Depression and anxiety

Question 1

Diathesis- Stress Model

Answer 1

• Inborn predosposition (diathesis) + Environmental stress = psychopathology.
• The idea is that stress may activate someones underlying vulnerability to mental illness
• For people with a low “diathesis” it would take alot of stress to trigger psychopathology. However, for people with a high “diathesis” it would take very little stress to trigger psychopathology. This model helps to explain why when some people experience the same stress, only same will develop mental illness. To further complicate things, the stress and mental illness have a receiprocal relationship where stress exacerbates the disorder and the disorder makes life more stressful.
• Examples of diathesis: genetics, cognition, personality, family history, brain abnormalities, and neurological problems
• Examples of stress: stress can be acute or chronic and can include numerous different things - parental neglect/abuse, death of a family member, relationship problems, traumatic events, etc.

Question 2

Hypothalamic-pituitary adrenal (HPA) axis

Answer 2

• HPA axis is an important system in response to stressors. It released cortisol in short-term stress scenarios. Chronically acitvated HPA axis is seen in many people with MDD and anxiety disorders.
• Hypothalamus -(CRH)-> anterior pituitary-(ACTH)-> Adrenal cortex–> cortisol

Question 3

Cortisol Receptors

Answer 3

• Two types of receptors bing cortisol - mineralcorticoid type 1 and glucocorticord type 2. Cortisol binds more strongly to the mineralcorticord receptors. This helps maintain low levels of cortisol circulating in blood. it is only when cortisol concentrations are very high (i.e., stress) that is binds to the glucocorticoid receptors - this then provides the negative feedback that terminates the response.

Question 4

Function of cortisol

Answer 4

• Cortisol is the main glucocorticoid in humans. It’s primary function is to increase blood glucose levels by inducing production of glocose molecules. Cortisol also modifies fat and protein metbolism to support nutrient requirements of CNS during stress. However, when it binds to glucocorticoid receptors it also effects other wide-ranging effects influencing cardiovascular function, immunologic status (inflammatory reactions), arousal, and learning and memory.

Question 5

Healthy vs. unhealthy stress response

Answer 5

• Healthy - characterized by quick rise in cortisol followed by rapid decline with termination of stressful event.
• Unhealthy - when individual faces cumulative stress that cortisol burden increases, exposing individual to catabolic properties of glucocorticoids, stress peptides, and proinflammatory cytokines.

Question 6

Unipolar Depression

Answer 6

• Disruptive mood dysregulation disorder
• Major depressive disorder
• Persistent depressive disorder
• Premenstrual dysphoric disorder
• Substance/medications induced depressive disorder
• Depressive disorder due to another medical condition
• Other specified depressive disorder
• Unspecified depressive disorder

Question 7

Disruptive Mood Dysregulation Disorder

Answer 7

• Severe recurrent temper outbursts grossly out of proportion to situation, inconsistent with developmental levels, occuring 3⁺ times a weeks. Mood outside of outburts is persistently irritable or angry. Symptoms have been present for at least 1 year, and are present in at least 2 settings.
• Diagnosis should not be made for first time after 18 or before 6 years.
• Age of onset (by history or observation) is before 10.
• Never met hypomanic or manic episode criteria for more than 1 day.
• Behaviours don’t occur during an epiodes of MDD and are not better explained by another disorder, a sustance, or neurological condition.
• Consequences: Difficulty in peer and family relationships; poor school performances; suicidal ideation or attempts; severe agression; psychiatric hospitalizations

Question 8

Major Depressive Disorder

Answer 8

• Need to meet 5/9 criteria for diagnosis. Needs to be present persistently for 2 weeks. Must have either 1 or 2.
  
  1. Depressed mood most of the day, nearly every day (children an be irritable instead of sad).
  2. Markedly decreased interest or pleasure in all, or almost all, activities most of the day, nearly everyday.
  3. Significant weight loss not due to deleting or weight gain/decrease or increase in appetite nearly everyday
  4. Insomnia or hypersomia
  5. Pscyhomtor agitation or retardation
  6. Fatigue or loss of energy
  7. Feeling or worthlessness or guilt
  8. Dimished ability to think or concentrate
  9. Recurrent thoguhts of death, recurrent suicidial ideations, suicidal attempts.
• Symptoms cause significant distress or impairment
• Symptoms are not better explained by substances or other medical condition
• There has never been a manic or hypomanic episode

Question 9

Disease course MDD

Answer 9

• Recovery begins within 3 months for 2/5 people and within 1 year for 4/5 people. Many who are depressed for only a few months will have spontaneous recovery.
• Risk of recurrence - becomes lower as duration or remission increases; its higher in those with more severe episodes and those with multiple episodes; increase risk of relapse when people have residual symptoms during remission
  
  • 1 Episode = 50%
  • 2 Episodes = 75%
  • 3 Episodes = 90%

Question 10

Risk Factors MDD

Answer 10

• Temperament - negative affectivity
• Environmental - Adverse childhood experiences, stressful life events, etc.
• Genetic and physiological - First degress relative
• Presence of other nonmood disorders, especially SUD, anxiety, and BPD

Question 11

Persistent Depressive Disorder

Answer 11

• Depressed mood for most of the day, for most days, for at least 2 years (1 year for children).
• Two or more of the following: poor appetite or overeating; insomnia or hypersomnia; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; feelings of hopelessness.
• Within 2 year period patient has never been without the above >2 months
• Criteria for MDD may be continuously present for 2 years.
• Never met critieria for manic, hypomania, or cyclothymia
• Not better explained by other disorders, substance, or medical condition
• Symptoms cause clinically significant distress or impairment

Question 12

Premenstrual Dysphoric Disorder

Answer 12

• In most menstrual cycles at least 5 symptoms must be present in week before and start to improve a few days after onset and become minimal in the week after.
• One or more of the following - marked affect lability; marked irritability, anger, or increased interpersonal conflicts; marked depressed mood, feelings of hopelessness, or self-depecating thoughts; marked anxiety, tensions, and/or feeling on edge.
• One or more of the following (together with above must add to 5) - decreased interest; difficulty concentrating; lack of energy; changes in appetite; sleep disturbance; sense of being overwhelmed; physical symptoms
• Symptoms associated with clincally significant distress or inteferences in function
• Not just an exacervation of another disorder
• Should confirm by daily rating during at least 2 symptoms cycles.
• Not attributable to physiological effect of substnace

Question 13

Substance/medications-induced depressive disorder

Answer 13

• Porminent and persistent depressed mood or reduced interest with evidence that it developed after substance intoxication or withdrawal or after medication exposure. The involved substance has to be capable of producing the symptoms
• Disturbance is not better explained by non-sub-substnace induced causes
• Disturbance is not exclusively during the course of delirium
• Disturbances causes clinically significiant distress or impairment
• Symptoms should have developed within 1 month of using the substance
• Medications: antiviral agents (efavirenze), cardiovascular agents (clonidine, methyldopa), retinoic acid derviates, antidepressants, anticonvulstans, triptans, antipsychotics, hormonal agents, smoking cessation agents, and immunological agents have all been implicated.

Question 14

Depressive disorder due to another medical condition

Answer 14

• Prominents and persistent depressed mood or diminished interest with evidence that it is due to another medical condition
• Disturbance is not better explained by another mental disorder
• Disturbance does not occur exclusively during course of delirium
• Disturvance causes clinically signficant distress or impairment
• Medical condition - Stroke, Huntingtons, PD, TBI, Cushings disease, hypothyrodism (this list is not extensive).
  *

Question 15

1. Othe specified depressive disorder
2. Unspecified depressive disorder

Answer 15

1. Applies to peresentation in which symptoms are characteristic of a depressive order that causes clinically significant distress or impairment, but that do not meet full criteria for any depressive disorder diagnostic class. Used in situations where physician chooses to indicated the specific reasons why the presentation does not meet full criteria.
2. Applies to peresentation in which symptoms are characteristic of a depressive order that causes clinically significant distress or impairment, but that do not meet full criteria for any depressive disorder diagnostic class. Used in situations where physician chooses not to indicated the specific reasons why the presentation does not meet full criteria.

Question 16

Specifiers for Depressive disorders

Answer 16

• With anxious distress - At least 2 symptoms present during majority of days of MDD or persistent depressive disorder - feeling keyed up or tense; feeling unusually restless; difficulty concentrating because of worry; fear that something awful may happen; feeling that individual may lose control of themselves.
• With mixed featues - At least 3 manic/hypomanic symptoms present nearly every day during MDD. (Should not meet full certeria for mania/hypomania).
• With melancholic features - one of the following is present during most severe period of current episode - loss of pleasure in activities, lack of reactivity to usually pleasurable stimuli + 3 or more of the following (distant quality of depressed mood characterized by profound despondency, despair, and/or moroseness; depression is worse in morning; early morning awakening (2hrs before); marked psychomotor agitation or retardation; significant anorexia or weight lossl excessive or inappropriate guilt.
• With atypical featues - Mood reactivity (mood brightens in response to acutal or potential positive events) + 2 or more of the following (significant weight gain or increase in appetite, hypersomnia, leaden paralysis, long standing pattern or interpsonal reject sensitivity.
• With psychotic features
• With catatonia
• Wither peripartum onset - during pregnacy or 4 weeks following
• With seasonal pattern

Question 17

Fist Line Psychological Treatments for Unipolar Depression

Answer 17

• First line: CBT, IPT, behavioural activation
• First line for maintenance: CBT, mindfulness-based cognitive therapy

Question 18

First Choice Antidepreesants

Answer 18

SSRIs

• Escitalopram (Cipralex) - 10-20mg/d. Start at 10 and increase to 20mg after at least 1 week of treatment.
• Sertraline (Zoloft) (50-200mg/d - start at 50 and increase 25mg at least 1 week) + Fluoxetine (Prozac) (20-60 - start at 20 and increase by 10-20 as needed) = for children

SNRIs

• Desvenlafaxine (Pristiq) - 50-100mg/d
• Duloxetine (Cymbalta) - 60mg/d (start at 40mg given as 20mg 2X day)
• Levomilnacipran (Fetzima) - 40-120mg/d- start at 20mg then increase to 40mg after 2 days. Can further increase in increments of 40mg every 2⁺ days.

Multimodals

• Vortioxetine (Trintellix) - 10-20mg (start at 10 and increase)
• Vilazodon (Viibryd) - 20-40mg/d tritrate from 10mg.

Others

• Mirtazapine (Remerone) - 15-45mg/d - start at 15mg and increase by 15 every 1-2 weeks
• Bupropion (Wellbutrin) - 150-300mg/d - start at 100mg 2X day. Titrate after 3⁺ days to 100mg X3 day if needed.

Question 19

Antidepressant Selection based on symptoms

Answer 19

• Cognitive Dysfunction
  
  1. Vortioxetine (Trintellix)
  2. Bupropion (Wellbutrin), Duloxetine (cymbalta), SSRIs
• Sleep disturbance

2. *Trazodone (12.5 mg); Mirtazapine (sedating at lower doses), Quetiapine

• Somatic Symptoms
  
  1. Duloxteine (pain); Buproprion (fatigue); Levomilnacipran (fatigue).

Question 20

Well tolerated antidepressants for

1. Weight
2. Sex
3. Sleep

Answer 20

1. Buproprion (Wellbutrin); Vilazodon (Viibryd)
2. Buproprion, Mirtazapine, Vilazodone
3. Desvenlafaxin (Pristiq), Levomilnacipran (Fetzima), Mirtazapine, Vilazadone, Vortioxetine (trintellix)

Question 21

Switching or Adding an Adjunctive Medication

Answer 21

Consider if no response after 2-4 weeks

• Consider switching:
  
  • They’ve only tried one
  • 1^st antidepressant poorly tolerated
  • No response (<25%)
  • Non-urgent situations
  • Patient preference
• Consider Adjunctive
  
  • ≥ 2 antidepresant trial
  • Tolerability is not the issue
  • Partial response (>25%)
  • To target specific residual symptoms or side effects
  • Urgent situations
  • Patient preference

Question 22

Adjunctive Strategies for Depression

Answer 22

• Aripirazole - 2-15mg
• Quetiapine - 15-200mg
• Brexpiprazole - 1-3mg

Question 23

Fear Vs. Anxiety Vs. Anxiety Disorder

Answer 23

• Fear - emotional response to real or perceived imminent threat. More often associated with durges of automonic arousal (fight or flight)
• Anxiety - anticipation of future threat. More often associated with muscle tension, vigilance, and avoidance behaviours.
• Anxiety Disorder - differs from normal fear or anxiety by being excessive

Question 24

Types of Anxiety Disorder

Answer 24

• Separation Anxiety Disorder
• Selectve Mutism
• Specific Phobia
• Social Anxiety Disorder/ social phobia
• Panic Disorder
• Agoraphabia
• Generalized anxiety disorder
• Substance/medication induced
• Anxiety disorder due to another meidcal condition
• Other specified anxiety disorder
• Unspeicified anxiety disorder

Question 25

Seperation Anxiety Disorder

Answer 25

* Developmentally inappropriate and excessive fear/anxiety about being separated from attachment figures. Evidenced by at least 3 of: * Distress when anticipating or experiencing separation * Persistent worry about losing major attachment figure * Persisent worry about experiencing an event that will cause separation * Persistnt reluctance to go out for fear of separation * Persistent fear at being along without attachment figure * Persistent reluctance to sleep away from home or go to sleep without being with attachment figure * Repeated nightmares involving themes of separtion * Repeated complaints of physical symptoms when separated or having anticipated separation * Symptoms must last ≥ 4 weeks in children and ≥ 6 months in adults * Causes clinically significant distress or impairment * Not better explained by another disorder

Question 26

Selective Mutism

Answer 26

* Consistent failure to speak in social situations when it is expected, despite speaking in other situations. * Impaires functions - education, job, social life * ≥ 1 month * Not due to lack of knowledge of language * Not better explained by other disorder

Question 27

Social anxiety Disorder/ Social Phobia

Answer 27

* Significant fear and anxiety surroudning one or more social situation where the individual is exposured to possible scrutinty * Fear of acting in a way that shows anxiety symptoms that will be negatively evaluated * Social situations almost always cause anxiety * Anxiety is out of proportion to situation * ≥ 6 months * Causes significant distress or impairment in functioning * Not due to a substance or other medical condition * Not better explained by another mental disorder * If another medical condition is present, anxiety is unrelated or excessive

Question 28

Panic Disorder

Answer 28

* Recurrent (more than 1) unexpected panic attacks - abrupt surge of intense fear or intense discomfort that reaches peak within minutes and during which time 4⁺ of the following occur: * Palpittions, pounding hear, or accelerated heart rate * Sweating * Trembling or shaking * Sensations of SOB or smothering * Feelings of choking * Chest pain or discomfirt * Nausea or abdominal distress * Feeling, dizzy, unsteady, light-headed, or faint * Chills or heat sensations * Paresthesias * Derealization or depersonalization * Fear of losing control or going crazy * Fear or dying * At least 1 attack has been followed by 1 month (or more) of both of the following: * Persistent concern or worry about addition panic attacks or their consequences * A significant maladaptive change in behaviour related to the attacks * Not due to substances or another medical condition * Not better explained by another mental condition

Question 29

Panic Attack Specifier

Answer 29

* Panic attack is NOT a mental disorder. However, they can occur in the context of anxiety and other mental health disorder. When presence of panic attack is noted, it should be as a specifier. * Indicated by abrupt surge of intense fear or intense discomfort that reaches peak within minutes, during which 4⁺ of the panic symptoms occur. * Expected panic attack - obvious cue or trigger * Unexpected panic attack - no obvious cue or trigger

Question 30

Agoraphobia

Answer 30

* Significant fear or anxiety about 2 or more of the following: * using public transport * being in open spaces * being in enclosed places * standing in line or being in a crowd * being outside of the home alone * Patient fears above because of thoughts that **escape may be difficult or help might not be available in event of panic** * Agoraphobic situations almost always cause anxiety * Agoraphobic situations are actively avoided, require companion, or are endured with intense anxiety * Fear is out of proportion to situation * ≥ 6 months * Causes significant distress or functional impairments * If another medical condition is present, the anxiety is excessive * Not better explained by other condition * \* Patient can have dianosis of both panic disorder and agoraphobia

Question 31

Generalized Anxiety Disorder

Answer 31

* Excessive anxiety and worry about a number of events and acitivities for ≥6months * Individual finds it hard to control worry * Anxiety and worry is associated with 3 or more of the following (only 1 in children) * Restlessness or feeling keyed up * Being easily fatigued * Difficulty concentrting or mind going blank * Irritability * Muscle tension * Sleep disturbance * Causes significant distress or impairment * Not due to substance or other medical condition * Not better explained by another mental condition

Question 32

Panic Disorder and Agoraphobia Treatment

Answer 32

* CBT with exposure. Either alone or with pharmacotherpy * First line - Esctialopram (cipralex), Fluoxetine (prozac), fluoxamine (Luvox), Sertraline (zoloft), venlafxin (effexor)

Question 33

Treatment GAD

Answer 33

* CBT or pharm. No current evidence to support routine combination of CBT and pharm. However, if patients don't benefit or have a limited response to CBT a trial of pharamcotherapy is advisable. * Pharmacological treatment: * First line: Duloxetine (cymbalata), Escitalopram (cipralex), Pregablalin (lyrica), Sertraline (zoloft), venlataxine (effexor) * Adjunctive: * 2: Pregabaline * 3: Aripiprazole, quetiapine risperidone