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Year 3 - OSCE > Depression > Flashcards

Depression Flashcards

1
Q

Describe SSRI use for depression

A
  • 1st line in uncomplicated px (physically healthy, outpatient, no CI)
  • Citalopram = fewest DIs; sertraline is 2nd least
  • All are about equally effective; choice of one over another depends on pt profile and drug profile
  • If pt fails trial due to non-response or limiting adverse effect -> ensure adherence and maximize dose (try to wait 8 weeks until increasing)
  • If pt experiences partial response -> consider adding 2nd antidepressant, lithium, or LT4 or switch agent
    • If pt fails this -> switch agent
  • Flat dose response (most px respond at lowest effective dose)
  • Advantage -> less SE vs. TCAs b/c more selective
  • AE = nausea, agitation, nervousness, restlessness, insomnia/ drowsiness
  • Toxic effects -> tremor, sinus tachycardia, N/V/D, seizures, serotonin syndrome
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2
Q

What are the sx of SSRI withdrawal syndrome? When do they occur and how long do they last?

A
  • *FINISH -> flu-like sx, insomnia, nausea, imbalance, sensory disturbance, hyperarousal
  • Occur w/in 1-3 days (up to 1 week)
  • Last up to 7-14 days (may be several weeks)
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3
Q

Describe venlafaxine

A
  • Similar to SSRIs at low doses, but similar to TCAs at high doses
  • AE = BP increases (dose dependent; risk greater w/ increased age), dose-related GI effects, dizziness, sexual dysfunction, dry mouth
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4
Q

Describe TCA use for depression

A
  • Last option for most px
  • Nortriptyline generally better tolerated than amitriptyline and clomipramine
  • Has antihistaminic effects -> sedation, weight gain
  • Has anticholinergic effects, so caution in BPH and glaucoma (desipramine has least ACh effects)
  • At usual doses, cardiac effects -> hypertension, tachycardia, antiarrhythmic properties, orthostatic hypotension
  • Toxic effects in overdose -> CV (sinus tachycardia, ventricular arrhythmias, hypotension), CNS (coma, delirium, seizures), urinary retention
  • Withdrawal sx -> cholinergic & adrenergic rebound = dizziness, N/D, insomnia, hot or cold flashes
  • If d/c, taper over 2-4 weeks
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5
Q

Describe bupropion use for depression

A
  • Good option for those previously on venlafaxine who can’t tolerate AE
  • AE = insomnia, agitation, anxiety, seizures (at high doses), dry mouth, N/V, rash, headache
  • Advantages -> less sexual dysfunction and little weight gain
  • CI = seizures, anorexia
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6
Q

Describe mirtazapine use for depression

A
  • AE = orthostatic hypotension (not great for elderly); can be fairly sedating
  • Advantages -> little sexual dysfunction and less serotonergic effects (so little weight gain)
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7
Q

Describe MAOI use for depression

A
  • Indicated for atypical or resistant depression
  • Only antidepressant that requires washout when switching
  • AE = orthostatic hypotension, dry mouth, constipation, sexual side effects, insomnia
  • Dosed in AM and mid-day to avoid overstimulation
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8
Q

Which antidepressants can be used in combination?

A
  • Venlafaxine + bupropion
  • SSRI + bupropion
  • SSRI + TCA
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9
Q

What is the typical tx duration for antidepressants?

A
  • 4-9 months after remission

- Lifelong if < 40 y/o and 2+ episodes OR any age & 3+ episodes

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10
Q

Sx and tx of serotonin syndrome

A
  • *Diagnosis of exclusion
  • Cognitive/behavioural = agitation, mental status changes (confusion, hypomania)
  • Autonomic = diarrhea, fever, shivering
  • Neuromuscular = incoordination tremor, myoclonus, hyperreflexia
  • Tx = supportive care, BZD for neuromuscular sx, tylenol for fever, cyproheptadine 4 mg q4h for severe sx
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11
Q

Depression in pregnancy

A
  • Weigh risks vs. benefits to mother and fetus!!
  • Most evidence for safety of fluoxetine
  • Can do ECT and psychotherapy (CBT)
  • After delivery, watch for direct drug effects and transient withdrawal sx in infant
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12
Q

Depression in breastfeeding

A
  • Safe = paroxetine, sertraline*, fluoxetine, nortriptyline

- Monitor infant daily for changes in sleep, feeding patterns, and behaviour

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13
Q

Depression in children/ adolescents

A
  • 1st line for moderate to severe major depression = fluoxetine and citalopram
  • 2nd line = other SSRIs (paroxetine has most AE)
  • 3rd line = venlafaxine
  • Best outcomes when combine antidepressant w/ CBT
  • Monitor suicidal thoughts!!
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14
Q

Red flags for antidepressants (when to avoid certain ones)

A
  • Avoid bupropion and TCAs in seizures
  • Avoid SSRIs, venlafaxine, TCAs, and MAOIs in sexual dysfunction
  • Avoid TCAs, MAOIs, and mirtazapine if pt doesn’t want weight gain
  • Avoid TCAs if possible in elderly (urinary retention, excessive sedation)
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15
Q

Case specific assessment questions for depression

A
  • Are you having suicidal thoughts?
  • Are you having psychotic sx? (hallucinations, delusions)
  • Are you still able to go to school/work? (impairment in functioning warrants tx)
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16
Q

Non-pharms for depression (general)

A
  • Cognitive behavioural therapy
  • Interpersonal
  • Bright light therapy
  • Exercise and good nutrition
17
Q

What can be done to manage AE of antidepressants?

A

Normally can decrease dose or switch agent if very bothersome to pt

18
Q

General monitoring for depression

A
  • Pt should monitor sx daily
    • Anxiety and insomnia improve in 3-5 days
    • Energy and somatic sx in 2-3 weeks
    • Sleep patterns in 4-6 weeks
    • Depressed mood and sexual dysfunction in 4 weeks
  • Monitor suicidal thoughts (especially in children)
19
Q

General follow up for depression

A
  • Pharmacist follow-up in 1-2 weeks when meds are added or increased to see about side effects
  • Consistently follow-up w/ pt regarding depressive sx to see if deprescribing is appropriate
    • Continue full dose for at least 6-12 months after remission (when sx go away)
20
Q

Describe monitoring for depression when adding therapy

A
  • Monitor for symptom improvement and side effects of the medication daily/weekly
  • If now taking 2 serotonergic drugs, monitor for serotonin syndrome
    (common sx = excitement, anxiety, muscle rigidity, fever, tremor, increased HR; on pg. 151)
    – Typical onset for serotonin syndrome = 1 h to 1 day (so if pt is experiencing similar sx after 1 week of taking the drug, can attribute it to normal SE of the drug)
    – Generally, doesn’t occur from just 1 drug (possible at max. dose), generally happens when pt uses 2-3 serotonergic drugs
  • If new med -> all adverse effects on page 152
  • **Most common SE of SSRI’s are GI effects and headaches
21
Q

Describe when to go to a Dr for depression when adding therapy

A
  • Go to doctor/talk to pharmacist if side effects become unbearable, or if you feel like this medication isn’t working
  • For women -> go to Dr. if you become pregnant b/c we may need to switch to a safer antidepressant
22
Q

Describe when to go to emergency for depression when adding therapy

A

Go to emergency if you do experience serotonin syndrome, you are having suicidal thoughts, any dramatic mood changes (lots of energy; can indicate bipolar which normally presents first as depression)

23
Q

Describe non pharms for depression when adding therapy

A
  • Diary of symptoms
  • CBT, psychotherapy
  • Mindfulness, meditation
  • Exercise and good nutrition
24
Q

Describe follow up for depression when adding therapy

A
  • I will follow up with you 5 days to discuss any side effects you might be experiencing as well as your adherence
  • I will also follow up with you in 2 and 4 weeks to discuss if you are seeing any sx improvement with the medication
  • I would like to give this at 4-6 weeks before we re-assess if you need a dose increase or to be switched to a different antidepressant
25
Q

A patient asks “how long will I have to take my antidepressant”

A
  • At least 1 year after a good response is achieved

- Response/remission typically takes 6-12 weeks to see

26
Q

Describe monitoring for depression after hospitalization (starting new med, increasing dose)

A
  • Monitor for sx improvement and side effects of medication daily/weekly
  • Common SE of meds -> in RxFiles pg. 152
  • Anxiety and insomnia improve in 3-5 days
  • Energy and somatic sx improve in 2-3 weeks
  • Sleep patterns improve in 4-6 weeks
  • Depressed mood and sexual dysfunction improve in 4 weeks
  • **Common for physical sx to remain after mood has increased
27
Q

Describe when to go to a Dr for depression after hospitalization (starting new med, increasing dose)

A

Go to doctor if you don’t notice any sx improvement within 2-3 months

28
Q

Describe when to go to emergency for depression after hospitalization (starting new med, increasing dose)

A

Go to emergency if you experience any suicidal thoughts, any dramatic mood changes, or any serious SE to the drug

29
Q

Describe non pharms for depression after hospitalization (starting new med, increasing dose)

A
  • Diary of symptoms
  • CBT, psychotherapy
  • Mindfulness, meditation
  • Exercise and good nutrition
30
Q

Describe follow up for depression after hospitalization (starting new med, increasing dose)

A
  • I will follow up with you in 1 week to discuss any side effects of the medication
  • And I will follow up with you in 1-2 months to discuss sx improvement. Unfortunately, it does take time for this medication to work and for you to see improvement, but I am always here to answer any questions you have

Year 3 - OSCE (6 decks)

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