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RC Nuggets > Depression/Antidepressants > Flashcards

Depression/Antidepressants Flashcards

1
Q

Which ADs don’t give SIADH?

A

Mirtazapine

Bupropion

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2
Q

Neurobiology MDD

A 
Decreased hippocampus volume
Increased activity HPA axis (no suppression of cortisol with dexamethasone test)
Decreased somatostatin in CSF
Short allele 5HTT transporter
NO PROLACTIN CHANGES
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3
Q

Sleep changes in MDD

A

DECREASED SLOW WAVE SLEEP
DECREASED REM LATENCY (get to REM sleep quicker)
INCREASED TOTAL REM TIME + DENSITY
INCREASED REM IN FIRST PART OF NIGHT

Serotonin anti-REM so most antidepressants suppress REM sleep

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4
Q

Most common presenting symptom of MDD?

A

Insomnia

Fatigue

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5
Q

MDD epidemiology?

A

Prevalence 7%
1.5-3 F : 1 M
Heritability 40%
RR 2-3 with first degree relative

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6
Q

Timing for remission specifier of MDD?

A

2 months partial vs. complete

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7
Q

MDD specifiers?

A

With anxious distress (2)

Mixed characteristics (3) RISK FACTOR FOR DEVELOPING BAD

Melancholia (Anhedonia + 3)

Atypical (Mood reactivity + 2)

Psychosis (mood congruent vs. incongruent)

Catatonia (3)

Peripartum characteristics (up to 4 weeks PP)

Seasonal characteristics (2 episodes in last 2 years and no non-seasonal episodes…can happen in lifetime but outnumbered by seasonal ones)

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8
Q

Persistent depressive disorder criteria?

A

Depressed mood for most of the day for more days than not x 2 years
(ONE YEAR IN CAP)

Never without symptoms for more than 2 MONTHS

At least TWO
Appetite change
Sleep change
Low energy
Low self-esteem
Low concentration
Hopelessness
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9
Q

Persistent depressive disorder specifiers?

A

Early vs. late onset based on 21 YEARS OLD
Pure dysthymic syndrome (if no MDD in 2 years)
With persistent or intermittent MDD episodes

Same others as MDD including peripartum!
Except SEASONAL

MORE PSYCHIATRIC CO-MORBIDITIES THAN MDD

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10
Q

Persistent depressive disorder conversion rates?

A

TO MDD = 20%
TO BAD 2 = 15%
TO BAD 1 = < 5%

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11
Q

Which disorders cannot be diagnosed with DMDD?

A

ODD
IED
BAD

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12
Q

What disorders typically developed by kids with DMDD?

A

MDD and anxiety

NOT BAD

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13
Q

DMDD criteria?

A

Temper outbursts at least 3 TIMES PER WEEK for AT LEAST 12 MONTHS and never without symptoms for more than 3 MONTHS
In 2-3 settings and SEVERE in at least 1
Criteria for hypomania/mania never for more than 1 day

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14
Q

Difference between DMDD and IED?

A

Need only 3 months for IED
vs.
Need 12 months for DMDD

Irritability usually doesn’t persist in between outbursts in IED

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15
Q

Premenstrual dysphoric disorder criteria?

A

In the majority of menstrual cycles in the past year
At least FIVE symptoms with particular pattern of onset and disappearance.

PROVISIONAL DIAGNOSIS UNTIL GET DAILY RATINGS WHICH CONFIRM IN AT LEAST 2 SYMPTOMATIC CYCLES

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16
Q

Premenstrual dysphoric disorder treatment?

A

Mild to moderate = non-pharmaco
Moderate to severe =
1st line = SSRI during LUTEAL phase or continuous
2nd line = clomipramine, Xanax
3rd line = OCP
4th line = surgical or chemical menopause (GnRH agonist)

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17
Q

First neuropsychiatric symptom of Huntington’s?

A

Depression

Precedes motor and cognitive impairments

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18
Q

Atypical MDD

A

Mood reactivity + 2

  • Increased weight
  • Hypersomnia
  • Leaden paralysis
  • Pattern of interpersonal rejection

Also known as HYSTEROID DYSPHORIA
RESPOND BETTER TO MAOI & SSRI

Starts earlier, psychomotor slowing more severe
Panic/substance/somatization co-morbidities

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19
Q

Peripartum MDD

A

3-6%
50% start DURING pregnancy
Up to 4 weeks post-partum

With psychotic features most common in

  • primiparous
  • prior post-partum mood episode
  • history of mood d/o (especially BAD1)
  • family history of BAD

R/o post-partum delirium

Risk of recurrence 30-50%

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20
Q

Seasonal pattern MDD

A

In last 2 years = 2 seasonal episode and NO non-seasonal ones

Non-seasonal episodes can happen in lifetime but do not outnumber the seasonal ones

Higher in BAD2

Winter type associated with younger people and higher altitude

Treat with light therapy (65% remission)
Wellbutrin 1st line
Prozac/Moclobemide 2nd line

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21
Q

State effect?

A

Decreased ability to register pleasure when depressed

Amygdala HYPOACTIVITY during positive memory recall

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22
Q

Trait effect?

A

Keep overacting to negativity even when recovered

Amygdala HYPERACTIVITY during negative memory recall

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23
Q

Suspect BAD when depressed if?

A 
Atypical sx
< 21 yo
> 5 episodes
Psychotic in < 25 yo
Loss of response to antidepressants
Hypomania due to Rx
Post-partum 
Substance use disorder
Mixte symptoms
Rapid onset and remission (3 MONTHS)
Psychomotor retardation
Seasonal pattern
Mood lability
Hyperthymic temperament
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24
Q

Most frequent physical co-morbidity with MDD?

A

COPD

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25
Q

Depression following TBI

A

50% MDD
NOT LINKED TO SEVERITY

Linked to accumulated TBIs, age, SUD, personal and family history of psychiatric d/o, post-TBI amnesia, stressors, epilepsy post-TBI

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26
Q

Menopause tx?

A

1st line = PRISTIQ, CBT
2nd line = transdermal estradiol > Celexa, etc.
3rd line = mindfulness, supportive therapy

HOT FLASHES AND NIGHT SWEATS are risk factors for perimenopausal depression

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27
Q

Cardiovascular illness and MDD

A

20% cardiovascular patients have mood disorder
2F > 1M

Post-MI: RR 3-6 of mortality in 6-12 months if MDD co-morbid

NO association between beta-blockers and depression

Risk of MI if have depression is RR 4-5

Most predictive of white matter lesion (late-onset MDD) = HYPERTENSION

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28
Q

MDD Prognosis

A

33% don’t remit
50% remit at 3 months with treatment

30-50% relapse at 2 years
50-75% relapse at 5 years

5-10% switch to mania (average 32yo, after 2-4 depressive episodes)

6-13 month episodes if no Rx
3 month episodes if treated

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29
Q

Symptoms that respond well to Rx?

A

Mood
Suicidal ideations
Psychomotor retardation

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30
Q

Symptoms that tend to persist?

A 
INSOMNIA
Fatigue
Somatic
Anhedonia
Concentration
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31
Q

HAM-D

A

Remission = 7
Out of 17 points

Mainly neurovegetative and somatic symptoms

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32
Q

MADRS

A

Remission = < 10-12

Mainly psychological symptoms
To monitor evolution
Sensitive to changes with Rx

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33
Q

STAR*D

A

33% response at 6 weeks with Celexa
Predicted response at 14 weeks
Therefore 66% don’t achieve remission with first AD trial

Cumulative remission rate of 67% in trial

Minimum trial 6 weeks, optimal 8-10 weeks
Augment after 14 weeks

Choosing Rx based on symptoms not needed

34
Q

Psychotherapy tx in MDD

A

Acute: COMBO > CBT = Rx
Maintenance: CBT = Rx (but less relapse with CBT)

Increased efficacy with increased FREQUENCY of sessions rather than increased total number of sessions (same result for 8 than 16)

INDIVIDUAL > group
CBT efficacious in resistant MDD

Acute
1st line = CBT, IPT, behavioural activation

Maintenance
1st line = CBT, mindfulness (adjuvant to Rx)

35
Q

Pharmacotherapy tx in MDD

A

Superiority: Cipralex, Effexor XR, Mirtazapine, Sertraline

Trazodone and TCAs second line because of tolerability
Moclobemide (reversible MAOI) second line but other MAOIs third line because of tolerability and diet necessary

Adjunct:
1st line = Abilify, Seroquel, Risperdal
2nd line = Wellbutrin, Mirtazapine, Lithium (target 0.5-1), Modafinil, Olanzapine, T3

36
Q

When would monotherapy with stimulant be recommended in MDD?

A

In mildly depressed patient with physical illnesses

37
Q

Suicidality and SSRIs warning

A

RR 1.5-2 increased suicidality in 14-18 yo (warning extended to include up to 24 yo)

Highest with Paxil and Effexor

Protective in > 24 yo

YOUNG ADULTS MORE LIKELY TO RESPOND TO SEROTONIN than noradrenaline

38
Q

Pharmacotherapy in MDD with co-morbid alcohol use disorder?

A

1st line = MIRTAZAPINE, NALTREXONE, NALTREXONE + SERTRALINE

2nd line = Antabuse adjunct

3rd line = Cipralex, TCAs, Epival, Memantine

39
Q

Pharmacotherapy in MDD with co-morbid ADHD?

A

1st line = WELLBUTRIN, ANTIDEPRESSANT + LONG-ACTING STIMULANT, ANTIDEPRESSANT + CBT

2nd line = TCAs, Effexor

3rd line = antidepressant + Strattera, antidepressant + short-acting stimulant

IF NOT IN ACUTE DEPRESSIVE EPISODE, USE FIRST LINE TREATMENTS FOR ADHD (regardless of whether maintenance treatment for MDD or not)

40
Q

Which SSRI inhibits dopamine recapture?

A

SERTRALINE (increases dopamine)

41
Q

Which SSRI is least linked to proteins?

A

CIPRALEX

42
Q

Which SSRIs are most linked to proteins?

A

PAXIL
PROZAC
SERTRALINE

43
Q

At what does do we get NE effects from Effexor?

A

> 150mg

44
Q

Noradrenergic and specific serotinergic (NASSA)

A

MIRTAZAPINE

  • Alpha 2 antagonist
  • 5HT 2a (sexual side effects), 2c (weight), 3 (nausea) antagonist
    NO EFFECT OF SEROTONIN REUPTAKE

Risk of AGRANULOCYTOSIS

45
Q

MAO enzymes?

A

MAO-A: metabolizes serotonin, norepinephrine, epinephrine

MAO-B: metabolizes dopamine and tyramine

46
Q

MAOI frequent side effects?

A 
Orthostatic hypotension
Weight gain
Edema
Insomnia
Sexual dysfunction

NO ANEMIA
NO ICTERIA

47
Q

Moclobemide

A

Reversible MAO-A inhibitor (return to normal activity 24-48H after last dose)

(but at doses higher than 600mg/d can block MAO-B as well and therefore needs tyramine-free diet)

48
Q

Selegiline

A

MAO-B inhibitor (so increases dopamine)

Parkinson’s treatment

49
Q

TCAs

A

2ry = desipramine (most specific noradrenergic), nortriptyline (only one with a therapeutic window)

3ry = clomipramine (most serotonergic), doxepin (most histaminic), amitriptyline (can be used for sialorrhea), imipramine (can be used for enuresis)

MEN respond better than woman overall

Contraindications

  • QTc > 450ms
  • Seizure risk
  • Closed angle glaucoma

Compared with SSRIs:

  • less sexual side effects
  • less weight gain
  • less sleep disturbance
50
Q

Wellbutrin

A

Inhibits reuptake of NOREPINEPHRINE + DOPAMINE

51
Q

Trazodone

A

SARI
Serotonin antagonist and reuptake inhibitor

Priapism
Hepatotoxicity
Orthostatic hypotension

52
Q

Buspirone

A

5HT1A pre-synaptic AGONIST

5HT1A post-synaptic partial agonist

53
Q

Cipriani study

A

Efficacy:
Mirtazapine > Cipralex > Effexor > Sertraline > Celexa > …

Tolerability
Cipralex > Sertraline > Wellbutrin > Celexa > Prozac > …

54
Q

Sexual dysfunction with SSRIs

A

50-80% with SSRI, tends to persist with Rx tx
Worst with Sertraline, Paxil, Prozac, Luvox
Better with Wellbutrin and Mirtazapine, Moclobemide

55
Q

SSRIs and pregnancy?

A

Celexa
Cipralex
Sertraline

Risk of withdrawal in 15-30% of babies
But not dangerous and resolves spontaneously in 2-14 days

56
Q

SSRIs and breastfeeding?

A

Celexa
Cipralex
Sertraline

57
Q

rTMS

A

1st line if don’t respond to AT LEAST ONE antidepressant
3rd line in maintenance

Target = DLPFC
1-4cm deep
Stimulate 2-10 seconds at 10-60 second intervals for 15-45 minutes

5x / week for up to 20-30 sessions

25% response
17% remit
Same cost as ECT but less efficacious

Need to use ear plugs (LOUD)

Contraindication: METAL IN HEAD (except in mouth), pacemaker, epilepsy, cerebral lesion

58
Q

Deep brain stimulation

A

SUBCALLOSAL GYRUS

59
Q

Surgical for MDD?

A

Anterior cingulectomy
Sub-caudal tractotomy

34-62% response

60
Q

Luminotherapy

A

1st line mono therapy if seasonal
2nd line mono/adjunct if mild-moderate MDD

10 000 lux 30 minutes daily x 6 weeks

61
Q

Exercise

A

1st line mono therapy in mild-moderate MDD
2nd line adjunct in moderate-severe MDD

30 minutes 3x/week moderate intensity x 9 weeks
Aerobic = anaerobic

62
Q

Yoga

A

2nd line adjunct mild-moderate MDD

63
Q

Acupuncture

A

3rd line adjunct mild-moderate MDD

64
Q

Millepertuis

A

1st line mono therapy in mild-moderate MDD
2nd line adjunct in moderate-severe MDD

Contains HYPERICINE and HYPERFORINE

REUPTAKE INHIBITOR OF SEROTONIN, DOPAMINE AND NOREPINEPHRINE

Main side effect = SKIN PHOTOSENSITIVITY
Reduced OCP EFFECTIVENESS

65
Q

Omega-3

A

2nd line mono/adjunct in mild-moderate MDD
2nd line adjunct in moderate-severe MDD

Can INCREASE COUMADIN levels

66
Q

SAM-e

A

2nd line adjunct all MDDs
Risk of serotonin syndrome
Can induce mania

67
Q

DHEA/Acetyl-L-carnitine/Crocus Sativus/L-methylfolate/Lavender

A

3rd line monotherapy/adjunct in mild-moderate MDD

68
Q

What alternative/complementary medicine not recommended?

A

Tryptophan

Inositol

69
Q

ECT recommendations

A

1st line in acute SI, psychotic depression and resistant depression (level 1)

1st line in catatonia, past response to ECT, intolerance to medication, PREGNANCY and physical deterioration (level 3)

1st line in patient preference (level 4)

70
Q

ECT contraindications

A

NO ABSOLUTE

Relative

  • recent MI or CVA
  • dental problems
  • irreversible MAOI (need to stop x 2 weeks)
  • clozapine (prolonged seizures)
  • increased ICP
  • cerebral bleeding
  • retinal detachment
71
Q

ECT efficacy

A

70-80% response
40-50% remission

Superior to Rx acutely
Equal to Rx in maintenance

Aim for seizure length of 20-25 seconds

72
Q

ECT parameters

A

1st line = BIFRONTAL
RIGHT UNILATERAL BRIEF

2nd line = bitemporal (gold standard but many side effects), ultra brief (less side effects but SLOWER improvement)

Bilateral = 1.5 - 2x seizure threshold
RUL = 5-8x seizure threshold

SINUSOIDAL = memory problems

73
Q

ECT side effects

A 
HEADACHE (most common)
Nausea
Muscular pain
Dental lesions
Mania (IN 10-30% BAD PATIENTS)
Delirium
Amnesia (BENZOS, LITHIUM, CLOZAPINE)
Increased prolactin
Hypertension, tachycardia, ST changes 24-H post-ECT

HYPERVENTILATION does not influence cognitive troubles

Mortality 0.01% for each patient
Same risk as general anesthesia and delivery
LESS mortality than with antidepressants

74
Q

ECT stimulus threshold

A

1/2 of age
Increases with treatment by 25-200%

Good response:

  • post-ictal suppression
  • ictal amplitude
75
Q

Child and adolescent depression

A

Relapse 20-60% @ 2 yrs, 70% @ 5 yrs

Conversion 20-40% to BAD (compared to 5-10% in adults)

76
Q

Geriatric depression

A

1st line = Cymbalta, Mirtazapine, Nortriptylline

77
Q

Suicide

A

DEMENTIA DOES NOT INCREASE THE RISK

Most common psychiatric diagnoses:

  • mood disorder
  • schizophrenia
  • substance use disorder
78
Q

Pseudocholinesterase deficiency

A

CAUTION ECT

Succinulcholine is acetylcholine receptor blower so this interferes = apnea; use non-depolarizing anesthetic instead

79
Q

Maintenance Rx after ECT?

A

Lithium + nortriptyline

80
Q

ECT for which symptoms in Parkinson’s?

A

BOTH MOTOR AND MOOD

81
Q

CORE study?

A

Antidepressant failure does NOT predict lower ECT response rates.

Lithium + nortriptyline in ECT-responsive patients

82
Q

Most specific and sensitive sleep change in MDD?

A

INCREASED REM DENSITY

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