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General Internal Medicine > Depression > Flashcards

Depression Flashcards

1
Q

Features of SSRI associated sexual dysfunction

A

decreased libido, anorgasmia

delayed ejaculation, common cause of nonadherence

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2
Q

Assessment and management of SSRI related sexual dysfunction

A

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

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3
Q

If patient responds to drug but has sexual dysfunction:

A

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

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4
Q

SSRI sexual dysfunction is anorgasmia

A

try to sildenafil or phosphodiesterase 5 inhibitor.

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5
Q

benefit of using mirtazapine

A

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.

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6
Q

How does mirtazapine work?

A

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.

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7
Q

what is the benefit of using bupropion

A

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

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8
Q

Who should avoid bupropion?

A

people with seizures, anorexic patients

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9
Q

When can olanzapine be used for depression?

A

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

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10
Q

what is an adequate antidepressant trial?

A

6 weeks at a therapuetic dosage.

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11
Q

most common preceived reason for inefficacy of a SSRI

A

inadequate dosage or duration.

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12
Q

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

A

6 months following acute response (continuation phase treatment)

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

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13
Q

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

A

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

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14
Q

When do we continue maintenance therapy indefinitely?

A

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

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15
Q

how long is maintenance SSRI therapy usually last?

A

1-3 years

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16
Q

risk factors for suicide

A 
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
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17
Q

protective factors against suicide

A

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

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18
Q

what to do for high risk for suicide patients

A

they need to be hospitalized and then stabilized.

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19
Q

what is antidepressant discontinuation syndrome?

A

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.

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20
Q

how to treat antidepressant discontinuation syndrome?

A

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

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21
Q

Symptoms of antidepressant discontinuation syndrome

A

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

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22
Q

difference between postpartum blues and postpartum depression

A

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)

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23
Q

post partum psychosis occurs when

A

days to weeks,

start to see delusions, hallucinations

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24
Q

symptoms of postpartum blues

A

mild depression and tearfulness and irritability

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25
Q

symptoms of post partum depression

A

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

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26
Q

symptoms of post partum psychosis

A

delusions, hallucinations, thought disorganization

bizarre behavior

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27
Q

management of postpartum blues

A

reasssurance and monitoring

28
Q

management of postpartum depression

A

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

29
Q

management of postpartum psychosis

A

antipsychotics, antidepressants, mood stabilizers

hospitalization ( do not leave mom alone with infant for risk for infanticide)

30
Q

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

A

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

31
Q

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

A

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.

32
Q

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

A

buproprion would be best choice

33
Q

antidepressant with least amount of weight gain?

A

bupropion

34
Q

bupropion is good for pts who have

A

low energy, hypersomnia
it’s activating

(not great for those who are already anxious)

35
Q

antidepressant associated with most weight gain?

A

paroxetine

36
Q

treatment resistant depression pharmacology:

A

switch to another antidepressant or augment with a second agent.

37
Q

treatment resistant depression is

A

pt failed to respond to an adequate trial >6 weeks

38
Q

non responders of depression tx

A

no improvement with medication

benefit with switching to a different SSRI

39
Q

partial responders of depression tx

A

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

40
Q

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

A

non somatic symptoms like loss of interest or pleasure

feelings of worthlessness and excessive guilt and suicidal ideation.

41
Q

who is at highest risk for suicide?

A

elderly white men.

42
Q

indications for electroconvulsive therapy for depression

A

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

43
Q

safety of electroconvulsive therapy (ECT)

A

no absolute contraindications

increased risk- severe cardiovascular dx, recent MI, space occupying brain lesion, recent stroke, unstable aneurysm

44
Q

1st line treatment for psychotic depression is

A

combo of antidepressant with an antipsychotic
OR
ECT

45
Q

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

A

ECT or electroconvulsive therapy

46
Q

why do we like ECT or electroconvulsive therapy

A

it provides rapid clinic response compared to medication.

47
Q

severe suicidality treatment

A

ECT or electroconvulsive therapy

48
Q

treatment of catatonia

A

ECT or electroconvulsive therapy

49
Q

treatment of treatment resistant depression

A

ECT or electroconvulsive therapy

50
Q

what is ECT or electroconvulsive therapy?

A

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

51
Q

adverse cognitive effects of ECT or electroconvulsive therapy

A

acute confusion, anterograde or retrograde amnesia are usually transient

52
Q

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

A

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

53
Q

risk factors for depression recurrence are:

A

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

54
Q

Highly recurrent depression is defined as:

A

> 3 lifetime depressive episodes

55
Q

chronic depression episodes is defined as

A

> 2 years of depression

56
Q

Severe episode of depression is known as:

A

suicide attempts

57
Q

who should be on SSRI or antidepressant medication indefinitely:

A

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

58
Q

when do you add augmentation to a SSRI?

A

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

59
Q

dysthymia is:

A

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

60
Q

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

A

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

61
Q

pregnant woman with depression should be treated with

A

psychotherapy

can treat moderate to severe with SSRI except paroxetine

62
Q

ECT therapy for pregnant women is reserved for those who

A 
need rapid treatment
actively suicidal
homicidal
psychotic
not eating or drinking
those who have failed previous.
63
Q

duloxetine (SNRI) is also helpful for treating:

A

pts who have diabetic neuropathy
chronic lower back pain
fibromyalgia
osteoarthritis

64
Q

most common discontinuation syndrome symptoms:

A

agitation, anxiety, dysphoria, irritability

onset is 1-4 days after abruptly stopping antidepressant therapy

or after a rapid taper

65
Q

lowest incidence of discontinuation therapy:

A

fluoxetine

still needs to be tapered

66
Q

who does a PCP treat with depression?

A

PHQ9- <15.

referral to psychiatrist is indicated for pts with severe

General Internal Medicine (54 decks)

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