Depression

Question 1

Features of SSRI associated sexual dysfunction

Answer 1

decreased libido, anorgasmia

delayed ejaculation, common cause of nonadherence

Question 2

Assessment and management of SSRI related sexual dysfunction

Answer 2

rule out if related to depression, medical conditions, primary sexual disorder, stress/relationship issues, substance abuse.

Switch to non SSRI med: bupropion or mirtazapine
add adjunctive therapy with sildenafil or bupropion
dose reduce for pts on high dose SSRI and watch for loss of efficacy

Question 3

If patient responds to drug but has sexual dysfunction:

Answer 3

Either augment with sildenafil or for women, augment with bupropion.

Question 4

SSRI sexual dysfunction is anorgasmia

Answer 4

try to sildenafil or phosphodiesterase 5 inhibitor.

Question 5

benefit of using mirtazapine

Answer 5

atypical antidepressant and has sedating properites and stimulates the appetite and allows person to gain weight. Helpful in geriatric depression associated with weight loss and poor sleep.

Question 6

How does mirtazapine work?

Answer 6

it’s a noradrenergic and specific serotonergic antidepressant because it antagonizes presynaptic alpha 2 adrenergic receptors and post synaptic serotonin 5 HT2 and serotonin 5HT3 receptors.

Question 7

what is the benefit of using bupropion

Answer 7

activating effects and doesn’t cause weight gain. Not good for people who have insomnia or anxiety.

Good for ppl with lethargy and sedation

LESS SEXUAL SIDE EFFECTS

Question 8

Who should avoid bupropion?

Answer 8

people with seizures, anorexic patients

Question 9

When can olanzapine be used for depression?

Answer 9

it’s really a 2nd generation antipsychotic and so only should be for treatment resistant depression and not a 1st line for monotherapy.

Question 10

what is an adequate antidepressant trial?

Answer 10

6 weeks at a therapuetic dosage.

Question 11

most common preceived reason for inefficacy of a SSRI

Answer 11

inadequate dosage or duration.

Question 12

long is treatment supposed to last for a single episode of major depressive disorder?

Answer 12

6 months following acute response (continuation phase treatment)

After that, can taper off as long as continued remission.

Question 13

who (what conditions need) needs to be on maintenance SSRI therapy?

Answer 13

have multiple episodes of recurrent major depressive disorder
chronic episodes >2 yrs
severe episodes (suicide attempt)

Question 14

When do we continue maintenance therapy indefinitely?

Answer 14

in patients who have history of highly recurrent >3 lifetime episodes and very severe chronic major depressive episodes

Question 15

how long is maintenance SSRI therapy usually last?

Answer 15

1-3 years

Question 16

risk factors for suicide

Answer 16

psychiatric disorders, 
prior suicide attempts, 
hopelessness,
 never married 
divorced, separated men, 
living alone,
 elderly white men, 
unemployed, unskilled, physical illness,
 family history of discord or suicide, 
access to fire arms and
 substance abuse or impulsivity

Question 17

protective factors against suicide

Answer 17

social support and family connectedness
pregnancy
parenthood
religion and participation in religious activities

Question 18

what to do for high risk for suicide patients

Answer 18

they need to be hospitalized and then stabilized.

Question 19

what is antidepressant discontinuation syndrome?

Answer 19

abrupt discontinuation of SSRI which causes both physical and psychological symptoms which begin a few days from drug discontinuation and lasts for several weeks.

worse with antidepressants with shorter half life like paroxetine or venlafaxine.

Question 20

how to treat antidepressant discontinuation syndrome?

Answer 20

restart pts paroxetine or SSRI and then do a slow taper over 2-4 weeks. Provide reassurance that symptoms are not medically dangerous.

Question 21

Symptoms of antidepressant discontinuation syndrome

Answer 21

anxious, depressed, frequent tearfulness, feeling panicky and having body aches or pains. may have irritable mood.

Question 22

difference between postpartum blues and postpartum depression

Answer 22

post partum blues is 2-3 days and resolves by 14 days and post partum depression happens 4-6 weeks (can be up to a year)

Question 23

post partum psychosis occurs when

Answer 23

days to weeks,

start to see delusions, hallucinations

Question 24

symptoms of postpartum blues

Answer 24

mild depression and tearfulness and irritability

Question 25

symptoms of post partum depression

Answer 25

>2 weeks of moderate to severe depression, sleep, appetite changes, low energy, psychomotor changes and guilt and concentration difficulty and suicidal ideation

Question 26

symptoms of post partum psychosis

Answer 26

delusions, hallucinations, thought disorganization | bizarre behavior

Question 27

management of postpartum blues

Answer 27

reasssurance and monitoring

Question 28

management of postpartum depression

Answer 28

SSRI (sertraline or paroxetine are first line) since low to undetectable amounts in breast milk and pscyhotherapy

Question 29

management of postpartum psychosis

Answer 29

antipsychotics, antidepressants, mood stabilizers | hospitalization ( do not leave mom alone with infant for risk for infanticide)

Question 30

what is most common: postpartum blues, postpartum depression or postpartum psychosis?

Answer 30

postpartum blues: 40-80% postpartum depression: 8-15% postpartum psychosis: 0.1-0.2%

Question 31

sleep disturbance and fatigue who don't have a medical illness needs to be elevated for

Answer 31

depression. ask about mood, interest, and ability to feel pleasure in activities and screened for depressive symptoms such as appetite disturbance, impaired concentration and pessimism and excessive guilt or SI.

Question 32

antidepressant with less sexual side effects and pt who has low libido?

Answer 32

buproprion would be best choice

Question 33

antidepressant with least amount of weight gain?

Answer 33

bupropion

Question 34

bupropion is good for pts who have

Answer 34

low energy, hypersomnia it's activating (not great for those who are already anxious)

Question 35

antidepressant associated with most weight gain?

Answer 35

paroxetine

Question 36

treatment resistant depression pharmacology:

Answer 36

switch to another antidepressant or augment with a second agent.

Question 37

treatment resistant depression is

Answer 37

pt failed to respond to an adequate trial >6 weeks

Question 38

non responders of depression tx

Answer 38

no improvement with medication benefit with switching to a different SSRI

Question 39

partial responders of depression tx

Answer 39

have some benefit but not feeling better need augmentation as first line tx as switching carries a risk of losing the partial therapeutic benefit from original drug augmentation strategy incldues adding a second gen antispychotic, antidepressant with a different mech of action or occasionally lithium or T3

Question 40

Depression in cancer pts can be best differentiated from somatic symptoms of cancer (low energy, anorexia, weight loss and sleep disturbance) by

Answer 40

non somatic symptoms like loss of interest or pleasure feelings of worthlessness and excessive guilt and suicidal ideation.

Question 41

who is at highest risk for suicide?

Answer 41

elderly white men.

Question 42

indications for electroconvulsive therapy for depression

Answer 42

treatment resistance psychotic features present emergency conditions- pregnancy, refusal to eat or drink, imminent risk for suicide

Question 43

safety of electroconvulsive therapy (ECT)

Answer 43

no absolute contraindications | increased risk- severe cardiovascular dx, recent MI, space occupying brain lesion, recent stroke, unstable aneurysm

Question 44

1st line treatment for psychotic depression is

Answer 44

combo of antidepressant with an antipsychotic OR ECT

Question 45

preferred method of treatment for people who have depression and not eating or drinking

Answer 45

ECT or electroconvulsive therapy

Question 46

why do we like ECT or electroconvulsive therapy

Answer 46

it provides rapid clinic response compared to medication.

Question 47

severe suicidality treatment

Answer 47

ECT or electroconvulsive therapy

Question 48

treatment of catatonia

Answer 48

ECT or electroconvulsive therapy

Question 49

treatment of treatment resistant depression

Answer 49

ECT or electroconvulsive therapy

Question 50

what is ECT or electroconvulsive therapy?

Answer 50

it's 30-60 second generalized tonic clonic seizure and this is safe and efficient for geriatric depression. Hemodynamic changes are brief and cardiac complications are rare

Question 51

adverse cognitive effects of ECT or electroconvulsive therapy

Answer 51

acute confusion, anterograde or retrograde amnesia are usually transient

Question 52

how long to keep someone on SSRI or antidepressant treatment if they have: recurrent major depression, or at high risk for recurrence

Answer 52

need maintenance therapy which last for 1-3 years to reduce risk of relapse.

Question 53

risk factors for depression recurrence are:

Answer 53

early age of onset <18 years, persistent depressive symptoms, and comorbid psychiatric disorders

Question 54

Highly recurrent depression is defined as:

Answer 54

>3 lifetime depressive episodes

Question 55

chronic depression episodes is defined as

Answer 55

>2 years of depression

Question 56

Severe episode of depression is known as:

Answer 56

suicide attempts

Question 57

who should be on SSRI or antidepressant medication indefinitely:

Answer 57

pts with chronic depression episodes >2 yrs at a time, or have had severe depression episodes (suicide attempts)

Question 58

when do you add augmentation to a SSRI?

Answer 58

Only add augmentation to a SSRI once pt has failed to respond to a maximally dosed SSRI

Question 59

dysthymia is:

Answer 59

persistent depressive mood for most of the day for at least 2 years.

Question 60

Are SSRI's ok and safe to use in pregnancy?

Answer 60

yes. except for paroxetine which can have a slight increase in congenital cardiac deficits.

Question 61

pregnant woman with depression should be treated with

Answer 61

psychotherapy | can treat moderate to severe with SSRI except paroxetine

Question 62

ECT therapy for pregnant women is reserved for those who

Answer 62

``` need rapid treatment actively suicidal homicidal psychotic not eating or drinking those who have failed previous. ```

Question 63

duloxetine (SNRI) is also helpful for treating:

Answer 63

pts who have diabetic neuropathy chronic lower back pain fibromyalgia osteoarthritis

Question 64

most common discontinuation syndrome symptoms:

Answer 64

agitation, anxiety, dysphoria, irritability onset is 1-4 days after abruptly stopping antidepressant therapy or after a rapid taper

Question 65

lowest incidence of discontinuation therapy:

Answer 65

fluoxetine | still needs to be tapered

Question 66

who does a PCP treat with depression?

Answer 66

PHQ9- <15. referral to psychiatrist is indicated for pts with severe