Depression (Other Decks) Flashcards
What is the purpose of the MHSA?
assist people suffering from serious mental illness in receiving treatment
What is MHSA involuntary treatment?
Where a person needs hospitalization for a mental disorder but it is not possible for them to be admitted voluntarily
3 methods for initiating a psychiatric exam which may lead to involuntary hospitalization
Physician
Peace Officer
Provincial Court Judge
What is a caveat about involuntary patient admittence?
Non-mental health treatment cannot be authorized
What is Form A of the MHSA?
Certificate of Physician or Prescribed Health Professional that Psychiatric Examination is Required
What is Form G of the MHSA form?
Certificate of Medical Practitioners for Compulsory Admission of a Person to a Mental Health Centre
What is the field of psychiatry in terms of mental health diagnosis?
Symptoms are cross-referenced to a diagnostic/classification manual containing 100s of potential syndromes, and 1 or more diagnostic labels are applied
- DSM-V
- ICD
What is current practice of psychiatry for most clinicians
Symptom-based classification systems
What is DSM – five?
Manual that is used to establish diagnosis
How many symptoms need to result in change in functioning for major depressive disorder diagnosis
5+
What is the issues with DSM-5?
Defines illness too close to “normal” leading to over diagnosis (e.g. ADHD)
over simplification
What are the 4 components of a mental status exam?
General Observations
Thinking
Emotion
Cognition
What are some tools used to measure MDD?
Ham-D, PHQ-9, BDI
What is the limitations of current psychotropic nomenclature?
Outdated
Does not support clinical decision making
Inconsistent with other areas of medicine
May confuse patients
Negatively contributes to stigma
What is the nbN initiative?
- Based on contemporary scientific knowledge
- Help clinicians make informed choices when working out the next ‘pharmacological step’
- System of naming that does not conflict with the actual use of medications
- Be future-proof to accommodate new compounds
- Help patients understand and accepta prescribed treatment for a condition
What does the acronym ALGEE stand for?
Where does MDD fall on the mood spectrum?
Persistently and abnormally low mood, characterized by feelings of sadness, emptiness or irritability, and accompanied by other somatic or cognitive changes that significantly affect the individual’s capacity to function
When is onset of MDD usually?
Late 20s, but can occur at any age
Generally see a sharp increase between ages 12-16
What are the risk factors of MDD?
What does the acronym SIG: E. CAPS mean?
What is Peristent depressive disorder?
What is Substance/Medication Induced Depressive Episode?
What is the acronym Sig: E Caps used in?
Diagnosis of MDD and PHQ-9, Describes the symptoms of depression
What are the suicide risk factors?
In mild psychological treatment what treatment recommendations should be
Psychological alone, but active guidelines should be involved
Moderate and Severe MDD should be treated?
With both psychotherapy and pharmacological
What is the value of psychological treatments?
Seems to work about as well as antidepressants especially in less severe cases
Has no side effects associated with this treatment
Best evidence-base psychological treatments is from?
- ***cognitive behavioural therapy (CBT)
(The ones below are not as much)
* behavioural activation (BA)
* interpersonal psychotherapy (IPT)
* Mindfulness-based cognitive therapy (MBCT)
What is Transcranial Magnetic Stimulation TMS therapy?
Used for refractory depression where the magnetic fields are used to stimulate nerve cells in regions of the brain involved in mood regulation and depression
How long is TMS?
4-6 weeks
What is the primary evidence of TMS?
TMS is effective but unclear how long the benefits lasts
What is ECT?
Electroconvulsive Therapy
Used for severe depression
Is effective in 80-90% of patients
How many treatments are their with ECT?
6-12
What is the time taken for response to ECT?
10-14 days
What is the acute treatment of symptom remission of MDD?
8-12 weeks Where remission is
HAM-D score <7 and PHQ-9 <7
Response HAMD and PHQ-9 less then 50%
What is maintenance treatment used for with MDD?
Prevent recurrence of mood episode
What is important for managing psych conditions?
What are the two landmark papers for MDD treatment?
What does the Cipriana 2018 paper show?
Concluded that basicaly all antidepressants have equal efficacy
What does the NICE 2022 paper recognize?
Initial treatment for less severe MDD should be SSRI
What does the BAP 2015 paper tell us?
Choose antidepressants that are tolerated
What does the Star*D trial tell us?
What is the general response to antidepressant treatment?
First treatment 30% remission
Usually 40-60% symptom resposne rate
What occurs when the NMDA receptors are inhibited?
What occurs when the opioid receptors are activated?
What occurs when the AMPA receptors are activated?
What is the chronic stress theory?
With the usage of ketamine which racemic version has been approved as nasal spray for TRD?
S-ketamine or Esketamine
What is one issue with with injecting ketamine with naltrexone?
They saw smaller reductions in depressive symptoms when given together. Hence trial was ended earlier and naltrexone is not recommended to be used together
What are the adverse reactions seen with ketamine when given at TRD doses?
Dissociation
Dizziness
Increase blood pressure
Possible blood in urine
Which antidepressants in order have more nausea associated with them?
How do we manage GI adverse effects with Antidepressants?
Divide doses if possible, If SSRI decrease dose
Take medication with a small amount of food
Take ginger contianing food
With respect to diarrhea ADE is it temporary?
With respect to management of Diarrhea what can be done?
Which antidepressant is associated with higher rates of constipation?
paroxetine and also common with TCAs
What is the management of constipation caused by antidepressants?
During what period does suicidality may occur when taking antidepressants?
First 4-8 weeks of therapy
Which age groups do we generally see an increase in suicide ideation when starting antidepressants?
<24
If someone is first starting an antidepressant what management can be done with respect to suicidality? With respect to kids too?
For those who develop suicidality during treatment what should be considered?
Dose reduciton, switching, discontinuing offending agent
With respect to sexual dysfunction which drug class has the highest risk?
SSRIs
TCAs
SNRIs
Which drug has the lowest risk of sexual dysfunction?
Bupropion
What is the management for ADE with respect to sexual dysfunction?
- No intervention
- Reduce
- Drug holidays
- Using medications to augment sexual side effects such as bupropion or mirtazipine, sildenafil or tadalafil
- Switching
Which medication classes have higher risk of QT prolongation?
TCAs and anything that is dosed out of therapeutic range
What is baseline QTC?
360-400ms
What is serotonin syndrome?
What causes serotonin syndrome?
What should serotonin syndrome be treated as?
Life threatening and requires medical aid
Which drugs cause the worst AE with respect to discontinuation syndrome?
Venlafaxine and paroxetine
Who is at high risk for discontinuation syndrome?
Those who have been on tx for >6-8 weeks
What does the finish mnemonic stand for?
What does the finish mnemonic relate to?
discontinuation syndrome
When does discontinuation syndrome usually start?
24-72 hours after medication stop
How do we prevent discontinuation syndrome?
Taper dose down for 2-4 weeks
Which drug would you be able to full stop without taper?
Fluoxetine
If discontinuation syndrome occurs what should be considered?
If symptoms of MDD persist after 6-8 weeks what should an adequate
-Switch to alternate first line agents
-Augment with an alternate mechanism
antidepressant SGA or psychotherapy
What are the reasons for nonresponse to therapy?
How do we categorize treatment resistant depression?
Lack of improvement or <20% reduction in depression score after two or more antidepressant trials
What are the options for TRD?
May switch antidepressant
May choose to use augmentation therapy
Combining antidepressants
What are the augmentation therapies people with TRD can try?
What medications are usually combined with TRD?
How do we go about SSRI/SNRI within class direct switch?
When would be consider cross-tapering AD?
What is the MAOIs washout period?
What medicaitons are considered first line for adjunct medication options?
Aripiprazole, quetiapine, risperiodone
With respect to lithium when should we begin to see a response?
3-4 weeks,
If patient responds continue the combo for 6-9 monhts
Using Triiodothyronine or T3 what does this do?
Improves and accelerates antidepressant effects.
Why is T3 sometimes preferred over lithium?
Better tolerance
Which medications should be avoided in depression in childrem/adolescents?
SNRI and TCA
Which drug class is 1st line in pregnancy?
SSRIs, most data for sertraline, citalopram, escitalopram
What is the neuroplasticity hypothesis?
Altered cell growth and adaptation
Chronic stress leading to redevelopment of hippocampus
