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Behavioral Health > Depression > Flashcards

Depression Flashcards

1
Q

Pathogenesis of Depression

5 factors that contribute?

A
  1. Genetics
  2. Early Life Adversity
  3. Social Factors
  4. Psychological Factors
  5. Secondary Depression (general medical disorders/medications/substance of abuse)
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2
Q

How does ealry life adversity predispose pts to major depression?

A

by altering sensitivity to stress and response to negative stimuli

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3
Q
  1. Pathologically how does early life stress affect the stress response?
  2. How can this affect the child for life?
A
  1. hyperactive corticotropin releasing factor cells in hypothalamus – increased stress response. (HPA axis)
  2. Stress responses can be set for life and modify the activation of certain genes (epigenetics!) and transmitted to offspring
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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

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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
  1. Isolation
  2. Poor social relationships
  3. Criticism from family members (expressed emotion)
  4. Depression in social networks

Influence symptoms expressed and willingness/ability to access care.

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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
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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.

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8
Q

Pathogenesis - Secondary Depression
can be caused by?
3

A
  1. General Medical Conditions
  2. Medications
  3. Drugs of Abuse
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9
Q

Medical conditions that can lead to depression?
Top 5

Other?

A
  1. Sleep Apnea
  2. Hypothyroidism/Vitamin D deficiency/Diabetes
  3. Chronic Pain
  4. Stroke
  5. Heart Disease – ischemic, HF, cardiomyopathy
Parkinson's
MS
Epilepsy
Head injury
Cancer
COPD
Dementia
HIV/Neurosyphilis
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10
Q

Medications that may cause depresison?

5

A
  1. Interferon
  2. Corticosteroids
  3. Benzodiazepines/Opiods
  4. Varenicline (Chantix)/
  5. Beta-Blockers
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11
Q

Drugs of abuse that may cause depression? 8

A
  1. PCP
  2. Amphetamines
  3. Cocaine
  4. Marijuana
  5. Sedative-hypnotics
  6. Alcohol
  7. Opiates
  8. Steroids
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12
Q

Neurobiology of Depression
Structural abnormalities that may cause this?
4

A
  1. increased ventricular-brain ratio
  2. smaller frontal lobe volumes
  3. smaller hippocampal volumes
  4. number/density/size of neurons and glial cells are abnormal
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13
Q

Hypothalamic-pituitary-adrenal axis (HPA axis) excess excretion of glucorticoids may lead to what?

A

suppression of neurogenesis and hippocampal atrophy

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14
Q

Sleep/Circadian rhythms – leads to decreased?

A

REM latency and slow wave sleep Inflammation – higher levels of inflammatory markers

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15
Q

Symptoms of Major Depression

three categories?

A
  1. Psychological
  2. Neurovegetative
  3. Psychomotor/physical
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16
Q

Psychological symptoms?

7

A
  1. Depressed Mood (Dysphoria)
  2. Numbness
  3. Anhedonia (inability to experience joy)
  4. Decreased Interest
  5. Irritability/Anxiety
  6. Guilt/worthlessness
  7. Suicidal Ideation
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17
Q

Neurovegetative symtpoms?

4

A
  1. Appetite
  2. Sleep
  3. Energy
  4. Concentration
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18
Q

Psychomotor symptoms? 2

Phsyical symptoms? 3

A

Psychomotor

  1. retardation (walking through mud or having bricks tied to feet)
  2. agitation

Physical

  1. aches/pain
  2. weakness/malaise
  3. GI distress
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19
Q

Qualifiers for Dx of depression?

55

A
  1. Symptoms occur in the same two weeks
  2. Most of the day nearly every day
  3. Distress or impairment
  4. R/O substances/general medical condition
  5. R/O bereavement
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20
Q

Subtypes of Depression

8

A
  1. Anxious
  2. Atypical
  3. Catatonic
  4. Melancholic
  5. Mixed Features
  6. Peripartum
  7. Psychotic
  8. Seasonal
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21
Q

What are the subcategories of depression?

A
  1. Bipolar

2. Secondary

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22
Q

Secondary causes of depression? 3

A
  1. Medical illness
  2. Medications
  3. Drugs of abuse
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23
Q

Comorbid Psychiatric Conditions

2

A
  1. Anxiety Disorders

2. Substance Abuse

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24
Q

Types of anxiety disorders?

4

A
  1. Generalized Anxiety
  2. Panic Disorder
  3. Obsessive compulsive disorder
  4. PTSD
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25
Q

Evaluate Symptoms

3

A
  1. Questions/Evaluation
    - -Major depression or a subtype
  2. Scales
  3. Observation
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26
Q

What is SIGECAPS?

A 
Sleep
Interest
Guilt/worthlessness
Energy
Concentration
Appetite
Psychomotor disturbance
Suicidal Ideation
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27
Q

Depression Evaluation

4 steps?

A
  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
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28
Q

Depression Evaluation
Things to look for?
7

A
  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
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29
Q

What things should we ask about for family Hx?

4

A
  1. depression,
  2. suicide,
  3. psychosis,
  4. bipolar disorder
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30
Q

Social Hx questions to ask?

4

A
  1. interpersonal,
  2. occupational,
  3. financial stressors –
  4. sources of support, assessment of family/relationship dynamics
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31
Q

PE for depression 2

Labs?
8

Imaging? 1

Procedures? 2

A
  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
  2. +/- EEG,
  3. LP (psychosis or neuro findings
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32
Q

Psychotic Features
3

What are they at higher risk for with these symtpoms?

A
  1. Delusions
  2. Hallucinations
  3. Disordered thought

Markedly higher suicide risk

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33
Q

Psychotic Depression

3 questions to ask?

A
  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?
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34
Q

Suicide – Risk Factors

SAD PERSONS

A 
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)
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35
Q

You need to ask about the plan and history. Specifically what?
5

A
  1. Organized Plan
  2. Access to lethal means
  3. Previous attempts
  4. Family History
  5. Non-suicidal self injury
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36
Q

Suicidal Ideation – Assessment

3

A
  1. “Do you feel hopeless?
  2. “Do you feel like life is not worth living?”
  3. “Do you think about suicide?”
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37
Q

Intent, Plan, Means

3 questions to ask about these thoughts?

A
  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
Q

What do you need to ask about previous attempts?

6

A
  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
Q
  1. If they have a plan, intent, means then what must you do?

2. Less acute plan then what? 4

A
  1. Plan, Intent, Means – hospitalization
  2. Less acute -
    - safety plan
    - Crisis Center,
    - stay with family,
    - more frequent visits (even daily)
40
Q

Safety Treatment Plan
what needs to be in the plan?
4

A
  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
Q

What are the four depression scales?

A
  1. Beck Depression Inventory
  2. Quick Inventory of Depressive 3. Symptomatology
    Mood Disorder Questionnaire
  3. Hamilton Anxiety Rating Scale
42
Q

BDI-II
Beck Depression Inventory
1. Administered by who?
2. Used for? 2

A
  1. Self administered
    • Screening
    • Treatment response
43
Q

QIDS-SR
Quick Inventory of Depressive Symptomatology Self Report
-What can you access from this? 2

A

Free

www. ndmda.org
1. Also have MDQ and HAM-A in online format
2. DSMIV-tr criteria

44
Q

MDQ
Mood Disorder Questionnaire
1. Is used for what?
2. What makes a positive result? 3

A
  1. Mania Screening
    • 7 positive responses to #1-13
    • AND positive response to #14
    • AND moderate or serious #15
45
Q

HAM-A
Hamilton Anxiety Rating Scale
1. How many questions and what are the ratings?

  1. What indicates significant anxiety?
  2. Patients with what tend to score higher?
A 
1. 
14 questions
0= absent
1= mild
2= moderate
3= severe
4= incapacitating
  1. > 20 indicates significant anxiety
  2. Patients with depression tend to score higher
46
Q

Observation – Mental Status Exam
What areas are we assessing here?
7

A

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
Q

What are the Antidepressant Categories?

5

A
  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
Q
  1. What is first line treatment for depression?

2. WHy are these first line treatment? 2

A
  1. First line treatment of depressive disorders
    No real differences in efficacy
  2. Difference in side effects and half lives
49
Q

What are the SSRIs?

6

A
  1. Fluvoxamine (Luvox)
  2. Paroxetine (Paxil)
  3. Sertraline (Zoloft)
  4. Citalopram (Celexa)
  5. Escitalopram (Lexapro)
  6. Fluoxetine (Prozac)
50
Q

Common AD Side Effects

6

A
  1. GI disturbance – nausea, diarrhea, appetite
  2. Sexual dysfunction
    - -SSRI/SNRI 50-70%
  3. Anxiety
  4. Insomnia or sedation
  5. Sweating
  6. Dizziness
51
Q
  1. What are the SNRIs? 2

2. Acts on what receptors? 2

A
    • Venlafaxine (Effexor)
    • Duloxetine (Cymbalta)
  2. Acts on both serotonin and norepinephrine

Not clearly more efficacious

52
Q

Venlafaxine less than 225mg = SSRI. More than that acts as a SNRI.

SE? 2

A

Hypertension

Tachycardia

53
Q

Duloxetine is used for what?

A

indication for neuropathy

54
Q

Tricyclic Antidepressants
are which drugs? 4

What kind of side effects? 4

Overdose risk?

Other disadvantage?

A
  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
Q

What are the MAOis? 2

A
  1. phenelzine (Nardil),

2. tranylcypromine (Parnate)

56
Q
  1. MAOis advantage?

2. Disadvantage? 6

A
  1. More efficacious
    • Poorly tolerated
    • Drug-Drug interactions
    • Serotonin Syndrome,
    • Hypertensive Crisis
    • Dietary restrictions
    • Avoid Tyramine Containing Foods
57
Q

TCA’s and MAOi’s

Poorly tolerated why? 2

A
  1. Sedation

2. weight gain

58
Q

What serious complications can occur with MAOis? 2

A
  1. Serotonin syndrome

2. hypertensive crisis

59
Q

Trazodone

  1. good for sleep at low doses?
  2. If tolerated functions as a what at higher doses?
  3. Watch for what? 3
A
  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
Q

Unique Buproprion Consideration
1. Avoid in who?

  1. Enhances what?
  2. Use in caution with who? 3
A
    • Avoid in seizure disorders
    • Avoid in bulimia
  2. Enhances dopamine = caution
    • anxiety
    • psychosis
    • dopaminergic agents
61
Q

Unique Bupropion Consideration
1. Advantages? 5

  1. How does it help with SSRIs? 2
  2. Consider in what kind of pts?
A
    • No sexual side effects
    • Smoking cessation
    • Comorbid ADHD
    • Often used with SSRI’s
    • Safe in pregnancy
    • Augment antidepressant
    • Reverse sexual side effects
  3. Consider with sleepy, slowed down patients
62
Q

Unique Mirtazapine Consideration
1. Advantages? 2

  1. Disadvantages? 2
A
    • Sedation
    • Weight gain
    • Less sexual side effects
    • Good for patients with nausea
63
Q

STARD
Sequenced Treatment Alternatives to Relieve Depression
-Four points of STARD?

A
  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
Q

Remission

Positive Predictors? 4
Negative Predictors? 5

A

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
Q

What does Remission mean?

4

A
  1. Return of normal functioning
  2. Lower rates of relapse
  3. Lower risk of suicide
  4. Less alcohol and drug abuse
66
Q

Acute Treatment of Depression The first 12 weeks

  1. Mild?
  2. Moderate/Severe? 2
  3. Bipolar? 2
  4. Psychotic? 2
A
  1. Mild: consider psychotherapy alone
  2. Moderate-severe: medication +/- therapy
  3. Bipolar: mood stabilizer +/- antidepressant
  4. Psychotic: antipsychotic + antidepressant
67
Q

Continuation Phase

  1. What is this?
  2. What are they at high risk for?
  3. Use what kind of dosage?
A
  1. 4-6 months following remission
  2. High risk for relapse
  3. Use full therapeutic dosage
68
Q

Classic Presentation of symptoms? 2

Atypical features? 2

A
    • Insomnia or hypersomnia -
    • Classical early morning awakening vs initial/middle insomnia
  2. Atypical features –
    -eat more,
    -sleep more.
    Seasonal affective disorder –also
69
Q
  1. Maintenance Phase is what?

2. Risk of recurrence 3

A
  1. relapse prevention
    • Number/Severity of previous episodes
    • Residual symptoms
    • Comorbid disorders
70
Q

What leads to non-adherence?

5

A
  1. Socioeconomic factors
  2. Tolerability - SSRI, SNRI > TCA
  3. Psychiatric = Nonpsychiatric
  4. lack of Psychotherapy
  5. lack of Education
71
Q

What do we need to educate the pt on?

4

A
  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
Q

General Principles

  1. Titrate to the target dose within what time frame?
  2. Monitor for side effects like? 4
A
  1. Titrate to target dose within first few weeks
  2. Monitor for side effects
    • agitation/anxiety
    • suicidal ideation
    • insomnia
    • sexual
73
Q

Decision Therapy

  1. No improvement 4-6 weeks?
  2. Limited response?
  3. Side effects?
A
  1. Consider switch
  2. consider increase or augmentation
  3. switch or augment
74
Q

Choosing an Antidepressant: what things are involved in this?
9

A
  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
Q

Which are the cheapest ADs?
6

Which are the more expensive ones?
4

A
  1. Citalopram
  2. Paroxetine
  3. Fluoxetine
  4. Sertraline
  5. Bupropion SR, XL (300mg)
  6. Mirtazapine
  7. Escitalopram
  8. Bupropion XL (150mg)
  9. Venlafaxine XR
  10. Duloxetine
76
Q

What is the complication to know about Lithium!

A

Lithium - lethal

-shown to decrease SI/impulsivity

77
Q

Black-box warning on all ADs?

A
  1. Increased risk of SI with antidepressants up to 24 yrs
  • Treating depression beneficial
  • Risk of suicide with untreated depression
78
Q

Suicide attempts are highest when and decline when?

A

Suicide attempt rates highest in month before treatment

Decline after AD or psychotherapy begins

79
Q

Antidepressants and Suicide
1. Monitor at regular intervals. What things? 4

  1. Refer to?
  2. How can we encourage follow up?
  3. Dose how in 18 to 24 yr olds?
A
    • 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
Q

What to do for side effects? 4

A
  1. WAIT!
  2. Lower dose, slow titration
  3. Change dosing schedule
  4. Augment
81
Q

Sexual Side Effects

A
  1. Drug Holiday – watch for withdrawal
  2. Augment
  3. Lower dose
  4. Wait
82
Q

Sexual Side Effects: What drugs can we augment with?

4

A
  1. Bupropion
  2. Trazodone – rare risk of priapism
  3. ED medication
  4. Buspirone
83
Q

Anxiety AD Tx? 5

Insomnia AD Tx? 4

A
  1. Benzodiazepines
  2. Gabapentin
  3. Lyrica
  4. Buspirone
  5. Therapy/Meditation/Exercise
  6. Benzodiazepines
  7. Sleepers – zolpidem etc.
  8. Trazodone
  9. Therapy/Meditation/Exercise
84
Q

Benzodiazepines

  1. Goal of what?
  2. Scheduled how?
  3. Longer acting with lower abuse potential. Which drugs? 3
  4. Caution in who?
A
  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
Q

AD Discontinuation symtpoms? 5

Tapering Strategy?

Which drugs are the worst?

Which ones are self tapering?

A
  1. Nausea,
  2. headache,
  3. irritability,
  4. vivid dreams,
  5. vertigo
  6. Slow taper +/- short term benzodiazepines
  7. Worst - paroxetine, venlafaxine
  8. Fluoxetine – self tapering
86
Q

SSRI’s: 2D6 inhibition

  1. Which have the most interactons? 3
  2. Which have the least? 1
A
    • fluoxetine,
    • paroxetine,
    • fluvoxamine
  2. escitalopram – least
87
Q

2D6 Inhibition from Paroxetine

Which drugs does it interact with and which does it cause? 3

A
  1. Increased risperdone → extrapyramidal symptoms
  2. Increased metabolite of trazodone → anxiety
  3. Decreased conversion of codeine to morphine → pain
88
Q

Psychotic depression

Higher remission with combination of what?

A

AD and antipsychotic

89
Q

Bipolar depression

30-50% risk of cycling into mania on AD without a what?

A

mood stabilizer

90
Q

What are the kinds of psychotherapy?

2

A
  1. Cognitive Behavior Psychotherapy
    - understand distortions in thinking
    - learn new ways of coping
  2. Interpersonal Therapy
    - Grief
    - Role transition/role dispute
    - Interpersonal deficits
91
Q

Augmentation Strategies

5

A
  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

Behavioral Health (20 decks)

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