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Board Certification 2 (Purple book) > Depressive disorders > Flashcards

Depressive disorders Flashcards

1
Q

As opposed to normal sadness, what makes pathological sadness abnormal

A

Disproportionate to the situation or it’s unrelated to any specific event (just comes out of no where)
Sustained
Impairs function
Causes somatic complaints

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2
Q

Object Loss Theory (theory of what causes MDD)

A

Problems early in life make the person vulnerable to depression later.

The 1st stage of development is normal, which means they can form a normal relationship.

Then in the 2nd stage though, there’s a traumatic separation (usually from the mother)

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3
Q

Freud’s theory of what causes MDD

A

Aggression-turned-inward

It starts out the same as object loss theory: the child has a normal 1st stage of development, but then in the 2nd stage, there’s a traumatic separation.

The child is angry about the loss, but afraid to express it. The only safe way to express it is direct it inward. The child tells himself that he deserves the anger because he caused the loss somehow. He also feels guilt about the anger.

The depression comes out as an adult when they expect another loss will happen.

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4
Q

Cognitive Theory of what causes MDD

A

Things that happen early in life sensitize a person and causes them to respond to future stressors with depression.

Depressed people have a distorted world view, and think bad things will happen to them because there’s something wrong with them.

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5
Q

Learned Helplessness-Hopelessness theory of MDD

A

By Martin Seligman

It’s like cognitive theory but modified.

They have no control over what happens, so they just give up.

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6
Q

Biological theories of the cause of MDD

A

It’s possible there is a polygenic single nucleotide polymorphism (SNP) disorder

Having a depressed parent is the single strongest predictor of depression (the kids are 3x more likely to have MDD, and 40% chance of having an episode before age 18)

The earlier the depression starts, the worse the prognosis

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7
Q

Neurovegetative symptoms (sleep, eating, sex, energy) are related to the functioning of

A

the hypothalamus and pituitary, and the hormones they secrete

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8
Q

A high incidence of postpartum mood disturbances is suggestive of

A

endocrine dysfunction

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9
Q

Deregulation of the hypothalamic-pituitary-adrenal axis (theory of what causes depression)

A

HPA controls the physiological response to stress and consists of feedback pathways between the hypothalamus, pituitary gland, and adrenal glands.

MDD is caused by an abnormal response to stress.

When stressed, the hypothalamus releases corticotropin-releasing hormone, which stimulates the pituitary to release adrenocorticotropic hormone. This then stimulates the adrenals to release cortisol.

Hyperactivity of the HPA (and maybe elevated cortisol) is found in people with MDD.

Overtime, cortisol can actually damage the nervous system, including changing the size of the brain.

MDD can also be associated with proinflammatory cytokine activation

(fyi, this theory was why they used to do the dexamethasone test, but not anymore because it’s too nonspecific)

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10
Q

Neurotransmitter theory of MDD

A

besides 5HT, DA, and NE, this theory says MDD might be related to:

  • low levels of endogenous catecholamines in specific brain areas
  • low tyrptophan
  • low level of the serotonin metabolite 5HTIAA
  • receptor sensitivity is too high in certain areas (a stronger response from transmitters is needed)
  • not enough receptors
  • hypometabolism in certain brain areas
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11
Q

Structural brain changes theory of MDD

A

MDD people can have hypovolemic hippocampus and hypovolemic prefrontal cortex-limbic striatal regions

Also MDD is very common in people who had brain damage, from trauma or stroke.

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12
Q

Chronobiological theory of MDD

A

messed up circadian rhythms produces symptoms that are like MDD.

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13
Q

Statistics of MDD

A

5% of the population in the U.S.

It’s the leading cause of disability

Only 50% of MDD people get treatment

Over the life time, women have a 25% chance, men have a 12% chance

MDD is the greatest source of morbidity for women (more than any other illness)

15% of people with MDD die of suicide

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14
Q

MDD age of onset

A

mid 20s

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15
Q

If left untreated, an MDD episode usually lasts

A

4 months or longer

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16
Q

One year after the MDD diagnosis,

A

40% will still have enough symptoms to meet the dx
20% of clients don’t meet the dx anymore, but still have symptoms
40% have no symptoms

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17
Q

People with a first episode of MDD have a __% chance of another episode

A

60%

2 episodes = 70% chance of a 3rd

3 episodes = 80% change of a 4th

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18
Q

MDD risk factors

A

Female

Unmarried

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19
Q

EPDS

A

Edinburgh postnatal depression scale

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20
Q

MDD diurnal variation

A

low in the morning, better later on

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21
Q

MDD, the sleep disturbance is typically

A

middle or terminal insomnia

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22
Q

Weight changes in MDD

A

5% change (gain or lose).

Sometimes there’s craving for specific foods, like carbs

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23
Q

Bereavement

A

MDD symptoms that start within 2 months of the loss, and only last for 2 months

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24
Q

MDD assessment: Memory

A

impaired recent and short term

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25
General guidelines for med treatment for MDD
Treat for a minimum or 6 to 12 months If they have more than 2 episodes of MDD, continue the meds indefinitely Not all symptoms will respond to medication Stopping abruptly can cause rebound depression
26
TCA mechanism
elevate 5HT and NE
27
MAOI mechanism
elevate 5HT and NE
28
Citalopram
20 to 40 mg daily Sedation, agitation, yawning, weight gain Pregnancy category, Lactation L2 Warning about prolonged QTc interval in doses above 40 (or above 20 in older adults) and in those susceptible to prolonged QTc
29
Escitalopram
10 to 20 mg daily Somnolence Pregnancy C, Lactation L2
30
Fluoxetine
20 to 80 mg daily. There's a liquid form Insomnia Pregnancy C, Lactation L2
31
Fluvoxamine
SSRI 100 to 300 mg daily Sedation, agitation Doses above 150mg should be given BID Pregnancy C, Lactation L2
32
Paroxetine
20 to 60 mg daily Somnolence Pregnancy category D!, Lactation L2 Discontinuation syndrome is a big problem
33
Sertraline
50 to 200mg daily Somnolence Pregnancy C, Lactation L2
34
Vilazodone
SPARI (serotonin paritial agonist reuptake inhibitor) 20 to 40 mg daily Dry mouth Pregnancy C, Lactation category is not established but we do know it's excreted in the breast milk
35
Amitriptyline
50 to 300mg Comes in IM form too TCA Used for chronic pain and insomnia Pregnancy C, L2
36
Clomipramine
100 to 250 TCA Approved for OCD Seizures can occur if the dose goes over 250 Pregnancy C, L2
37
Desipramine
100 to 300 mg TCA Also used for ADHD in adults (and in kids off label) Pregnancy C, L2
38
Doxepin
100 to 300 mg TCA Also used for insomnia Pregnancy C, L5 (avoid!)
39
Imipramine
100 to 300 TCA Also comes in IM Used for enuresis and separation anxiety Pregnancy D, L2
40
Nortriptyline
50 to 150 mg TCA Also used for enuresis and ADHD Pregnancy D, L2
41
Protriptyline
15 to 60mg daily TCA Pregnancy C, L is unknown
42
Trimipramine
100 to 300 mg daily TCA Pregnancy C, L is unknown
43
SSRI pregnancy and lactation categories
Everything is Pregnancy C and L2 except: Paroxetine is Pregnancy D
44
Pregnancy and lactation for TCAs
Most are Pregnancy C and L2 Imipramine and nortriptyline are Pregnancy D Doxepine is L5 Protriptyline and trimipramine are L unknown
45
SARIs
Serotonin agonist and reuptake inhibitors Trazadone and Nefazodone
46
Isocarboxazid
20 to 60 mg daily MAOI Also used for panic disorder, phobic disorders, and selective mutism give BID or TID Pregnancy C, L unknown
47
Phenelzine
45 to 90 mg daily MAOI Also used for panic disorder, phobic disorders, and selective mutism give BID or TID Pregnancy C, L unknown
48
Tranylcypromine
30 to 60 mg daily MAOI Also used for panic disorder, phobic disorders, and selective mutism give BID or TID Pregnancy C, L unknown
49
Selegiline
6 to 12mg daily No dietary restrictions with the 6 mg dose, but 6 mg might not be high enough to be therapeutic Pregnancy C, L4 (Avoid!)
50
SSRIs are first line for
MDD with mild to moderate symptoms
51
Side effects that are common to most TCAs
Anticholinergic: Dry mouth, blurred vision, constipation, memory impaired (from muscarinic receptor blockade) Antiadrenergic: Orthostatic hypotension (from alpha 1 blockade) Antihistaminergic: Sedation, weight gain EKG changes (not safe if they have another cardiac disease) Can induce hypomania in susceptible patients
52
TCA considerations
You can monitor blood levels (especially with nortriptyline) They're cheap The anticholinergic effects can actually be helpful if they have bowel irritability Don't stop suddenly or you'll have discontinuation syndrome Let an SSRI washout for 2 weeks (5 with fluoxetine) before starting an TCA (although you can use both at the same time with caution)
53
MAOIs and hypertensive crisis
Hypertensive crisis happens when taken with foods with tyramine (a precursor for NE) ``` In addition to tyramine, other things can cause HTN: Meperidine Decongestants TCAs 2nd gens St John's Wort L-tryptophan Stimulants/sympathomimetics Asthma meds ```
54
Symptoms of a HTN crisis
Sudden explosive headache, usually occipital Facial flushing Pupils dilate Fever
55
Treatment of HTN crisis from an MAOI
Give phentolamine (binds with NE receptors, blocks NE) Stabilize the fever
56
Symptoms of serotonin syndrome
``` Agitation, restless Tachy and HTN Headache Sweating, shivering, goose bumps Myoclinic jerking and loss of coordination Confusion, fever, seizures, unconsciousness Altered sensorium Hyperreflexia Hyperthermia Chills Insomnia Autonomic instability ```
57
Treatment of serotonin syndrome
If it's mild, you might *carefully* use benzos. If it's more severe, you'll use cyproheptadine, anticonvulsants, and autonomic support.
58
Treatment of serotonin syndrome
If it's mild, you might *carefully* use benzos. If it's more severe, you'll use cyproheptadine, anticonvulsants, and autonomic support.
59
MAOI side effects
Insomnia Weight gain Anticholinergic effects Sexual side effects
60
Venlafaxine
75 to 375 mg daily for immediate release 75 to 225 mg daily for XR Needs to be above 150mg to be therapeutic Sweating Dizziness Can raise BP For the immediate release, give BID or TID Pregnancy C L3 Don't stop suddenly (discontinuation syndrome)
61
Duloxetine
30 to 120mg Dizziness Can elevate BP Can elevate LFTs Don't stop suddenly (discontinuation syndrome) Pregnancy C, L3
62
Vortioxetine
20mg daily Serotonin 3 and 7 antagonist, and serotonin 1A agonist Dizziness Pregnancy C, L is unknown
63
Levomilnacipran
40 to 120 SNRI ``` Constipation Sweating Palpitations Urinary hesitancy HTN or hypotension Decreased appetite ``` Pregnancy C, L is unknown
64
ECT theories of how it works
Do 6 to 12 treatments Possibly increases DA, NE, 5HT Possibly releases hormones like prolactin, TSH, pituitary, endorphins, and adrenocorticotropic hormones Possibly has an anticonvulsant effect
65
Reasons for choosing ECT
Patient preference Need for a quick response because the illness is severe MDD with psychotic features Treatment resistance
66
Possible contraindications for ECT
``` Cardiac disease Pulmonary disease Brain injury Brain tumor Anesthesia complications ```
67
ECT adverse effects
Cardiovascular effects Systemic effects (headaches, muscle aches, drowsiness) Cognitive effect
68
Burpropion
contraindicated in eating disorders Pregnancy C, L3 With SR (not so much XL), use with caution with caffeine and panic disorder
69
Mirtazapine
alpha 2 and 5HT 2 antagonist 15 to 45 Increased cholesterol The higher the dose, the less sedating Pregnancy C, L3
70
Trazadone
Serotonin antagonist and reuptake inhibitor (SARI) 200 to 600 (but as a hypnotic it's given at 50 to 200mg) At the dose needed to have an antidepressant effect, it's usually too sedating Hypotension Prolonged QTc Pregnancy B, L2
71
Nefazodone
Serotonin antagonist and reuptake inhibitor (SARI) 300 to 600mg daily Drowsiness Very important to monitor LFTs because it can cause liver failure QHS or BID dosing Inhibits the P450 3A4 Pregnancy C, L4
72
TMS
Transcranial magnetic stimulation The put a small wire in your scalp Anesthesia is not used 40 minute sessions, 5 times a week, for 6 weeks There are minimal side effects, but it can cause pain, tingling, twitches in the face, lightheadedness, hearing discomfort from the noise of the procedure. Seizures are rare, but have been reported
73
Vagal nerve stimulation
Pacemaker-like device placed in the chest. Anesthesia is required, although it can be done outpatient. It can cause voice changes, hoarseness, cough, throat/neck pain, chest spasm, dyspnea on exertion, tingling, and dysphagia It's intended to be used alongside other treatments
74
Phototherapy
2,500 to 10,000 lux light for 30 minutes up to 2 hours, 1 or 2 times a day
75
Brief Therapy (Solution focused therapy)
Focus on the stressor that started everything Cope with the immediate impacts of MDD Modify the environment
76
Risk factors for suicide
``` 45 or older if male 55 or older if female Single/separated White Living alone Psyc illness Physical illness Substance abuse previous attempt Recent loss Male ```
77
MDD in children is similar to adults, but certain features tend to be pronounced
Irritability Somatic complaints Social withdrawal Separation anxiety
78
Some symptoms are less common in children before puberty
Psychosis Motor retardation Hypersomnia Increased appetite
79
Different medication classes for MDD kids
They respond well to SSRIs, but not TCAs All antidepressants have a blackbox warning for kids
80
MDD in older adults
To distinguish between memory symptoms of MDD and symptoms of dementia, check if they had a premorbid cognitive slowing (dementia). With MDD, the cognitive changes will be acute. Skill deficit is when they can't perform a skill. Performance deficit is when they have the ability to perform a skill, but don't have the motivation.
81
Components of a functional assessment
ADLs- bathing, eating, dressing IADLs- instrumental activities of daily living, shopping, cooking, driving Executive functioning- judgement, planning, maintaining a calendar, prioritizing
82
Some long term effects of SSRIs
Increased blood sugar levels Hyperlipidemia Elevated LFTs
83
SSRI discontinuation syndrome
``` Flu like Fatigue Myalgia Decreased concentration and memory N/V Paresthesias and "shocks" Irritable/anxious Insomnia Crying randomly Dizziness/vertigo ```
84
Risk factors for SSRI discontinuation syndrome
Irregular use pattern High dose Long term treatment History of discontinuation syndrome
85
How long after remission of MDD should you take meds?
12 months If you've had 3 or more MDD episodes, you need lifelong meds
86
Persistent depressive disorder (dysthymia)
Doesn't have psychotic features Doesn't have neurovegetative symptoms like sleep and appetite problems The mood occurs for most of the day, on more days than not Low self esteem, feeling that you're incompetent compared to others
87
Dysthymia in children
It's equal among boys and girls Only requires a 1 year history Mood is often irritable instead of sad
88
Grief and Bereavement
Develops within 3 months of a stressor If there are not other significant symptoms, it's usually classified as adjustment disorder (with depressed mood, with disturbed conduct, etc)
89
Meds for Grief
Benzos Nonbenzo hypnotics like zolpidem TCAs Antihistamines
90
Premenstrual dysphoric disorder
Symptoms usually start in the luteal phase, 1 week before the start of menses. The symptoms usually stop a day or two after menses starts Symptoms may worsen when the patient is perimenopausal Treatment can be SSRIs, hormonal contraceptives, or both

Board Certification 2 (Purple book) (22 decks)

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