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Psychiatry > Depression and Treatment > Flashcards

Depression and Treatment Flashcards

1
Q

List the risk factors for major depressive disorder

A
  • Past or family history
  • chronic medical condition
  • substance use
  • psychosocial adversity
  • high users of the medical system with many somatic complaints
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2
Q

List the good and poor prognostic features of depression

A
  • 40% recover within 3 months and 80% recovery within 1 year
  • those with 1 episode have 50% risk of relapse and those with two have 75%
    Good
  • recent onset
  • short duration of depression
    Poor
  • chronic or severe depression
  • psychotic features
  • melancholic features
  • anxiety
  • personality disorder
  • young age
  • multiple episodes
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3
Q

List the MSIGECAPS diagnostic criteria

A

M: Mood that is depressed everyday or nearly every day
S: Sleep is increased or decreased
I: Interest is lost or loss in pleasure in almost all activities
G: Guilt/Worthlessness feelings everyday
E: Energy is lost or severely decreased
C: Concentration is decreased
A: Appetite is increased or decreased
P: Psychomotor retardation or agitation
S: Suicide recurrent thoughts of death with or without plan

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4
Q

List the diagnostic criteria for a major depressive episode

A
  • > =5 of the MSIGECAPS symptoms for at least two weeks where mood or interest must be included
  • symptoms must cause distress and impair functioning
  • not due to substances or medical condition
  • not another psychotic disorder
  • no manic or hypomanic episode
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5
Q

List the specifiers for major depressive disorder

A
  • mixed features when 3 manic or hypomanic symptoms are present
  • anxious distress
  • melancholic features when have loss of pleasure and at least 3 of (PAGE MD):
    • psychomotor agitation or retardation
    • anorexia
    • guilt
    • early morning awakenings
    • morning worsening of depression
    • different quality of depressed mood
  • atypical features when have reactive mood and 2 of the following (WILL):
    • weight gain
    • increased sleep
    • leaden paralysis
    • longstanding pattern of intepersonal rejection
  • with psychotic features
  • with catatonia when have greater than 2 of the following (SPENT):
    • stupor/motor immobility
    • peculiar voluntary movements
    • echolalia
    • negativism
    • too much motor activity
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6
Q

List the investigations for major depressive disorder

A
  • CBC for anemia or infection
  • electrolytes
  • Metabolic work up (Ca, Glucose, B12)
  • kidney function
  • liver function
  • TSH
  • albumin
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7
Q

List common medical conditions and substances that can cause depression

A 
Medical conditions
- stroke
- Parkinsons
- hypothyroidism
- cancer
- anemia
- coronary artery disease
- HIV
- SLE
- OSA
Substances
- alcohol
- sedativ
- opioid
- steroids
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8
Q

List the diagnostic criteria for persistent depressive disorder (dysthymia)

A 
>=2 years of depressed mood for most days with >=2 of the following (ACHEWS)
- appetite change
- concentration decreased
- hopelessness
- energy decreased
- worthlessness
- sleep change
Not symptom free for >2 months
No manic or hypomanic episode
Not other psychotic disorder or susbtance
Cause distress and impair function
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9
Q

List the diagnostic criteria for premenstrual dysphoric dirsorder

A

Cyclical pattern of depressed mood coinciding with menstrual cycle

  • Present in majority of cycles with >=5 symptoms
    • Group 1: affective liability, irritability, depressed mood, anxiety
    • Group 2: Sleep, interest, energy, concentration, appetite, physical symptoms
    • must have 1 symptoms from group 1 and group 2
  • symptom onset week prior to menses and subside few days after menses
  • symptoms cause distress and impair functioning
  • confirmed by prospective daily rating of at least 2 symptomatic cycles
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10
Q

Discuss the pathophysiology of depression

A

Have insufficient mono-amine neurotransmitter resulting in upregulation of neurotransmitter receptors -> decreased gene expression and abnormal mood state

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11
Q

List the function of each of the primary neurotransmitters have on symptoms of depression

A 
Psychomotor activity
- serotonin
- norepinephrine
- dopamine
Mood
- serotonin
- norepinephrine
- dopamine
Sleep
- serotonin
- norepinephrine
- dopamine
Appetite and Weight
- serotonin
Guilt and Worthlessness
- serotonin
Suicide
- Serotonin
Interest
- Norepinephrine
- dopamine
Energy
- Norepinephrine
- dopamine
Executive function
- norepinephrine
- dopamine
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12
Q

List the mechanism of action of SSRI and a few examples

A 
- act at dendrite synapses of the pre-synaptic neuronto increase serotonin in the synapse
Examples
- paroxetine (paxil)
- fluoxetine (prozac)
- citalopram (celexa)
- sertraline (zoloft)
- cipralex (escitalopram)
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13
Q

List the side effects of SSRIs

A 
- transient increase risk of suicide that decreases after few weeks
Common (HANDS)
- headache
- anxiety and agitation
- nausea
- diarrhea
- sexual dysfunction and sleep disruption 
Rare
- upper GI bleed, especially when used with NSAID
- Syndrome of inappropriate ADH release
- Osteoporosis 
- Serotonin syndrome
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14
Q

List the features of SSRI discontinuation syndrome

A
  • Occur 3 days after discontinuation
  • Greatest risk with paxil and effexor
    FINISH
  • flu-like symptoms
  • insomnia
  • nausea
  • imbalance
  • sensory disturbance
  • hyperarousal
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15
Q

List the contraindications to starting a SSRI

A
  • use of a MAO inhibitor, triptan or other serotonergic drug due to risk of serotonin syndrome
  • pregnancy
  • bipolar
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16
Q

Discuss the mechanism of action of NDRI and provide an example

A
  • norepinephrine and dopamine are prevented from reuptake at pre-synaptic neuron
    Example
  • Bupropion (wellbutrin)
17
Q

List the side effects of NDRI

A

SHAARES

  • seizures (cannot use with bulimia or electrolyte disturbance)
  • headaches, hypertension
  • Agitation
  • Anticholinergic symptoms
    - flushing
    - dry mouth
    - blurred vision
    - delirium
    - hyperthermia
    - urinary retention and constipation
  • rash
  • emesis
  • sleep disruption
18
Q

Discuss the mechanism of action and provide examples of SNRI

A
  • blockade of serotonin at lower doses
  • blockade of serotonin and norepinephrine at mid doses
  • blockade of serotonin, norepinephrine and dopamine at high doses
    Examples
  • Venlafaxine (effexor)
  • Duloxetine (cymbalta)
19
Q

Discuss the mechanism of action and provide examples of NaSSA (noradrenergic and specific serotonergic antidepressants)

A
  • block alpha 2 auto receptor on norepinephrine receptor and heteroreceptor on 5HT neurons increasing release of norepinephrine and serotonin
  • also block 5HT2 so not sleep or sexual side effects, 5HT3 so no GI side effects and H1 histamine receptor leading to sedation and weight gain
    Example
  • Mirtazepine (remeron)
20
Q

List the side effects of NaSSA

A 
Common (WADE)
- weight gain
- anticholinergic effects
- drowsiness
- equilibrium problem
Rare
- neutropenia
- serotonin syndrome
- hepatoxicity 
- SIADH
21
Q

Discuss the mechanism of action and provide examples of SARI (Serotonin 2A antagonist reuptake inhibitor)

A
  • weak serotonin reuptake inhibitor
  • block 5HT2A so no sleep disruption or sexual dysfunction
  • block H1 histamine so sedating
  • block alpha 1 so orthostatic hypotension
    Example
  • trazodone (desyrel)
22
Q

List the side effects of SARI

A
  • headache
  • sedation
  • orthostatic hypotension
  • vivid dreams
  • dry mouth
  • priapism
  • serotonin syndrome
23
Q

Discuss the mechanism of action and provide examples of TCA

A
  • block all three monoamine reuptake
  • block 5HT2 so no sex or sleep side effects
  • block H1 histamine, muscarinic, alpha 1 adrenergic, and sodium channels in heart and brain
    Examples
  • amitriptyline
24
Q

List the side effects of TCAs

A 
Common
- weight gain
- sedation
- anticholinergic
- orthostatic hypotension
- prolonged QTc
Rare
- serotonin syndrome
- Torsade de Pointes
       - Before starting: ECG to rule out bradycardia or prolonged QTc, electrolyte imbalance, taking type 1 or 3 antiarrhythmic
- SIADH
25
Q

Discuss the mechanism of action and provide examples of MAOI (Monoamine oxidase inhibitor)

A
  • irreversible bind and inhibit MAO thereby increasing 5HT, NE and DA levels
  • irreversible inhibition last for 2 weeks
    Examples
  • moclobemide
26
Q

List the rare side effects of MAOI

A

3Hs

  • hyperthermia due to serotonin syndrome
  • Hypertensive crisis
  • Hepatotoxicity
  • Teratogenicity
  • Blood dyscrasia
27
Q

Discuss the features of serotonin syndrome

A

HARMED

  • hyperthermia
  • agitation and autonomic instability (tachy, diarrhea)
  • rigidity and reflexes increased
  • myoclonus
  • encephalopathy
  • diaphoresis
28
Q

List the indications for treatment in depression

A
  • medication indicated for mild to moderate if patient prefer over psychotherapy
  • medication required in moderate to severe with or without psychotherapy or ECT
  • psychotic depression require ECT or antidepressant and antipsychotic
29
Q

List the first line medications and how they are started

A 
First Line
- SSRI: escitalopram or sertraline
- SNRI: venlafaxine or duloxetine
- NaSSA: mirtazapine
Starting
- begin at lowest possible dose and increase weekly until: 
     - intolerable side effects
     - full response
     - maximum dose
- usually do not find subjective benefit until 4-6 weeks, objective benefit after 2 weeks
30
Q

List the starting and target doses for the common medications from each class

A 
SSRI
- Escitalopram 10mg/10-20mg
- Fluoxetine 20mg/20-80mg
- Sertraline 50mg/50-200mg
SNRI
- Venlafaxine 75mg/75-375mg
- Duloxetine 60mg/60-120mg
NDRI
- Buproprion 150mg/150-300mg
NaSSA: 
- Mirtazapine 30mg/30-60mg
MAOI/RIMA
- Moclobemide 300mg/300-600mg
SARI:
- Trazadone 150-200mg/150-300mg
TCA
- Nortriptyline 25mg/150-250mg
31
Q

Discuss response after assessing at 4 weeks following achievement of therapeutic dose

A

Remission
- maintain antidepressant for 1 year post-remission months
- if more severe depression may require continued therapy for 2 years
Little to No Improvement (<20% reduction in score)
- re-evaluate diagnosis
- switch to another antidepressant with evidence of superiority
- if no benefit with switch then add-on another agent
- or combine with atypical antipsychotic or lithium

32
Q

List the indications for ECT

A
  • severe major depressive disorder when lack of response to medication, intolerant to medication or require fast improvement
  • mania in bipolar
  • mixed state
  • catatonia
  • psychosis
33
Q

List the predictors of good outcome with ECT

A
  • older age
  • shorter duration of symptoms
  • unipolar depression
  • depression with psychotic features
  • adequate seizure of adequate duration
34
Q

Discuss the mechanism of action of ECT

A
  • use electricity to ellicit seizure that results in
    - neurotransmitter theory: ECT enhances action of monoamines
    - neuroendocrine theory: ECT releases prolactin, TSH, ACTH, endorphines, brain derived neurotrophic factor (BDNF) and BDNF-R in frontal cortex
    - neurogenesis: ECT increases neuroplasticity via BDNF increasing neuron connection and growth
    - anticonvulsant theory: ECT alters GABA
35
Q

List the investigations required before ECT

A
  • CBC, electrolytes
  • creatinine, BUN
  • liver function
  • drug levels
  • pregnancy
  • ECG
  • CXR
36
Q

Discuss the ECT procedure

A
  • Anesthesia to establish airway and provide bite block and induction
  • EEG to assess seizure quality
  • beta blocker (esmolol) to prevent tachycardia
  • Electrodes placed on patient along bilateral temporal temporal or bifrontal or right unilateral temporal (ranked in greatest effectiveness and increasing side effects)
  • Monitor EEG for recruitment (low amplitude, high frequency), tonic (high amplitude, high frequency, spike and poly-spike activity), clonic (high amplitude, spike and slow wave complexes) termination (slow wave amplitude and frequency) and post ictal silence
37
Q

Discuss the treatment regimen for ECT

A
  • provided for 8-12 sessions where receive ECT 2-3 times per week
  • have high relapse rate following conclusion so must continue with medication
38
Q

List the side effects of ECT

A 
Common
- headache
- nausea
- muscle pain
Severe
- cardiovascular: vagal stimulation leading to bradycardia/asystole, sympathetic discharge leading to tachycardia and hypertension or rebound parasympathetic effect causing secondary bradycardia
- prolonged seizure (>3 minutes)
- prolonged apnea
Cognitive
- amnesia which is transient and disappear within 6 months
- delirium post-ictal
39
Q

List the contraindications for ECT

A

Relative

  • brain disease (space occupying lesion, subdural hematoma, raised ICP)
  • cardiovascular disease (recent MI/stroke or aortic stenosis)
  • retinal detachement
  • pheochromocytoma

Psychiatry (15 decks)

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