Depression Flashcards
Define stigmafree
we should treat patients without bias (or stigma)
Why is depression treatment so important?
- common problem –> massive public health consequences
- often undetected
- CAN be treated
- the generic meds we have are really effective and not expensive
- we have the ability to greatly improve function and health in seniors with careful screening
In what patients are we most likely to see depression?
females; age of onset in 20s
its really common
Depression increases risk of:
- DM
- HTN
- CVD
- stroke morbidity/mortality
What is needed for a MINOR depression diagnosis?
Depressed mood and/or loss of interest or pleasure
AND
- loss or change in appetite
- significant wt gain
- insomnia or hypersomnia
- psychomotor agitation (anxious/restlessness) or retardation (slowing down of thoughts/ decr. in physical movement)
- fatigue or loss of energy
- feelings of worthlessness or excessive or inappropriate guilt
- thoughts of death, suicide ideation with or without a specific plan, suicide attempt
What is required for a MAJOR depression diagnosis?
1+ major depressive episode
(it’s sx must be present every day for at least 2 weeks, be a change from baseline, and cause significant distress/impairment/functioning impairment)
AND
anhedonia (inability to feel pleasure) and/or depressed mood
AND
3 additional symptoms from DSM-V
What defines a major depressive episode?
1+ of these:
- depressed mood most of the day, nearly every day (subjective report or observation made by others)
- decr. interest/pleasure in all or most activities most of the day, almost every day (anhedonia)
others to make a total of 5:
- significant wt gain or loss/ change in appetite
- insomnia or hyperinsomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or excessive/ inappropriate guilt
- indecisiveness or diminished ability to think or concentrate
- recurrent thoughts of death, suicidal ideation with or without a specific plan, suicide attempt
–> the sx must cause significant distress or impairment in social, occupational, or other important areas of functioning
(not due to a substance, a general medical condition, or bereavement)
What are the 9 diagnostic symptoms of MDD?
SIG E CAPS
- sleep
- interest
- guilt
- energy
- concentration
- appetite
- psychomotor
- suicide
What are some screening tools?
- PHQ2
- Ham-D (7+ points - normal)
- Macarthur PHQ (<10 mild or minimal sx)
- Geriatric Depression Scale (GDS)
–> should question the patient further if a + screen to indicate a more specific diagnostic criteria for one or more of the depressive disorders
What would a + PHQ-2 screen look like?
3+ score
over the past 2 weeks how often have you been bothered by any of the following problems?
- little interest or pleasure in doing things
- feeling down, depressed or hopeless
How is the GDS scoring broken down?
0-9 = normal 10-19 = mild depression 20 = severe
What is non-pharm tx for MDD?
- psychotherapy (CBT or interpersonal psychotherapy (IPT))
- electroconvulsive tx (ECT)
- ECT + TMS (transmagnetic stimulation)
Which is more beneficial: psychotherapy or medication?
work about equally well!
psychotherapy is found to be useful in cognitive intact patients
How does CBT work?
help patients modify maladaptive cognitions, beliefs, assumptions, and behaviors that maintain depressive sx
(time limited: 10-12 sessions)
How does IPT work?
focus on goals related to relationships, role transitions, role conflicts, prolonged grief, and interpersonal deficits
How does ECT work?
anesthesia prevents muscle movements associated with tonic-clonic seizures
–> may be the ONLY effective tx for withdrawn SEVEREly depressed older pts (illness is severe, preventing oral intake); ECT may be more effective than medication in elderly in general
(time limited: 6-12 sessions over 2-5 wks)
SE:
- anterograde/retrograde amnesia
- post-ictal confusion (mental/physical exhaustion)
- post-treatment muscle aches
SSRI MOA?
selectively inhibits reuptake of 5-HT at presynaptic neuronal membrane
SNRI MOA?
Inhibit reuptake of 5-HT and NE
weakly inhibit dopamine reuptake
MAOi MOA?
competitively inhibit monoamine oxidase
there are differences within class of reversibility and activity against MAOa and MAOb
serotonin modulators MOA?
selective inhibition of 5-HT reuptake, 5-HT antagonist
trazadone, trazadone ER
dopamine-NE inhibitor MOA?
inhibit dopamine reuptake with some effect on NE
bupropion
NE and specific 5-HT antidepressants MOA?
block presynaptic central a2-adrenergic autoreceptors
–> incr. neurotransmission of NE and 5-HT
block post synaptic 5-HT2 and 5-HT3 receptors
(mirtazapine)
TCADs MOA?
inhibit reuptake of NE and 5-HT into presynaptic terminals
amitriptyline, nortriptyline, imipramine, desipramine
SSRI + partial agonist 5-HT1A MOA?
5-HT reuptake inhibitor with partial agonist activity at 5-HT1A
(vilazodone)
SSRI + antagonist at 5-HT1, -HT3 MOA?
5-HT reuptake inhibitor with inhibition of 5-HT1 and 5-HT3
vortioxetine
When would we want to use SSRI?
- anxiety (start low dose)
- adolescents [fluoxetine, sertraline, and escitalopram]
[sertraline]
- CV disease
[fluoxetine]
- psychomotor slowing
- overweight/obese
[paroxetine]
- underweight
- insomnia
Caution use with SSRI:
- QTc prolongation or Torsades risk
- pregnancy
[paroxetine] overweight/obese; elderly
[fluoxetine] agitation or insomnia
(QuinTin)
When would we want to use SNRIs?
- anxiety
- chronic pain from fibromyalgia/neuropathy
[duloxetine]
- psychomotor slowing
Caution use with SNRIs:
HTN
agitation
insomnia
(Hati)
Indications for mirtazapine
- agitation/insomnia
- sexual dysfunction concern
- underweight
u said
Mirtazapine caution:
- overweight/obese patients
- hyperlipidemia
Alistair OH
Indications for bupropion
- sexual dysfunction concern
- smokers
- psychomotor slowing/fatigue
- overweight/obese patients
SAM
Bupropion caution:
- seizure disorders
- HTN
- anxiety/insomnia
(SHAI)
Indications for Vilazodone or Vortioxetine
- sexual dysfunction concern
- overweight/obese pts
- cognitive dysfunction
Victor
Vilazodone or Vorioxetine caution:
nausea
Nate
What side effect could women on SSRI/SNRI experience?
women on TCAD?
SSRI/SNRI: problems with arousal
TCAD: problems with desire, lubrication, orgasm
What side effect could men on SSRI/SNRI experience?
ED, desire, and orgasm
Which agents are least likely to cause sexual side effects?
- mirtazapine
- bupropion
- vortiolexetine
- vilazodone
- duloxetine
- fluovoxamine
- levomilnacipran (this is a 5-HT-NE reuptake inhibitor)
What type of agent has a higher risk for antidepressant withdrawal syndrome?
short acting
(paroxetine, desvenlafaxine, venlafaxine)
–> fluoxetine has the lowest risk
Why shouldn’t we prescribe concomitant tx of sympathomimetic amines + MAOis?
hypertensive crisis
- incr. BP
- stiff/sore neck
- N/V
- sweating
Why shouldn’t we combine SSRI/SNRI + MAOis/multiple serotonergic drugs?
serotonin syndrome
the multiple serotonergic drugs includes cocaine!
What are common sx of serotonin syndrome?
- confusion
- restlessness
- fever
- sweating
- hyperreflexia
- tachycardia
- hyperthermia
- diarrhea
- shivering
Of all of the depression medication classes discussed which should we avoid in the elderly?
TCADs!!!
How do we switch from one SSRI (except fluoxetine) to another?
- stop SSRI & start new SSRI at low dose (may taper off the first if a high dose)
- stop SSRI & start new agent within the same dose range
- Cross taper: taper and stop SSRI before starting new agent at low dose)
What are some pharmacodynamic SSRI/SNRI drug interactions?
- additive sedation
- additive anti-cholinergic effects
- increased seizure risk
- 5-HT syndrome - MAOis & linezolid
- Tramadol
(triptans are ok with SSRIs)
What are pharmacokinetic SSRI/SNRI drug interactions?
- CYP2C
- CYP3A4
[fluoxetine],[paroxetine]: CYP2D6
What when combined with MAOIs would result in hypertensive crisis?
- pseudoephedrine
- phenylephrine
- ephedrine
- phenylpropanolamine
- aged cheese & wine (tyramine containing foods)
What when combined with MAOIs would result in serotonin syndrome?
- SSRI
- TCADs
- methadone
- tramadol
- meperidine
- DM
- St. Johns wort :/
- cyclobenzaprine
- mirtazapine
What should we check before we dive into treatment decisions?
- suicidality/intent to harm others
- psychosis
- minimal verbal interaction
- severely restricted food intake
- manic sx (…different tx needed!)
When do we want to reassess?
4-6 wks or sooner for tolerance and efficacy
- watch for suicide risk & med adherence!
General treatment choices (assume progression to next step due to no remission)
- SSRI, bupropion, SNRI, or mirtazapine (reassess 4-6 wks)
- maximize dose of 1st agent
- Either:
- combine SSRI + bupropion
- augment with buspirone
- switch to another 1st line agent - Cycle through the different choices from step 3
- if all fail, either:
- augment with triiodothyronine
- TCA (2nd line drug) :(
- combine venlafaxine + mirtazapine
- refer to psychiatrist
When should we use a second generation antipsychotic (SGA)?
- depression with psychotic features
- augmentation strategy with SSRI/SNRI
- resistance to tx after trials with 1st and 2nd line agents
- equivocal efficacy
- consider referral to psychiatry
When would we d/c tx?
decr. risk of polypharmacy and drug interactions after a minimum of 6 months (usually 6-12 mo)
(some patients need long-term tx, and that’s okay –> keep them on)
Why should SSRIs be tapered off?
we want to avoid “discontinuation syndrome”
- flu-like symptoms
- insomnia
- nausea
- imbalance
- sensory disturbances
- hyperarousal
(these sx are usually mild, lasting 1-2 weeks. they will quickly stop if med re-instituted)
Which agents are best in pregnancy?
How do we feel about breast feeding and treating depression?
fluoxetine, citalopram, and TCAD have the best hx of safety data
benefits > risks
(let’s treat them!)
Geriatric Population key points:
- under recognized and under treated
- generally more sensitive to meds, so be careful
- SSRI > TCADs
- depression often leads to suicide in older adults (men!)
Pediatric population key points:
used if:
- severe or psychotic depression
- failed psychotherapy
- chronic/recurrent depression
SSRIs (initial choice)
CAUTION: incr. risk of suicidality in children & young adults
Indications for Esketamine Nasal Spray
- post-partum depression
- treatment resistant depression
What are the 6 possible specifiers for depressive disorder?
with:
- anxious distress
- mixed features
- melancholic features
- atypical features
- psychotic features
- seasonal pattern
(these specifiers are used when characteristics of depressive disorders are not fully met, but distress or impairment is still seen)
Antidepressant tx side effects (often not thought about)
- hyponatremia (serum Na < 125 mEq/L)
- bleeding
- incr. risk of falls & fractures
- inr. QTc intervals
Key points regarding dosing:
- start low, go slow, but don’t stop (“stall”) before at a therapeutic dose
- give it time to take effect
- when d/c taper to avoid withdrawal sx
