Depression Flashcards
Features of SSRI associated sexual dysfunction
decreased libido, anorgasmia
delayed ejaculation, common cause of nonadherence
Assessment and management of SSRI related sexual dysfunction
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
If patient responds to drug but has sexual dysfunction:
Either augment with sildenafil or for women, augment with bupropion.
SSRI sexual dysfunction is anorgasmia
try to sildenafil or phosphodiesterase 5 inhibitor.
benefit of using mirtazapine
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.
How does mirtazapine work?
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.
what is the benefit of using bupropion
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
Who should avoid bupropion?
people with seizures, anorexic patients
When can olanzapine be used for depression?
it’s really a 2nd generation antipsychotic and so only should be for treatment resistant depression and not a 1st line for monotherapy.
what is an adequate antidepressant trial?
6 weeks at a therapuetic dosage.
most common preceived reason for inefficacy of a SSRI
inadequate dosage or duration.
long is treatment supposed to last for a single episode of major depressive disorder?
6 months following acute response (continuation phase treatment)
After that, can taper off as long as continued remission.
who (what conditions need) needs to be on maintenance SSRI therapy?
have multiple episodes of recurrent major depressive disorder
chronic episodes >2 yrs
severe episodes (suicide attempt)
When do we continue maintenance therapy indefinitely?
in patients who have history of highly recurrent >3 lifetime episodes and very severe chronic major depressive episodes
how long is maintenance SSRI therapy usually last?
1-3 years
risk factors for suicide
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
protective factors against suicide
social support and family connectedness
pregnancy
parenthood
religion and participation in religious activities
what to do for high risk for suicide patients
they need to be hospitalized and then stabilized.
what is antidepressant discontinuation syndrome?
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.
how to treat antidepressant discontinuation syndrome?
restart pts paroxetine or SSRI and then do a slow taper over 2-4 weeks. Provide reassurance that symptoms are not medically dangerous.
Symptoms of antidepressant discontinuation syndrome
anxious, depressed, frequent tearfulness, feeling panicky and having body aches or pains. may have irritable mood.
difference between postpartum blues and postpartum depression
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)
post partum psychosis occurs when
days to weeks,
start to see delusions, hallucinations
symptoms of postpartum blues
mild depression and tearfulness and irritability
symptoms of post partum depression
> 2 weeks of moderate to severe depression, sleep, appetite changes, low energy, psychomotor changes and guilt and concentration difficulty and suicidal ideation
symptoms of post partum psychosis
delusions, hallucinations, thought disorganization
bizarre behavior
management of postpartum blues
reasssurance and monitoring
management of postpartum depression
SSRI (sertraline or paroxetine are first line) since low to undetectable amounts in breast milk and pscyhotherapy
management of postpartum psychosis
antipsychotics, antidepressants, mood stabilizers
hospitalization ( do not leave mom alone with infant for risk for infanticide)
what is most common: postpartum blues, postpartum depression or postpartum psychosis?
postpartum blues: 40-80%
postpartum depression: 8-15%
postpartum psychosis: 0.1-0.2%
sleep disturbance and fatigue who don’t have a medical illness needs to be elevated for
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.
antidepressant with less sexual side effects and pt who has low libido?
buproprion would be best choice
antidepressant with least amount of weight gain?
bupropion
bupropion is good for pts who have
low energy, hypersomnia
it’s activating
(not great for those who are already anxious)
antidepressant associated with most weight gain?
paroxetine
treatment resistant depression pharmacology:
switch to another antidepressant or augment with a second agent.
treatment resistant depression is
pt failed to respond to an adequate trial >6 weeks
non responders of depression tx
no improvement with medication
benefit with switching to a different SSRI
partial responders of depression tx
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
Depression in cancer pts can be best differentiated from somatic symptoms of cancer (low energy, anorexia, weight loss and sleep disturbance) by
non somatic symptoms like loss of interest or pleasure
feelings of worthlessness and excessive guilt and suicidal ideation.
who is at highest risk for suicide?
elderly white men.
indications for electroconvulsive therapy for depression
treatment resistance
psychotic features present
emergency conditions- pregnancy, refusal to eat or drink, imminent risk for suicide
safety of electroconvulsive therapy (ECT)
no absolute contraindications
increased risk- severe cardiovascular dx, recent MI, space occupying brain lesion, recent stroke, unstable aneurysm
1st line treatment for psychotic depression is
combo of antidepressant with an antipsychotic
OR
ECT
preferred method of treatment for people who have depression and not eating or drinking
ECT or electroconvulsive therapy
why do we like ECT or electroconvulsive therapy
it provides rapid clinic response compared to medication.
severe suicidality treatment
ECT or electroconvulsive therapy
treatment of catatonia
ECT or electroconvulsive therapy
treatment of treatment resistant depression
ECT or electroconvulsive therapy
what is ECT or electroconvulsive therapy?
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
adverse cognitive effects of ECT or electroconvulsive therapy
acute confusion, anterograde or retrograde amnesia are usually transient
how long to keep someone on SSRI or antidepressant treatment if they have: recurrent major depression, or at high risk for recurrence
need maintenance therapy which last for 1-3 years to reduce risk of relapse.
risk factors for depression recurrence are:
early age of onset <18 years, persistent depressive symptoms, and comorbid psychiatric disorders
Highly recurrent depression is defined as:
> 3 lifetime depressive episodes
chronic depression episodes is defined as
> 2 years of depression
Severe episode of depression is known as:
suicide attempts
who should be on SSRI or antidepressant medication indefinitely:
pts with chronic depression episodes >2 yrs at a time, or have had severe depression episodes (suicide attempts)
when do you add augmentation to a SSRI?
Only add augmentation to a SSRI once pt has failed to respond to a maximally dosed SSRI
dysthymia is:
persistent depressive mood for most of the day for at least 2 years.
Are SSRI’s ok and safe to use in pregnancy?
yes. except for paroxetine which can have a slight increase in congenital cardiac deficits.
pregnant woman with depression should be treated with
psychotherapy
can treat moderate to severe with SSRI except paroxetine
ECT therapy for pregnant women is reserved for those who
need rapid treatment actively suicidal homicidal psychotic not eating or drinking those who have failed previous.
duloxetine (SNRI) is also helpful for treating:
pts who have diabetic neuropathy
chronic lower back pain
fibromyalgia
osteoarthritis
most common discontinuation syndrome symptoms:
agitation, anxiety, dysphoria, irritability
onset is 1-4 days after abruptly stopping antidepressant therapy
or after a rapid taper
lowest incidence of discontinuation therapy:
fluoxetine
still needs to be tapered
who does a PCP treat with depression?
PHQ9- <15.
referral to psychiatrist is indicated for pts with severe
