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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
Depression following TBI
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
26
Menopause tx?
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
27
Cardiovascular illness and MDD
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
28
MDD Prognosis
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
29
Symptoms that respond well to Rx?
Mood Suicidal ideations Psychomotor retardation
30
Symptoms that tend to persist?
``` INSOMNIA Fatigue Somatic Anhedonia Concentration ```
31
HAM-D
Remission = 7 Out of 17 points Mainly neurovegetative and somatic symptoms
32
MADRS
Remission = < 10-12 Mainly psychological symptoms To monitor evolution Sensitive to changes with Rx
33
STAR*D
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
Psychotherapy tx in MDD
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
Pharmacotherapy tx in MDD
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
When would monotherapy with stimulant be recommended in MDD?
In mildly depressed patient with physical illnesses
37
Suicidality and SSRIs warning
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
Pharmacotherapy in MDD with co-morbid alcohol use disorder?
1st line = MIRTAZAPINE, NALTREXONE, NALTREXONE + SERTRALINE 2nd line = Antabuse adjunct 3rd line = Cipralex, TCAs, Epival, Memantine
39
Pharmacotherapy in MDD with co-morbid ADHD?
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
Which SSRI inhibits dopamine recapture?
SERTRALINE (increases dopamine)
41
Which SSRI is least linked to proteins?
CIPRALEX
42
Which SSRIs are most linked to proteins?
PAXIL PROZAC SERTRALINE
43
At what does do we get NE effects from Effexor?
>150mg
44
Noradrenergic and specific serotinergic (NASSA)
MIRTAZAPINE - Alpha 2 antagonist - 5HT 2a (sexual side effects), 2c (weight), 3 (nausea) antagonist NO EFFECT OF SEROTONIN REUPTAKE Risk of AGRANULOCYTOSIS
45
MAO enzymes?
MAO-A: metabolizes serotonin, norepinephrine, epinephrine MAO-B: metabolizes dopamine and tyramine
46
MAOI frequent side effects?
``` Orthostatic hypotension Weight gain Edema Insomnia Sexual dysfunction ``` NO ANEMIA NO ICTERIA
47
Moclobemide
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
Selegiline
MAO-B inhibitor (so increases dopamine) | Parkinson's treatment
49
TCAs
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
Wellbutrin
Inhibits reuptake of NOREPINEPHRINE + DOPAMINE
51
Trazodone
SARI Serotonin antagonist and reuptake inhibitor Priapism Hepatotoxicity Orthostatic hypotension
52
Buspirone
5HT1A pre-synaptic AGONIST | 5HT1A post-synaptic partial agonist
53
Cipriani study
Efficacy: Mirtazapine > Cipralex > Effexor > Sertraline > Celexa > ... Tolerability Cipralex > Sertraline > Wellbutrin > Celexa > Prozac > ...
54
Sexual dysfunction with SSRIs
50-80% with SSRI, tends to persist with Rx tx Worst with Sertraline, Paxil, Prozac, Luvox Better with Wellbutrin and Mirtazapine, Moclobemide
55
SSRIs and pregnancy?
Celexa Cipralex Sertraline Risk of withdrawal in 15-30% of babies But not dangerous and resolves spontaneously in 2-14 days
56
SSRIs and breastfeeding?
Celexa Cipralex Sertraline
57
rTMS
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
Deep brain stimulation
SUBCALLOSAL GYRUS
59
Surgical for MDD?
Anterior cingulectomy Sub-caudal tractotomy 34-62% response
60
Luminotherapy
1st line mono therapy if seasonal 2nd line mono/adjunct if mild-moderate MDD 10 000 lux 30 minutes daily x 6 weeks
61
Exercise
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
Yoga
2nd line adjunct mild-moderate MDD
63
Acupuncture
3rd line adjunct mild-moderate MDD
64
Millepertuis
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
Omega-3
2nd line mono/adjunct in mild-moderate MDD 2nd line adjunct in moderate-severe MDD Can INCREASE COUMADIN levels
66
SAM-e
2nd line adjunct all MDDs Risk of serotonin syndrome Can induce mania
67
DHEA/Acetyl-L-carnitine/Crocus Sativus/L-methylfolate/Lavender
3rd line monotherapy/adjunct in mild-moderate MDD
68
What alternative/complementary medicine not recommended?
Tryptophan | Inositol
69
ECT recommendations
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
ECT contraindications
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
ECT efficacy
70-80% response 40-50% remission Superior to Rx acutely Equal to Rx in maintenance Aim for seizure length of 20-25 seconds
72
ECT parameters
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
ECT side effects
``` 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
ECT stimulus threshold
1/2 of age Increases with treatment by 25-200% Good response: - post-ictal suppression - ictal amplitude
75
Child and adolescent depression
Relapse 20-60% @ 2 yrs, 70% @ 5 yrs | Conversion 20-40% to BAD (compared to 5-10% in adults)
76
Geriatric depression
1st line = Cymbalta, Mirtazapine, Nortriptylline
77
Suicide
DEMENTIA DOES NOT INCREASE THE RISK Most common psychiatric diagnoses: - mood disorder - schizophrenia - substance use disorder
78
Pseudocholinesterase deficiency
CAUTION ECT | Succinulcholine is acetylcholine receptor blower so this interferes = apnea; use non-depolarizing anesthetic instead
79
Maintenance Rx after ECT?
Lithium + nortriptyline
80
ECT for which symptoms in Parkinson's?
BOTH MOTOR AND MOOD
81
CORE study?
Antidepressant failure does NOT predict lower ECT response rates. Lithium + nortriptyline in ECT-responsive patients
82
Most specific and sensitive sleep change in MDD?
INCREASED REM DENSITY

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