Depression - Block 3 Flashcards
Describe the mechanism of seratonin and melatonin?
What does the monoamine hypothesis?
Serotonin: obsession and compulsions, ax
Dopamine: Attention, motivation, pleasure
NE: Ax, attention
What are the medications used for depression?
Serotonergic: SSRIs: Citalopram, Escitalopram, Sertraline, Paroxetine, Fluoxetine
Noradrenergic: TCA
Dopaminergic: Bupropion
Dual mech: Venlafaxine, Duloxetine, desvenlafaxine -SNRIs
* SSRIs + Bupropion
* Mirtazapine, trazadone, vilazodone, vortioxetine
What SSRI has the longest half-life?
Fluoxetine
What is the SSRI MOA?
Selectively blocking the reuptake of serotonin to increase the amount of serotonin in the synapse
What are causes of depression?
- Unknown
- ELevated stress levels (genetics)
- Decreased levels or activity of NE and/or serotnin/dopamine
What are the main diagnosistic for depression?
DSM5 and ICD10
How do you diagnose a patient with depression?
- Screen patient for hx and psychiattic history
- DSM5 for diagnosis
- Exclude other potential causes of symptoms
- Use clinician rating scale like PHQ-9/ HAM-D/ GDS to determine severity and to set baseline for monitoring purposes
What is PHQ9?
Screening tool and aids the diagnosis of depression severity as well as track improvements of sx
What are the common sx of depression?
Sleep disturbances
Interest or pleasure is decreased
Guilt or feeling worthless
Mood is low or depressed
ENergy loss or fatigue
Concnetration problems or problems with memory
Appetitie disturbance, weight loss or gain
Psychomotor agitation or retardation
Suicidal ideation, thoughd of death
What is mDD?
sx must affect QOL-cause clinically significant disturbances of social, occupational, functioning
Depression must have:
- Depressed mood a/o anhedonia
- Additional symptoms (must total at least 5 for > 2 weeks):
* Sleep disturbance
* Changes in appetite or weight
* Decreased energy
* Feelings of guilt or worthlessness
* Psychomotor agitation or retardation
* Decreased concentration
* +/- Suicidal ideation
What disease states can be mistaken for depression?
- CNS disease
- Endocrine disorders
- Drug-related conditions
- SLeep-related disorders
- Bipoal
- Schizo
- Bereavement
What are the drugs that worsen depression?
A: Alcohol, amphetamines, ADHD med (withdrawal-likemethylphenidate,amoxeine)
B: BDZ, Barbiturates, B-Blockers(lipid soluble- propranolol)
C: CNS depressants, cocaine
How do you assess for deferential diagnosis?
- Patient hx ask about:
* Stressful events
* Consumption of illicit drugs, alcohol abuse
* Current medications
* Current medical conditions
* Family history of bipolar or schizophrenia
* Assess severity of symptoms
What are patient assessment tools we can use?
PHQ9, HAM-D, MADRS
What is the scoring of HAM-D?
Normal: 0-7
Mild: 8-13
Mod: 14-18
Severe: 19-22
Very severe: ≥23
Whay do we look for when evaluating a patient?
Suicidal ideation: hosptial should be considered if risk is significant
What are non-pharms for Tx?
CBT
Religion
Avoid stress
Excersise
Self-affirmation
Positivity
Motivational speakers
Types of med intervention?
- Medications
- Psychotherapy
- ECT
- VNS
- Combo
What complementary tx is good for depression but has a lot of DDIs?
St Johns wort: treatment of adults experiencing major depression of moderate severity
* Serotonergic, cause photosensitivity
How do we select a AD?
- All AD are equal in effectiveness and safety (anticipated DDI, SE)
- Consider prior response
- Comorbidities
- Presenting symptoms vs target receptors
What is the recommendations for administering an AD?
- Startlow gradual increase dose; 1-2 wks. to feel better 6-8 wks. For fulleffect
- Physical symptoms (energy levels, sleep disturbance) before mood improves- suicide risk
- Adequate trial of drug must be provided (4-8 wks) before considering (increase dose, switch, augment, combo)
What is the goal of AD tx?
- Remission may take 12 wks (HAM-D score of ≤7)
- 50% reduction in sx
What is the first line for MDD?
SSRI: fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine
BBW of all AD?
Suicidality
Common ADR of AD?
- N
- D
- COnstipation
- Insomnia
- Serotonin syndrome
- Sexual SE
SSRI
Counseling points
- Don’t D/C abruptly must taper to prevent withdrawals
- Start low gradual increase dose; 1-2 wks. to feel better 6-8 wks. For full effect
- Physical sx before mood improves
How do we manage SSRI-induced sexual SE?
- Will disappear spontaneously
- Dose reduction
- Add bupropion
- Drug holiday for patients on short-acting SSRI
- sildenafil or tadalafil for man, TD testosterone for women
How do we manage SSRI-induced GI SE?
N/V/C/D/Gi bleed
1. GI SE wanes after 2 or 3 weeks generally
2. Divide dose
3. Take with food
4. administering more of the dose at bedtime can help
5. Ginger
6. Antidiarrheal or switch to other agents
7. Constipation: physical activity, fluid and fiber intake, or laxatives
Fluoxetine
MOA, Counseling
Prozac
MOA: SSRI
Counseling: can cause insomnia and anxiety
Sertraline
MOA, Counseling
Zoloft
MOA SSRI
Counseling: Low concentration in breastmilk, causes insomnia and GI se