical condition
- R/O bereavement
20
Q
Subtypes of Depression
8
A
- Anxious
- Atypical
- Catatonic
- Melancholic
- Mixed Features
- Peripartum
- Psychotic
- Seasonal
21
Q
What are the subcategories of depression?
A
- Bipolar
2. Secondary
22
Q
Secondary causes of depression? 3
A
- Medical illness
- Medications
- Drugs of abuse
23
Q
Comorbid Psychiatric Conditions
2
A
- Anxiety Disorders
2. Substance Abuse
24
Q
Types of anxiety disorders?
4
A
- Generalized Anxiety
- Panic Disorder
- Obsessive compulsive disorder
- PTSD
25
Evaluate Symptoms
| 3
1. Questions/Evaluation
- -Major depression or a subtype
2. Scales
3. Observation
26
What is SIGECAPS?
```
Sleep
Interest
Guilt/worthlessness
Energy
Concentration
Appetite
Psychomotor disturbance
Suicidal Ideation
```
27
Depression Evaluation
| 4 steps?
1. Chronology of current symptoms
2. Symptoms occur in the same two weeks
3. Most of the day nearly every day
4. Distress or impairment
28
Depression Evaluation
Things to look for?
7
1. Prior History of Depressive Episodes (symptoms, course, treatment)
2. Impact of episode on occupational and interpersonal functioning
3. Alleviating and aggravating factors (stressful life events etc.)
4. Address comorbidity (substance, illness, medications, psychiatric)
5. Evaluate for mania/hypomania
6. Distinguish major depression from persistent depressive disorder (dysthymia) – 2 years without a symptom free interval of 2 months
7. Suicide Risk
29
What things should we ask about for family Hx?
| 4
1. depression,
2. suicide,
3. psychosis,
4. bipolar disorder
30
Social Hx questions to ask?
| 4
1. interpersonal,
2. occupational,
3. financial stressors –
4. sources of support, assessment of family/relationship dynamics
31
PE for depression 2
Labs?
8
Imaging? 1
Procedures? 2
1. +/- Complete physical and neurological exam
2. Mini mental status exam
```
1. Toxicological screen
Lab screen
2. CBC,
3. TSH,
4 LFT’s,
5. Chem7,
6. Ca,
7. B12, Folate,
8. HIV
```
1. Brain imaging (psychosis or neuro findings
1. +/- EEG,
2. LP (psychosis or neuro findings
32
Psychotic Features
3
What are they at higher risk for with these symtpoms?
1. Delusions
2. Hallucinations
3. Disordered thought
Markedly higher suicide risk
33
Psychotic Depression
| 3 questions to ask?
1. Does your mind ever play tricks on you?
2. Do you ever hear things/see things?
3. Do you ever feel like people are out to get you?
34
Suicide – Risk Factors
| SAD PERSONS
```
S ex (male)
A ge (elderly or adolescent)
D epression
P revious suicide attempts
E thanol abuse
R ational thinking loss (psychosis)
S ocial supports lacking
O rganized plan to commit suicide
N o spouse (divorced > widowed > single)
S ickness (physical illness)
```
35
You need to ask about the plan and history. Specifically what?
5
1. Organized Plan
2. Access to lethal means
3. Previous attempts
4. Family History
5. Non-suicidal self injury
36
Suicidal Ideation – Assessment
| 3
1. “Do you feel hopeless?
2. “Do you feel like life is not worth living?”
3. “Do you think about suicide?”
37
Intent, Plan, Means
| 3 questions to ask about these thoughts?
1. What specific thoughts have you had?
2. Do you have access to guns?
Can someone hold on to them?
3. Have you been stock piling medication?
Can you bring them in?
38
What do you need to ask about previous attempts?
| 6
1. Who, What, When, Where, Why, How?
2. “What exactly did you do?”
3. “Was it planned?”
4. “Did you tell anyone?”
5. Risk/Rescue
6. Do you ever feel like you are being punished?
39
1. If they have a plan, intent, means then what must you do?
| 2. Less acute plan then what? 4
1. Plan, Intent, Means – hospitalization
2. Less acute -
- safety plan
- Crisis Center,
- stay with family,
- more frequent visits (even daily)
40
Safety Treatment Plan
what needs to be in the plan?
4
1. Crisis Numbers – written and programmed in phone (family, friends, suicide hotline, ER, clinic number)
2. ROI for family in chart
3. Commitment to adhere to medications, appointments, contact office with concerns
4. Agree to remove lethal means – have someone take guns, bring in extra medications
41
What are the four depression scales?
1. Beck Depression Inventory
2. Quick Inventory of Depressive 3. Symptomatology
Mood Disorder Questionnaire
4. Hamilton Anxiety Rating Scale
42
BDI-II
Beck Depression Inventory
1. Administered by who?
2. Used for? 2
1. Self administered
2.
- Screening
- Treatment response
43
QIDS-SR
Quick Inventory of Depressive Symptomatology Self Report
-What can you access from this? 2
Free
www. ndmda.org
1. Also have MDQ and HAM-A in online format
2. DSMIV-tr criteria
44
MDQ
Mood Disorder Questionnaire
1. Is used for what?
2. What makes a positive result? 3
1. Mania Screening
2.
- 7 positive responses to #1-13
- AND positive response to #14
- AND moderate or serious #15
45
HAM-A
Hamilton Anxiety Rating Scale
1. How many questions and what are the ratings?
2. What indicates significant anxiety?
3. Patients with what tend to score higher?
```
1.
14 questions
0= absent
1= mild
2= moderate
3= severe
4= incapacitating
```
2. > 20 indicates significant anxiety
3. Patients with depression tend to score higher
46
Observation – Mental Status Exam
What areas are we assessing here?
7
Presence of depressive signs
1. Affect
2. Cognition (attention /concentration, memory)
3. Psychomotor activity
4. Ruminative thought process
5. Speech
6. Psychosis
7. Suicidal thoughts
47
What are the Antidepressant Categories?
| 5
1. SSRI – Selective Serotonin Reuptake Inhibitor
2. SNRI – Serotonin-Norepinephrine Reuptake Inhibitor
3. TCA – Tricyclic Antidepressants
4. MAOi – Monoamine Oxidase Inhibitors
5. Others – Mirtazapine, Buproprion, Trazodone
Atypical Antipsychotics
48
1. What is first line treatment for depression?
| 2. WHy are these first line treatment? 2
1. First line treatment of depressive disorders
No real differences in efficacy
2. Difference in side effects and half lives
49
What are the SSRIs?
| 6
1. Fluvoxamine (Luvox)
2. Paroxetine (Paxil)
3. Sertraline (Zoloft)
4. Citalopram (Celexa)
5. Escitalopram (Lexapro)
6. Fluoxetine (Prozac)
50
Common AD Side Effects
| 6
1. GI disturbance – nausea, diarrhea, appetite
2. Sexual dysfunction
- -SSRI/SNRI 50-70%
3. Anxiety
4. Insomnia or sedation
5. Sweating
6. Dizziness
51
1. What are the SNRIs? 2
| 2. Acts on what receptors? 2
1.
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
2. Acts on both serotonin and norepinephrine
Not clearly more efficacious
52
Venlafaxine less than 225mg = SSRI. More than that acts as a SNRI.
SE? 2
Hypertension
| Tachycardia
53
Duloxetine is used for what?
indication for neuropathy
54
Tricyclic Antidepressants
are which drugs? 4
What kind of side effects? 4
Overdose risk?
Other disadvantage?
1. Amitriptyline,
2. Clomipramine,
3. Doxepin,
4. Imipramine
More side effects
1. Anticholinergic
2. Antihistamine
3. Orthostatic hypotension
4. Cardiac
Lethal in overdose
More drug-drug interactions
55
What are the MAOis? 2
1. phenelzine (Nardil),
| 2. tranylcypromine (Parnate)
56
1. MAOis advantage?
| 2. Disadvantage? 6
1. More efficacious
2.
- Poorly tolerated
- Drug-Drug interactions
- Serotonin Syndrome,
- Hypertensive Crisis
- Dietary restrictions
- Avoid Tyramine Containing Foods
57
TCA’s and MAOi’s
| Poorly tolerated why? 2
1. Sedation
| 2. weight gain
58
What serious complications can occur with MAOis? 2
1. Serotonin syndrome
| 2. hypertensive crisis
59
Trazodone
1. good for sleep at low doses?
2. If tolerated functions as a what at higher doses?
3. Watch for what? 3
1. Good for sleep at low doses
2. If tolerated – functions as an AD at higher doses
3. Watch for
- sedation,
- orthostasis,
- priapism (prolonged sustained erection)
60
Unique Buproprion Consideration
1. Avoid in who?
2. Enhances what?
3. Use in caution with who? 3
1.
- Avoid in seizure disorders
- Avoid in bulimia
2. Enhances dopamine = caution
3.
- anxiety
- psychosis
- dopaminergic agents
61
Unique Bupropion Consideration
1. Advantages? 5
2. How does it help with SSRIs? 2
3. Consider in what kind of pts?
1.
- No sexual side effects
- Smoking cessation
- Comorbid ADHD
- Often used with SSRI’s
- Safe in pregnancy
2.
- Augment antidepressant
- Reverse sexual side effects
3. Consider with sleepy, slowed down patients
62
Unique Mirtazapine Consideration
1. Advantages? 2
2. Disadvantages? 2
1.
- Sedation
- Weight gain
2.
- Less sexual side effects
- Good for patients with nausea
63
STAR*D
Sequenced Treatment Alternatives to Relieve Depression
-Four points of STAR*D?
1. Switching classes does not improve remission
2. Tolerability similar between classes
3. Augmentation may be better than switching
4. Remission rate decreases with each failed medication trial
64
Remission
Positive Predictors? 4
Negative Predictors? 5
Positive predictors
1. Caucasian
2. Female
3. Employed
4. Education
Negative predictors
1. Longer index episodes
2. Drug abuse
3. Anxiety disorders
4. Medical disorders
5. Lower functioning
65
What does Remission mean?
| 4
1. Return of normal functioning
2. Lower rates of relapse
3. Lower risk of suicide
4. Less alcohol and drug abuse
66
Acute Treatment of Depression The first 12 weeks
1. Mild?
2. Moderate/Severe? 2
3. Bipolar? 2
4. Psychotic? 2
1. Mild: consider psychotherapy alone
2. Moderate-severe: medication +/- therapy
3. Bipolar: mood stabilizer +/- antidepressant
4. Psychotic: antipsychotic + antidepressant
67
Continuation Phase
1. What is this?
2. What are they at high risk for?
3. Use what kind of dosage?
1. 4-6 months following remission
2. High risk for relapse
3. Use full therapeutic dosage
68
Classic Presentation of symptoms? 2
Atypical features? 2
1.
- Insomnia or hypersomnia -
- Classical early morning awakening vs initial/middle insomnia
2. Atypical features –
-eat more,
-sleep more.
Seasonal affective disorder –also
69
1. Maintenance Phase is what?
| 2. Risk of recurrence 3
1. relapse prevention
2.
- Number/Severity of previous episodes
- Residual symptoms
- Comorbid disorders
70
What leads to non-adherence?
| 5
1. Socioeconomic factors
2. Tolerability - SSRI, SNRI > TCA
3. Psychiatric = Nonpsychiatric
4. lack of Psychotherapy
5. lack of Education
71
What do we need to educate the pt on?
| 4
1. Minimum of 2-4 weeks to be effective
2. Take every day even if feeling better
3. Will need to take for 4-6 months
4. Side effects often time dependent
72
General Principles
1. Titrate to the target dose within what time frame?
2. Monitor for side effects like? 4
1. Titrate to target dose within first few weeks
2. Monitor for side effects
- agitation/anxiety
- suicidal ideation
- insomnia
- sexual
73
Decision Therapy
1. No improvement 4-6 weeks?
2. Limited response?
3. Side effects?
1. Consider switch
2. consider increase or augmentation
3. switch or augment
74
Choosing an Antidepressant: what things are involved in this?
9
1. Personal history
2. Pharmacogenetics
3. Family history
4. Cost
5. Overdose/safety
6. Side effects/unique benefits
7. Drug-drug interactions
8. Comorbid conditions
9. Depression subtypes
75
Which are the cheapest ADs?
6
Which are the more expensive ones?
4
1. Citalopram
2. Paroxetine
3. Fluoxetine
4. Sertraline
5. Bupropion SR, XL (300mg)
6. Mirtazapine
1. Escitalopram
2. Bupropion XL (150mg)
3. Venlafaxine XR
4. Duloxetine
76
What is the complication to know about Lithium!
Lithium - lethal
| -shown to decrease SI/impulsivity
77
Black-box warning on all ADs?
1. Increased risk of SI with antidepressants up to 24 yrs
- Treating depression beneficial
- Risk of suicide with untreated depression
78
Suicide attempts are highest when and decline when?
Suicide attempt rates highest in month before treatment
| Decline after AD or psychotherapy begins
79
Antidepressants and Suicide
1. Monitor at regular intervals. What things? 4
2. Refer to?
3. How can we encourage follow up?
4. Dose how in 18 to 24 yr olds?
1.
- SI,
- substance abuse,
- hopelessness,
- impulsivity
2. Refer for psychotherapy
3. Avoid giving refills to encourage follow-up
4. Start low and go slow in 18-24 year-olds
80
What to do for side effects? 4
1. WAIT!
2. Lower dose, slow titration
3. Change dosing schedule
4. Augment
81
Sexual Side Effects
1. Drug Holiday – watch for withdrawal
2. Augment
3. Lower dose
4. Wait
82
Sexual Side Effects: What drugs can we augment with?
| 4
1. Bupropion
2. Trazodone – rare risk of priapism
3. ED medication
4. Buspirone
83
Anxiety AD Tx? 5
Insomnia AD Tx? 4
1. Benzodiazepines
2. Gabapentin
3. Lyrica
4. Buspirone
5. Therapy/Meditation/Exercise
1. Benzodiazepines
2. Sleepers – zolpidem etc.
3. Trazodone
4. Therapy/Meditation/Exercise
84
Benzodiazepines
1. Goal of what?
2. Scheduled how?
3. Longer acting with lower abuse potential. Which drugs? 3
4. Caution in who?
1. Goal of short term use
2. Scheduled over prn
3. Longer acting with lower abuse potential
- clonazepam,
- lorazepam over alprazolam,
- diazepam
4. caution in comorbid substance abuse
85
AD Discontinuation symtpoms? 5
Tapering Strategy?
Which drugs are the worst?
Which ones are self tapering?
1. Nausea,
2. headache,
3. irritability,
4. vivid dreams,
5. vertigo
1. Slow taper +/- short term benzodiazepines
1. Worst - paroxetine, venlafaxine
1. Fluoxetine – self tapering
86
SSRI’s: 2D6 inhibition
1. Which have the most interactons? 3
2. Which have the least? 1
1.
- fluoxetine,
- paroxetine,
- fluvoxamine
2. escitalopram – least
87
2D6 Inhibition from Paroxetine
| Which drugs does it interact with and which does it cause? 3
1. Increased risperdone → extrapyramidal symptoms
2. Increased metabolite of trazodone → anxiety
3. Decreased conversion of codeine to morphine → pain
88
Psychotic depression
| Higher remission with combination of what?
AD and antipsychotic
89
Bipolar depression
| 30-50% risk of cycling into mania on AD without a what?
mood stabilizer
90
What are the kinds of psychotherapy?
| 2
1. Cognitive Behavior Psychotherapy
- understand distortions in thinking
- learn new ways of coping
2. Interpersonal Therapy
- Grief
- Role transition/role dispute
- Interpersonal deficits
91
Augmentation Strategies
| 5
1. Bibliotherapy
2. Relaxation techniques (visualization/muscle relaxation
3. Meditation
4. Exercise – aerobic 3-5x/wk 45-60 min
5. Apps/support groups/telepsychology for rural areas
