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depression Flashcards

1
Q

What are the symptoms exhibited by a patient suffering from major depressive disorder as defined in DSM-5

A

In.SAD.CAGES. At least 5 symptoms present during the same 2 weeks period. One of the symptoms must be depressed mood or loss of interest

Symptoms causes significant distress and impairment in important areas of functioning

Symptoms NOT causes by underlying medical condition or substance abuse

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2
Q

What are the symptoms of In.SAD.CAGES

A

1) Loss of interest/ Decreased interest
2) Sleep: Poor sleep or excessive sleep
3) Appetite: Loss of appetite, weight loss
4) Depressed: Depressed mood in adults (Irritable mood in children)
5) Concentration: Impaired concentration and decision making
6) Activity: Pyschomotor retardation or agitation
7) Guilt: Feelings of guilt or worthlessness
8) Energy: Decreased energy or fatigue
9) Suicidal thoughts or attempts

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3
Q

What are the risk factor for suicide in the general population?

A

1) Previous attempts
2) Isolation
3) Poor health (Physical/mental comorbidities)
4) Poor wealth status
5) Male
6) Elderly

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4
Q

What are the neurotransmitters involved in depression?

A

1) Norepinephrine
2) Serotonin
3) Dopamine

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5
Q

What are the hormonal influences that can cause depression?

A

Increased secretion of cortisol (major stress hormone)

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6
Q

What are the secondary (Medical) causes for depression?

A

1) Endocrine disorder: Hypothyroidism
2) Cardiovascular: CAD, CHF, MI, ACS
3) Infections
4) Deficiency states
5) Neurological: Alzheimer’s, Epilepsy, Parkinson’s
6) Malignancy

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7
Q

What are the drug induced causes for depression?

A

1) Lipid-soluble beta blockers
2) Psychotropics: CNS depressants
3) Withdrawal from alcohol, stimulants
4) Systemic corticosteroids
5) Isotretinoin
6) Interferon-beta-1a

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8
Q

What are the relevant pt’s history to take prior to diagnosis and treatment?

A

1) Psychiatric hx
2) Substance use hx
3) Complete med and medications hx
4) Family, social, occupational, developmental hx
5) Hx of present illness

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9
Q

What must be assessed prior to diagnosis and treatment?

A

Assess suicidal/ Homicidal ideations and risks during mental state exam (MSE)

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10
Q

What is the “gold-standard” for clinician-rated psychiatric rating scales?

A

Hamilton rating scale for depression (HAM-D)

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11
Q

What is the remission criteria for HAM-D?

A

HAM-D score smaller or equal to 7.

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12
Q

How does PHQ-9 categorised severity of depression?

A 
Score:
1-4 : Minimal symptoms
5-9: Mild depression
10-14: Moderate
15-19: Moderately-severe
More than or equal to 20: Severe
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13
Q

At which PHQ-9 score is antidepressant recommended

A

For score 10 and above

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14
Q

What are the non-pharmacological managements for depression?

A

1) Sleep hygiene
2) Psychotherapy
3) Neurostimulation: Electroconvulsive treatment/ Repetitive transcranial magnetic stimulation

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15
Q

What are the first line medications for depression?

A

1) SSRI
2) SNRI
3) Mirtazapine or Bupropion

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16
Q

How many phases are there in the treatment of depression?

A

1) Acute phase

2) Continuation phase

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17
Q

Describe the acute phase treatment

A

1) Adequate trial = Adequate dose + duration
2) 4 - 8 weeks, maximum 12 weeks
3) Physical symptoms may improve in 1-2 weeks, mood symptoms may take 4-6 weeks to improve

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18
Q

Describe the continuation phase treatment

A

For the 1st episode of MDD, continue at least 4-9 months after acute-phase treatment

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19
Q

How long will depression treatment take?

A

Initiation + Acute phase + Continuation phase = 6-12 months

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20
Q

What are the different antidepressant classes?

A

1) Selective Serotonin Reuptake Inhibitor (SSRI)
2) Serotonin-Norepinephrine reuptake inhibitor (SNRI)
3) Tricyclic antidepressant (TCA)
4) Reversible MAOI
5) Noradrenergic and specific serotonergic antidepressant (NaSSA)
6) Others (Melatonin receptor agonist, Serotonin antagonist and reuptake inhibitor, Norepinephrine-Dopamine reuptake inhibitor)
7) Serotonin Modulators and Stimulators (SMS)

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21
Q

Why does mood symptoms take longer to improve?

A

This is due to time needed to downregulate the presynaptic monoamine autoreceptors

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22
Q

What is Duloxetine indicated for?

A

Depression and GAD

Diabetic neuropathy, stress urinary incontinence, fibromyalgia and Chronic musculoskeletal pain

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23
Q

Which drugs are in the TCA class?

A

1) Amitriptyline –> Nortriptyline
2) Imipramine –> Desipramine
3) Dothiepin
4) Clomipramine

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24
Q

MOA of TCA?

A

They block the reuptake of NE and 5-HT in the synapses

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25
What are the SE of TCAs?
1) Sexual dysfunction 2) Anticholinergic (Constipation, dry mouth, blurred vision, urinary retention) 3) Orthostatic hypotension 4) Sedation, weight gain 5) Arrhythmias 6) Seizure 7) Fatal on OD
26
What is Clomipramine indicated for apart from depression?
1) OCD | 2) Cateplexy associated with narcolepsy
27
Which TCAs have lesser anticholinergic, sedation and cardiotoxic SEs?
Secondary amines such as Nortriptyline and Desipramine
28
Starting doses for Amitriptyline?
50 - 100mg/day
29
Usual dose/ day for amitriptyline and Clomipramine?
Ami: 30 -300mg/day Clomi: 25-250mg/day
30
Max dose for Amitriptyline and Clomipramine?
300mg for both
31
Starting dose for Clomipramine?
25mg /day
32
Which drugs are in the SSRI class?
1) Fluoxetine 2) Fluvoxamine 3) Escitalopram 4) Citalopram 5) Paroxetine 6) Sertraline
33
Which SSRI has the long half-life?
Fluoxetine (4-6 days)
34
What is the MOA of SSRI?
Selective Serotonin reuptake inhibitor
35
SEs of SSRI?
1) Sexual dysfunction 2) GI side effects (N/V, diarrhoea) 3) Increased bleeding risk 4) EPSE 5) Insomnia (Fluoxetine specific) 6) Hyponatremia via SIADH 7) Headache and transient nervousness at initiation 8) QTc prolongation (arrhythmia) in elderly at high dose (Escitalopram/ Citalopram) 9) Sedation/ Anti-cholinergic (Paroxetine)
36
Special administration instruction for Sertraline?
Take with food
37
Which SSRI has the most SE?
Paroxetine. Most sedating, most anti-cholinergic, causes weight gain and risk of withdrawal due to short half life
38
Which SSRIs are indicated for OCD?
1) Fluoxetine 2) Fluvoxamine 3) Sertraline
39
Which SSRIs are indicated for anxiety disorder?
1) Escitalopram | 2) Paroxetine
40
Which SSRIs are indicated for panic disorder?
1) Citalopram | 2) Sertraline
41
Which SSRI is indicated for Bulimia nervosa?
Fluoxetine
42
Starting dose of Fluoxetine?
20 mg OM
43
Usual dose and max dose for Fluoxetine?
20-60mg/day Max: 80mg
44
Which drugs are in SNRI class?
1) Venlafaxine 2) Desvenlafaxine 3) Duloxetine 4) Levomilnacipran (??)
45
Which SNRIs are used in GAD?
1) Venlafaxine | 2) Duloxetine
46
MOA of SNRI?
Dual action. Serotonin and Norepinephrine reuptake inhibitor
47
SE of SNRI?
1) Increased BP 2) Urinary retention (Duloxetine) 3) GI side effects 4) Sexual dysfunction 5) Headache 6) Transient headache @ initiation 7) Bleeding risk 8) EPSE
48
Starting dose of Duloxetine?
60mg/day
49
Usual /Max dose of Duloxetine?
30 - 60 mg/day 120 mg/day
50
Starting dose of Desvenlafaxine?
50mg /day
51
Usual/Max dose of Desvenlafaxine?
50mg/day 100mg/day
52
Starting dose of Venlafaxine?
75mg/day
53
Usual/Max dose of Venlafaxine?
75 - 225mg/day 375mg/day
54
MOA of Mirtazapine?
Noradrenergic/ Specific Serotonergic antidepressant alpha-2-adrenoceptor antagonist, 5-HT(2/3) antagonist
55
Starting dose of Mirtazapine?
15mg/day
56
Usual/Max dose of Mirtazapine?
15-45mg/day 45mg/day
57
SE of Mirtazapine
1) Increase appetite 2) Weight gain 3) Drowsiness
58
What are the benefits of Mirtazapine over SSRIs/SNRI?
Reverse sexual and GI side effect of SSRI/SNRI
59
How does Mirtazapine reverse sexual and GI side effect of SSRI/SNRI
By antagonising 5-HT2 (Sexual dysfunction) and 5-HT3 (GI side effect)
60
MOA of Bupropion?
It is a norepinephrine/ dopamine reuptake inhibitor.
61
SEs of Bupropion?
1) Seizure 2) Insomnia 3) Psychosis
62
Starting dose of Bupropion?
150mg OM x 4d, then BD
63
Usual/Max dose of Bupropion?
150mg BD 300MG (2 divided doses)
64
What is bupropion indicated for?
Depression Smoking cessation
65
What drugs are in SMS class?
1) Vortioxetine | 2) Vilazodone
66
What is the MOA of SMSs?
Similar to SSRI, vortioxetine is also 5-HT1A agonist, while vilazodone is a 5-HT1A partial agonist
67
SEs of SMSs?
1) Similar to SSRI
68
What is the drug in reversible MAOI class?
Moclobemide
69
What is Moclobemide useful for?
Atypical depression
70
SEs of MAOI?
1) Hypertensive crisis 2) Anxiety 3) Arrhythmias 4) CVA 5) Weight gain 6) Sexual dysfunction
71
How long is the washout period for Moclobemide?
If switching from Moclobemide: 24hrs If switching to Moclobemide: 1 week (5 weeks for Fluoxetine)
72
Starting dose of Moclobemide?
300mg/day in divided doses
73
Usual/Max dose of Moclobemide?
150-600mg/day 600mg
74
MOA of MAOIs?
Increase availability of monoamines by inhibiting monoamine oxidase, which breaks down monoamine
75
What class is Trazodone in?
Serotonin antagonist and reuptake inhibitor
76
MOA of Trazodone?
Blocks reuptake of 5-HT, antagonizes 5-HT2A receptors
77
SE of Trazodone?
1) Similar to SSRI 2) Sedation (H1 antagonism) 3) Orthostatic hypotension (a1-adrenoceptor antagonism) 4) Priapism (Rare SE)
78
Indication of Trazodone?
Depression, off-label for insomnia. Trazodone is used more for insomnia than depression
79
MOA of Agomelatine?
Melatonin receptor (MT-1, MT-2) agonist 5-HT2C antagonist
80
SE of Agomelatine?
1) GI side effects | 2) Increased LFTs, check LFT at baseline and at week 3,6,12,24
81
Which drugs are contraindicated with concurrent use of Agomelatine?
1) Fluvoxamine | 2) Ciprofloxacin
82
What are the classes of adjunctive medications use in treatment of depression?
1) Benzodiazepines 2) Z-hypnotics 3) Antihistamines 4) Melatonin receptor agonist 5) Second generation antipsychotics 6) Esketamine
83
Which benzodiazepines are used as adjunct? State dose
1) Lorazepam PO 0.5-2mg at bedtime PRN | 2) Diazepam PO 2-15mg at bedtime PRN
84
How long should the course of benzodiazepines be?
2 weeks PRN
85
Which Z-hypnotics is used as adjunct? State dose
1) Zolpidem PO 10mg or 6.25-12.5mg at bedtime PRN (Adult) Female: Half dose Elderly: PO 5mg at bedtime PRN 2) Zopiclone PO 7.5mg at bedtime PRN Elderly: PO 3.75mg at bedtime PRN (increase if necessary)
86
Side effect of Zopiclone?
Taste disturbances
87
Which antihistamine are used as adjunct? State dose
1) Hydroxyzine 2) Promethazine PO 25-50mg ON PRN for both
88
Which antipsychotic are used as adjunct for MDD?
1) Aripiprazole, 2) Brexpiprazole 3) Quetiapine XR
89
Which antipsychotic are used as adjunct for treatment resistant depression (TRD)? State dose
Symbyax (Olanzapine 6mg + Fluoxetine 25mg)
90
What is Esketamine indicated for?
Adjunct to SSRI/SNRI for TRD
91
Which herb should not be used concomitantly with antidepressants?
St John's wort
92
What are the treatment options for Treatment resistant depression?
1) Neurostimulation (Electroconvulsive therapy, repetitive transcranial magnetic stimulation) 2) Symbyax 3) Spravato (Esketamine 28mg nasal spray) as adjunct to SSRI/SNRI
93
What can be combined to the existing antidepressant with a partial response?
1) Mirtazapine 2) Bupropion-SR 3) T3 (Liothyronine) 4) Lithium 5) SGA: Brexpiprazole, Quetiapine, Aripiprazole
94
Which antidepressants/SE should be avoided in elderly?
1) TCA 2) Anticholinergic 3) CNS 4) Hypotensive 5) Cardiac SE
95
What are the symptoms of hyponatremia?
1) Drowsiness 2) Confusion 3) Convulsion
96
Which drug leads to higher risk of hyponatremia? Which drug has a lower risk?
Higher risk: SSRI Lower risk: Bupropion, Mirtazapine, Agomelatine BUT hyponatremia is associated with all antidepressants
97
Suicidality is associated with?
Patient ≤ 24 years old, must counsel patients
98
What causes serotonin syndrome?
Concomitant rx of high-dose serotonergic meds
99
Serotonergic agent + Serotonergic agent = ?
Serotonin syndrome
100
What increases risk of bleeding with SSRIs?
Elderly on NSAIDs, warfarin, steroids. Consider adding PPI
101
What are the significant DDI with antidepressant
1) Alcohol and other CNS depressant (Benzo) 2) NSAIDs, Warfarin, Steroid 3) Serotonergic agents 4) Anticholinergic agents 5) Hepatic enzyme (specifically 2D6/3A4) inhibitors/ inducers
102
Which antidepressants are potent CYP inhibitors
1) Fluvoxamine (CYP1A2, 2C19) 2) Fluoxetine (CYP2D6) 3) Paroxetine (CYP2D6) 4) Bupropion (CYP2D6)
103
Which antidepressants have lesser CYP interactions?
1) Mirtazapine 2) Escitalopram 3) Venlafaxine 4) Desvenlafaxine 5) Vortioxetine 6) Levomilnacipran
104
What are the symptoms of antidepressant discontinuation syndrome
F.I.N.I.S.H 1) Flu-like symptoms 2) Insomnia 3) Nausea 4) Imbalance (Dizziness) 5) Sensory ("electric shock" sensations, paresthesia) 6) Hyperarousal (Anxiety, agitation)
105
How to prevent antidepressant discontinuation syndrome?
If patient is on long-term treatment (daily tx ≥ 8 weeks), gradually taper over 4 weeks. Taper by 25% every 1-2 week.
106
Which antidepressants do not need gradual tapering upon discontinuation? Why?
1) Fluoxetine 2) Bupropion Due to their long half-life
107
Goals of depression treatment?
1) Remission of symptoms 2) Treatment adherence 3) Suicide prevention
108
Rank the antidepressant class according to relevance in clinical practice
1) SSRI, SNRI, NaSSA 2) Bupropion 3) Agomelatine, Vortioxetine 4) TCA 5) MAOIs
109
Patients with history of ____ should avoid using Bupropion
1) Eating disorder 2) Psychosis 3) Seizures

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