Depression

Question 1

DSM critera for major depressive episode

Answer 1

A. 5 (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1) depressed mood most of the day, nearly every day
2) diminished pleasure
3) significant weight loss/weight gain
4) insomnia or hypersomnia nearly every day
5) psychomotor agitation
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness/inappropriate guilt nearly every day
8) diminished ability to concentrate
9) recurrent thoughts of death, suicidal ideation, plan, attempt

B. Symptoms impair social/occupational/other important areas of functioning

C. Not attributable to substance use/medical condition.

Question 2

Treatment of depression

Answer 2

Lifestyle:

• increase aerobic exercise
• mindfulness-based stress reduction
• zinc supplementation

Therapy:

• cognitive behavioural therapy
• interpersonal psychotherapy
• short-term dynamic therapy

Pharm (first line):

• SSRIs
• SNRIs
• mirtazepine

Not first line

• TCAs
• MAOI

ECT

Experimental:

• magnetic seizure therapy
• deep brain stimulation
• vagal nerve stimulation
• ketamine

Question 3

Name some SSRIs

Answer 3

• citalopram
• escitalopram
• fluoxetine
• fluvoxamine
• paroxetine
• sertraline

Question 4

Name some SNRIs

Answer 4

• desvenlafaxine(controlled-release)
• duloxetine
• venlafaxine (controlled-release)

Question 5

Name some TCAs

Answer 5

• Amitriptyline
• Clomipramine
• Dosulepin (dothiepin)
• Doxepin
• Imipramine
• Nortriptyline

Question 6

Name some monoamine oxidase inhibitors

Answer 6

• Phenelzine
• Tranylcypromine

Question 7

Name some other types of antidepressants

Answer 7

• Agomelatine
• Mianserin
• Mirtazapine
• Moclobemide
• Reboxetine
• Vortioxetine

Question 8

Side effects of SSRIs

Answer 8

Fewer than TCA, therefore increased compliance

Common (>1%)

nausea, diarrhoea, agitation, insomnia, drowsiness, tremor, dry mouth, dizziness, headache, sweating, weakness, anxiety, weight gain or loss, sexual dysfunction, rhinitis, myalgia, rash

Infrequent (0.1–1%)

extrapyramidal reactions (including tardive dyskinesia and dystonia), sedation, confusion, palpitations, tachycardia, hypotension, hyponatraemia (usually occurs early in treatment, may be asymptomatic, and is part of SIADH), abnormal platelet aggregation/haemorrhagic complications (eg bruising, nose bleeds, GI, vaginal or intracerebral bleeding), mydriasis

Rare (<0.1%)

elevated liver enzymes, hepatitis, hepatic failure, hyperprolactinaemia, eg galactorrhoea, blood dyscrasias, akathisia, paraesthesia, taste disturbance, acute angle-closure crisis (especially with paroxetine)

Relatively safe in OD

Question 9

Side effects of SNRIs

Answer 9

Common (>1%)

nausea, dry mouth, constipation, yawning, sweating, dizziness, increased BP (infrequent with duloxetine), weakness, sexual dysfunction (eg impotence), decreased libido, somnolence, insomnia, headache, blurred vision, mydriasis (infrequent with duloxetine), tremor, decreased appetite, rash

Infrequent (0.1–1%)

orthostatic hypotension and fainting, palpitations, tachycardia, abnormal liver function tests, hyponatraemia (usually occurs early in treatment, may be asymptomatic, and is part of SIADH)

Rare (<0.1%)

seizures, akathisia, stress-induced (takotsubo) cardiomyopathy, hyperprolactinaemia, eg galactorrhoea

Tachycardia and N/V seen in acute overdose

Question 10

Side effects of TCAs

Answer 10

Common (>1%)

sedation, dry mouth, blurred vision, mydriasis, decreased lacrimation, constipation, weight gain, orthostatic hypotension, sinus tachycardia, urinary hesitancy or retention, reduced GI motility, anticholinergic delirium (particularly in the elderly and in Parkinson’s disease), impotence, loss of libido, other sexual adverse effects, tremor, dizziness, sweating, agitation, insomnia, anxiety, confusion

Infrequent (0.1–1%)

slowed cardiac conduction, T wave inversion or flattening (particularly at high doses), arrhythmias, sinus tachycardia, nausea, hyperglycaemia, gynaecomastia in males, breast enlargement and galactorrhoea in females, allergic skin reactions, manic episodes

Rare (<0.1%)

blood dyscrasias, hepatitis, paralytic ileus, hyponatraemia (as part of SIADH), seizures, prolonged QT interval, increased intraocular pressure

Overdose

Toxic in OD, 3 times therapeutic dose is lethal
Presentation: anticholinergic effects, CNS stimulation, then depression and seizures ECG: prolonged QT (duration reflects severity)
Treatment: activated charcoal, cathartics, supportive treatment, IV diazepam for seizure, physostigmine salicylate for coma

Question 11

Side effects of MAOI

Answer 11

Hypertensive crises with tyramine rich foods (e.g. wine, cheese)

Common >1%

orthostatic hypotension, sleep disturbances (including insomnia and less commonly hypersomnia), headache, drowsiness, fatigue, weakness, agitation, tremors, twitching, myoclonus, hyperreflexia, dizziness, constipation, dry mouth, weight gain, elevated serum aminotransferases, sexual dysfunction, eg impotence, loss of libido

Infrequent (0.1–1%)

itch, rash, sweating, blurred vision, peripheral oedema, hypoglycaemia, mania

Rare (<0.1%)

hypertensive crisis (below) usually due to tyramine or medication interactions, hepatocellular damage, leucopenia, SIADH

OD

Toxic in OD, but wider margin of safety than TCA

Question 12

Symptoms of serotonin syndrome

Answer 12

TRIAD = CAN

CNS dysfunction, autonomic disturbance and neuromuscular hyperactivity

CNS - altered mental state, confusion, agitation

Autonomic - palpitations, tachycardia, flushing, dilated pupils

Neuromuscular hyperactivity - clonus, hyperreflexia, incoordination, ataxia, rigidity - can progress to seizures + coma

Question 13

What is discontinuation syndrome?

Answer 13

caused by the abrupt cessation of an antidepressant; most commonly with paroxetine, uvoxamine, and venlafaxine (drugs with shortest half-lives)

Symptoms usually begin 1-2 days after cessation and can last up to 1-3 weeks

SYMPTOMS (FINISH)

• Flu-like symptoms
• Insomnia
• Nausea
• Imbalance
• Sensory disturbances
• Hyperarousal (anxiety)

Question 14

Treatment for discontinuation syndrome?

Answer 14

• restart antidepressant therapy at the same dose patient was taking previously
• slowly taper dose over several weeks
• change to a drug with longer half-life (eg. fluoxetine)

Question 15

DSM criteria for major depressive disorder?

Answer 15

A. presence of a MDE
B. the MDE is not better accounted for by schizoa ective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder NOS

C. there has never been a manic episode or a hypomanic episode

Question 16

Risk factors for MDD?

Answer 16

• sex: F>M, 2:1
• family history: depression, alcohol abuse, suicide attempt or completion
• childhood experiences: loss of parent before age 11, negative home environment (abuse, neglect)
• personality: neuroticism, insecure, dependent, obsessional
• recent stressors:illness, nancial, legal, relational, academic
• lack of intimate, confiding relationships or social isolation
• low socioeconomic status

Question 17

Treatment of serotonin syndrome

Answer 17

Resuscitate

• seizure or coma -> intubation
• terminate seizures with benzodiazepine

Specific Treatment

• indicated if marked hyperthermia, rhabdomyolysis, DIC, renal failure, ARDS -> cyproheptadine and chlorpromazine
• cyprohepatidine – antihistamine with antiserotonergic action.
• olanzepine

Underlying cause

• single dose of charcoal if presents within 1 hr
• discontinue all serotonergic medications
• usually subsides over 24 hrs but deaths have been reported

Question 18

DSM criteria for dysthymia (persistent depressive disorder)

Answer 18

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.

B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite 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-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder,
schizophrenia, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.