Depression & ADHD Flashcards
Diagnostics for Major Depressive Episode:
- prolonged & cause SIGNIFICANT distress/dysfunction
- incl. depressed mood or anhedonia
What are the common Fx’s of a Major Depressive Episode (MDE)?
Depressed most of the day, Anhedonia, Weight Change, Sleep Disturbance etc.
- diagnosed when a change from baseline & sustained for 2 weeks or longer
What is the prevalence of major depression?
Yearly prevalence ~ 6-7%
Lifetime prevalence of about 16%, almost 1 in 6
leading cause of disability worldwide
What is the Neuropathology & Neuroimaging of Depression?
- small reduction in hippocampal size
- increased activation of the amygdala by (-) stimuli
- reduced activation of the nucleus accumbens by rewarding stimuli (+ events)
How is the presentation of depression often misleading?
- often complain of stomach upset, pain sensitivity, fatigue, fibromyalgia
- anxiety/insomnia often co-exist (req BZDs/Z drugs)
What is the global Pt assessment for depression?
- Medical - low thyroid, anemia, chronic pain, infections, electrolytes, liver, CV, epilepsy, PD’s, AD’s, Malignancy
- Substance-related - EtOH, THC, Nicotine, Opiate, Stimulant
- Drugs/Hormones
- Stresses/Losses
MUST include Thyroid Function!! - hard to get depression to improve if this is low
Use of BZD’s?
may be useful to reduce distress, anxiety, insomnia - esp. early in Tx
do NOT really treat the illness
consider potential for dependence & non-adherence
Antidepressants
What do they target?
Why don’t they work fast?
Why take them when things are going better?
Can you become addicted?
take several weeks to work (3-6 ish)
can get relapse?
cannot get addicted to them
Can you use St. John’s Wort for Depression?
- multiple active components which impact many NT’s/targets
- effective for MILD to MODERATE depression
____ is a key cause of depression
NT dysfunction
- altered communication b/t brain neurons & neuron tracts/systems
What are the 2 key potential sites for drug action?
- REUPTAKE into the nerve ending or UPTAKE into a glial cell
- Degradation
Antidepressants
Immediate effects vs Long-term effects
Immediate effects:
- enhance “impact” or signalling of NT across synapse (esp. 5HT, NE, & DA)
- IMMEDIATE BENEFITS UNLIKELY, SE’s ARE LIKELY
Over 2-4 weeks & beyond:
- sustained enhanced signalling
- DO NOT CAUSE ADDICTION, DEPENDENCY
Long-term admin is NEEDED for FULL & OPTIMAL BENEFITS
Ketamine for Depression?
lower dose of IV may produce Antidepressant effects within 4hrs
how? NO SPECIFIC EFFECTS ON NTs
RAPID effects on G proteins (like a flood of NT)
Try use something that targets more than 1 NT b/c…
if any of these are under-preforming, it can affect there effects
What is consistent with better outcomes?
- access to supports
- adherence to tx
- a history of “more rapid” response
- lower life stressors are consistent with better outcomes
If we don’t treat depression, ppl tend to…
get better
What is the Pharmacist’s role?
- Adherence
- Education
- Support & adverse effect reduction/management
Who is susceptible/vulnerable to depression?
- genetics
- pyscho-social elements like feeling connected, feeling valued & supported
- life events & stressors, socio-economic factors
- overall physical/medical health
- out “psych immune system”
ADHD main Sx
- inattention
- distractibility
- impulsivity
- hyperactivity
How many months are req’d for diagnose?
6 months (req’s thorough assessment)
What is seen with ppl with ADHD?
- more injuries
- lower grades
- worse driving record
- higher risk of drug abuse
- more antisocial
- lower job status & performance
COMORBITIES are common
What are the ADHD symptoms that are usually mixed?
Inattentive cluster
- distractibility
- forgetfulness
- poor organization
- lack persitence
- mistake-prone
- work avoidant
Hyperactive cluster
- fidgetiness
- intrusiveness
- restlessness
- noisiness
- talkativeness
- inappropriate activity
What is the ADHD course look like?
variable
- onset by 12 yoa, but usually earlier
- hyperkinesis improves 1st, inattention spectrum is last & least to remit
- (+) family Hx & comorbid disorders
What predominates in adults?
Sx often move away from the Hyperactive domains
- DISTRACTIBILITY & INATTENTION may predominate in adults
What is the etiology of ADHD?
multifactoral
- genetics!!!! (~80%)
- right-sided hypofrontality
- Locus Ceruleus “underperforms” (OPPOSITE FROM ANXIETY)
- more evident once they start school
What is the neuropathology & neuroimaging of ADHD?
- small increase in cerebrum growth at age 1-3 yoa
- reduced #’s of cerebellar Purkinje neurons
- reduced cell size & increased cell density in the limbic areas of the brain
What are the risk factors of ADHD?
- high risk in 1st degree relatives
- risk increases with diff situations during pregnancy
- D4 allele abnormalities
= response inhibition &/or arousal regulation deficits!
What is the multimodal approach for ADHD?
- behavioural - structure, checklists, attainable goals
- avoiding triggers, if known
- chiropractic approach
- use combo Tx DRUGS WITHOUT SUPPORT = LOW SUCCESS RATE
What are the Tx goals for ADHD?
- Collaborative: Support System & School
What are the ADHD deficits?
- inhibition of the ability to: control behaviour, resist distractions, maintain an awareness of space & time
- arousal dysregulation - leads to insufficient alertness, often alternating with overarousal
What are the neurochemical targets for ADHD?
- underperformance of DOPAMINERGIC & NORADRENERGIC tracts is consistent with the deficits seen in ADHD
- STIMULANTS, which increase BOTH of these systems, are considered 1st line Tx
- the improvement in “gating” ability can improve behaviour control, executive function & regulate arousal
What are ADHD’s stimulant targets?
- to SELECT restraint & to mentally FOCUS
- regulated arousal = IMPROVED PERFORMANCE
- increased control = reduced hyperactivity & distractibility, &/or aggression
What psychostimulants could be used?
Methylphenidate, Amphetamines
ALL block NE & DA reuptake
- INCREAED NE/DA ACTIVITY in Locus Ceruleus improves attention, ability to FOCUS or SELECT
- Amphetamines also promote DA & NE release from presynaptic neurons
What are the adverse effects of stimulants?
- may decrease appetite
- may increase BP, anxiety, irritability, difficulty falling asleep, stomach complaints, headache
etc.
What is recommended in terms of ADHD medication?
drug holidays
- to reassess tx/minimize growth effects
