Depression Flashcards
What is first line for depression in Parkinson’s?
SSRIs
What is the prevalence of depression in Parkinson’s?
20%
In what % of cases do depressive symptoms precede motor symptoms?
30%
Why should TCAs be avoided in depression in Parkinson’s?
They can cause confusion and cognitive impairment
Why antidepressant should be avoided in depression in Parkinson’s as it can worsen sleep quality?
Mirtazapine
which factors are likely to cause depression in patients suffering from Parkinson’s?
- left sided brain injury
- family hx of depression
- low dopamine levels in the limbic system
- cognitive impairment
- loss of functional independence
Which antidepressants have lower risk of sexual dysfunction side effects?
- Bupropion
- Mirtazapine
Which antidepressants should be avoided in Parkinson’s?
TCAs
Which symptom is least likely to be different between young and old people suffering from depressive disorder?
Sleep disturbance
Which symptoms are to be different between young and old people suffering from depressive disorder?
- Behavioural disturbances
- Complaints of loneliness
- Poor concentration and memory
- Paranoid and delusional ideation
Antidepressants in the elderly
- Newer antidepressants such as SSRI SNRIs are better tolerated as they have lesser side effects
- those who show resistance to first-line treatment tend to do well with lithium augmentation
- EECT is the most effective treatment for life-threatening depressive disorder.
What is a good prognostic factor for depression in the elderly?
Female gender
What are poor prognostic factor for depression in the elderly?
- male gender
- history of dysthymia
- atypical features
- active medical illness or poor physical health
Stress and depression often increase the risk of coronary artery disease by which biological markers?
- Interleukin 6
- Fibrinogen
- natural killer cells
- von Willebrand factor
What combination of medication has been found to be effective in treatment resistant depression?
“Californian rocket fuel” is a medical slang term for the combined administration of mirtazapine (a NaSSA) and venlafaxine (an SNRI). This combination is usually used in the treatment of treatment-resistant depression.
Which symptom is less likely to occur in adolescent onset depression vs adult onset?
Psychomotor retardation
What is the one year prevalence of depression?
5.3%
What is the life time prevalence of depression?
13%
What is the mean age of onset of depression?
30
What is the mean number of episodes in patients with MDD?
5 episodes
What is the most common comorbidity in patients with MDD?
Alcohol abuse
What percentage of patients with MDD attempt suicide?
9%
What proportion of patients diagnosed with depression by their GP go on to have an episode of mania within 10 years?
1 in 10
How long does an untreated episode of depression last?
6 to 13 months (compared to 3 months if treated)
What are the 5Rs (Kupfer curve?) of the treatment of depression
Response: 50% improvement of symptoms (<50% = partial response)
Remission: depression not detectable on any clinical scales
Recovery: remission continues for >6 months (untreated episode duration)
Relapse: further episode within 6 months
Recurrence: further episode after 6 months
What are the positive prognostic indicators of MDD?
Mild episodes
Absence of psychotic symptoms
Short admission
Hx of solid friendships during adolescence
Stable family functioning
Good social functioning during 5 years preceeding illness
Absence of co-morbid psychiatric disorders
No more than one previous admission for MDD
What the relapse indicators for MDD?
Persistent dysthymia
Co-morbid physical/psychiatric conditions
Female sex
Longer episodes of illness before seeking treatment
Greater number and duration of prior episodes
Never marrying
Severity of episodes i.e. suicidality, psychotic features
What are the NICE guidelines for management of mild depression?
Mild - Moderate:
- CBT based self help programme
- Computer cognitive based programme
- Physical activity programme
- Watchful waiting is acceptable but must review in 2/52
- Avoid antidepressants if possible (poor risk:benefit ratio)
- Other psychological therapies i.e. CBT, IPT
Moderate - Severe:
- Antidepressants (1st line = SSRIs)
- Psychological therapies
How long should antidepressants be continued after remission?
6 months
How long should patients with >2 episodes in the recent past or with residual symptoms continue antidepressants?
2 years
When is ECT indicated?
If other treatments have proven ineffective and/or condition is considered to be potentially life-threatening
What is the NNT for antidepressants in adults (response)?
4-5
What is the NNT for antidepressants in adults (remission)?
6-7
What are the differences between male and female patients in terms of suicidal ideation and attempts?
Men have more suicidal ideation
Women have more suicidal attempts
Men 2-4x more likely to be successful
What is the management of treatment resistant depression?
- Confirm true resistance by ruling out ‘5As’ - Alcoholism, inAdequate dosing, poor Adherence, Axis 2 Disorders (PD), Alternate diagnoses
- Switch to another drug (same or different class)
- Augment with lithium, antipsychotic, psychotherapy or another antidepressant
- If no response after 2-3 adequate trials, consider ECT/TMS/novel agent i.e. ketamine
What combination of antidepressants is high risk for serotonin syndrome?
SSRI + MAOI
Why is a combination of an SSRI and a TCA thought to be effective for treatment resistant depression?
Pharmacological (two different) and Kinetic mechanisms - SSRIs block metabolism of TCAs
What is Agomelatine?
A novel antidepressant - 5HT2C antagonist
What are the strategies for improving sexual dysfunction as a SE of antidepressants?
- Consider switching to an antidepressant with a better SE profile depending on overall improvement in depression with current medication
- Add sildenafil/tadafinil
- Add bupropion
How does St John’s Wort interact with SSRIs?
Increases effects
What is the MOA of ketamine as an antidepressant?
NMDA receptor antagonist
Proportion of patients that don’t respond to first trial of antidepressant?
1/3
Prevalence of clinical depression after stroke?
30-40%
SMR for patients with dysthymia is higher than the general population by a factor of?
12
SMR for patients with depression is higher than the general population by a factor of?
20
Which SSRI is contraindicated with Tamoxifen?
Fluoxetine
duloxetine
bupropion
paroxetine
Proportion of patients with MDD that show elevation in cortisol levels?
50%
SMR for major depression?
20%
What can be said about the trend in point prevalence of depression?
It’s increasing
Prevalence of depression in patients with coronary heart disease?
21%
2-3x that of general population
Which substance is implicated in epilepsy related depression in patients treated with certain anticonvulsants?
Folate
Prevalence of dysthymia
4%
Depression rating scale most sensitive to change
MADRS
Best antidepressant for use following MI?
Sertraline
SSRI with least placental exposure?
Sertraline
Most common side effect of SSRIs
Sexual dysfunction (nearly 60%)
Rating scale that covers larlgely somatic symtoms and fewer cognitive symptoms
Hamilton depression rating scale
Kubler Ross’s five stages of greif
Denial Anger Bargaining Depression Acceptance
According to ECA study what is the increased risk for depression in separated/divorces subjects vs continually married?
3x
Which antidepressants are contraindicated in children?
Venlafaxine
Paroxetine
Risk increase of giving birth to a child with septal defects on Citalopram?
2x
A 28-year-old lady has been caught for shoplifting. She does not have any previous history of shoplifting. The police are surprised that she did not make any efforts to remain undetected. What type of stealing is this?
Depressed stealing
Star*D trial overview
pragmatic (real world) trail which aimed to assess the effectiveness of treatments in patients diagnosed with major depressive disorder.
It consisted of four different levels of treatment
Level 1 - This consisted of citalopram (given for 14 weeks)
Level 2 - This consisted of either swapping to sertraline, Bupropion, or venlafaxine, or augmenting with Bupropion, or buspirone. Cognitive psychotherapy was also included as a switch or add on at this level.
Level 3 - This consisted of swapping to mirtazapine or nortriptyline or adding on lithium or triiodothyronine (T3).
Level 4 - This consisted of swapping to either tranylcypromine (MAOI) or a combination of venlafaxine and mirtazapine.
Outcome measure used was remission (becoming symptom free).
Main conclusions of star*d trial
In level 1 1/3 of participants achieved remission. A further 10-15% responded but not to the point of remission.
If treatment with an initial SSRI fails then 1 in 4 who choose to switch to another medication will enter remission regardless of whether the second medication is an SSRI or a medication of a different class. If patients choose instead to add a medication on 1 in 3 will get better
Most common cause of serotonin syndrome
The most frequent cause of severe reaction is the co-administration of an MAOI with an SSRI.
Which combinations of antidepressants should be avoided?
Phenelzine and sertraline (MAOI + SSRI)
The combination leads to a high risk of serotonin syndrome.
According to the NICE Guidelines, which medication is associated with a higher incidence of discontinuation symptoms?
Paroxetine
Which SSRI is most associated with causing diarrhoea?
Sertraline
Features of atypical depression
Low mood with mood reactivity (mood varies greatly in response to specific events)
reversal of the features normally seen in depression:
They have hypersomnia (sleep a lot), hyperphagia (eat a lot), weight gain, and libidinal increases
Best treatment option for atypical depression
People with atypical depression tend to respond best to MAOIs
Which antidepressants have the lowest risk of sexual dysfunction?
Agomelatine and Bupropion have probably the lowest risk of sexual dysfunction.
Which opthalmic problem may be caused by St John’s Wort?
Early macular degeneration
Which sexual dysfunction can Paroxetine cause?
Vaginismus
Lifetime prevalence of dysthymia
4%
Which SSRIs has an active metabolites?
Fluoxetine
Sertraline
What suggests life-threatening symptom of serotonergic syndrome?
High fever
Other Signs and symptoms include seizures, irregular heartbeat or unconsciousness
Which SSRI has been shown to be effective when administered sublingually?
Fluoxetine
Which SSRIs would be most likely to raise the levels of theophylline?
Fluvoxamine
Beck’s depression inventory
SELF RATED
Has 21 questions (max score of 63)
Each question scored from 0-3
Assesses severity of depression
Covers period of two weeks before the evaluation
14-19 mild depression, 20-28 moderate, and 29-63 severe depression.
HAMD (Hamilton depression rating scale)
CLINICIAN RATED
Multiple choice questionnaire used to rate the severity of depression
17 or 21 items
Each item is scored out of between 3 and 5 points
For the 17 item version (the most commonly used) scores range between 0 and 54
Scores over 24 indicate a severe depression.
MADRS (Montgomery-Asberg depression rating scale)
CLINICIAN RATED
10 diagnostic questionnaire used to measure the severity of depressive episodes
More sensitive to the changes brought on by antidepressants and other forms of treatment
Whihc antidepressants are recommended in liver failure?
Imipramine
Paroxetine
Citalopram
Which effect of SSRIs is presumed to be the cause of the associated sexual dysfunction?
5HT2 agonism
Which antidepressantss should be avoided in epilepsy?
Amitriptyline
Dosulepin
Clomipramine
Buproprion
What % of those who’ve had a first episode of depression will go on to have another?
50%
What 0% of those with a history of two episodes of depression will have another recurrence?
80%
What scales is used to measure effect of a treatment in depression?
MADRS
Drugs used in MS that are associated with developing depression
Dantrolene, baclofen, steroids and interferon beta are all associated with the development of depression.
