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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
Q

General guidelines for med treatment for MDD

A

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

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26
Q

TCA mechanism

A

elevate 5HT and NE

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27
Q

MAOI mechanism

A

elevate 5HT and NE

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28
Q

Citalopram

A

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

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29
Q

Escitalopram

A

10 to 20 mg daily

Somnolence

Pregnancy C, Lactation L2

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30
Q

Fluoxetine

A

20 to 80 mg daily.

There’s a liquid form

Insomnia

Pregnancy C, Lactation L2

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31
Q

Fluvoxamine

A

SSRI

100 to 300 mg daily

Sedation, agitation

Doses above 150mg should be given BID

Pregnancy C, Lactation L2

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32
Q

Paroxetine

A

20 to 60 mg daily

Somnolence

Pregnancy category D!, Lactation L2

Discontinuation syndrome is a big problem

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33
Q

Sertraline

A

50 to 200mg daily

Somnolence

Pregnancy C, Lactation L2

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34
Q

Vilazodone

A

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

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35
Q

Amitriptyline

A

50 to 300mg

Comes in IM form too

TCA

Used for chronic pain and insomnia

Pregnancy C, L2

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36
Q

Clomipramine

A

100 to 250

TCA

Approved for OCD

Seizures can occur if the dose goes over 250

Pregnancy C, L2

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37
Q

Desipramine

A

100 to 300 mg

TCA

Also used for ADHD in adults (and in kids off label)

Pregnancy C, L2

38
Q

Doxepin

A

100 to 300 mg

TCA

Also used for insomnia

Pregnancy C, L5 (avoid!)

39
Q

Imipramine

A

100 to 300

TCA

Also comes in IM

Used for enuresis and separation anxiety

Pregnancy D, L2

40
Q

Nortriptyline

A

50 to 150 mg

TCA

Also used for enuresis and ADHD

Pregnancy D, L2

41
Q

Protriptyline

A

15 to 60mg daily

TCA

Pregnancy C, L is unknown

42
Q

Trimipramine

A

100 to 300 mg daily

TCA

Pregnancy C, L is unknown

43
Q

SSRI pregnancy and lactation categories

A

Everything is Pregnancy C and L2 except:

Paroxetine is Pregnancy D

44
Q

Pregnancy and lactation for TCAs

A

Most are Pregnancy C and L2

Imipramine and nortriptyline are Pregnancy D

Doxepine is L5

Protriptyline and trimipramine are L unknown

45
Q

SARIs

A

Serotonin agonist and reuptake inhibitors

Trazadone and Nefazodone

46
Q

Isocarboxazid

A

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
Q

Phenelzine

A

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
Q

Tranylcypromine

A

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
Q

Selegiline

A

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
Q

SSRIs are first line for

A

MDD with mild to moderate symptoms

51
Q

Side effects that are common to most TCAs

A

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
Q

TCA considerations

A

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
Q

MAOIs and hypertensive crisis

A

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
Q

Symptoms of a HTN crisis

A

Sudden explosive headache, usually occipital
Facial flushing
Pupils dilate
Fever

55
Q

Treatment of HTN crisis from an MAOI

A

Give phentolamine (binds with NE receptors, blocks NE)

Stabilize the fever

56
Q

Symptoms of serotonin syndrome

A 
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
Q

Treatment of serotonin syndrome

A

If it’s mild, you might carefully use benzos.

If it’s more severe, you’ll use cyproheptadine, anticonvulsants, and autonomic support.

58
Q

Treatment of serotonin syndrome

A

If it’s mild, you might carefully use benzos.

If it’s more severe, you’ll use cyproheptadine, anticonvulsants, and autonomic support.

59
Q

MAOI side effects

A

Insomnia
Weight gain
Anticholinergic effects
Sexual side effects

60
Q

Venlafaxine

A

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
Q

Duloxetine

A

30 to 120mg

Dizziness

Can elevate BP

Can elevate LFTs

Don’t stop suddenly (discontinuation syndrome)

Pregnancy C, L3

62
Q

Vortioxetine

A

20mg daily

Serotonin 3 and 7 antagonist, and serotonin 1A agonist

Dizziness

Pregnancy C, L is unknown

63
Q

Levomilnacipran

A

40 to 120

SNRI

Constipation
Sweating
Palpitations
Urinary hesitancy 
HTN or hypotension 
Decreased appetite

Pregnancy C, L is unknown

64
Q

ECT theories of how it works

A

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
Q

Reasons for choosing ECT

A

Patient preference
Need for a quick response because the illness is severe
MDD with psychotic features
Treatment resistance

66
Q

Possible contraindications for ECT

A 
Cardiac disease
Pulmonary disease 
Brain injury 
Brain tumor 
Anesthesia complications
67
Q

ECT adverse effects

A

Cardiovascular effects
Systemic effects (headaches, muscle aches, drowsiness)
Cognitive effect

68
Q

Burpropion

A

contraindicated in eating disorders

Pregnancy C, L3

With SR (not so much XL), use with caution with caffeine and panic disorder

69
Q

Mirtazapine

A

alpha 2 and 5HT 2 antagonist

15 to 45

Increased cholesterol

The higher the dose, the less sedating

Pregnancy C, L3

70
Q

Trazadone

A

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
Q

Nefazodone

A

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
Q

TMS

A

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
Q

Vagal nerve stimulation

A

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
Q

Phototherapy

A

2,500 to 10,000 lux light for 30 minutes up to 2 hours, 1 or 2 times a day

75
Q

Brief Therapy (Solution focused therapy)

A

Focus on the stressor that started everything

Cope with the immediate impacts of MDD

Modify the environment

76
Q

Risk factors for suicide

A 
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
Q

MDD in children is similar to adults, but certain features tend to be pronounced

A

Irritability
Somatic complaints
Social withdrawal
Separation anxiety

78
Q

Some symptoms are less common in children before puberty

A

Psychosis
Motor retardation
Hypersomnia
Increased appetite

79
Q

Different medication classes for MDD kids

A

They respond well to SSRIs, but not TCAs

All antidepressants have a blackbox warning for kids

80
Q

MDD in older adults

A

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
Q

Components of a functional assessment

A

ADLs- bathing, eating, dressing

IADLs- instrumental activities of daily living, shopping, cooking, driving

Executive functioning- judgement, planning, maintaining a calendar, prioritizing

82
Q

Some long term effects of SSRIs

A

Increased blood sugar levels
Hyperlipidemia
Elevated LFTs

83
Q

SSRI discontinuation syndrome

A 
Flu like 
Fatigue
Myalgia 
Decreased concentration and memory
N/V
Paresthesias and "shocks"
Irritable/anxious
Insomnia 
Crying randomly
Dizziness/vertigo
84
Q

Risk factors for SSRI discontinuation syndrome

A

Irregular use pattern
High dose
Long term treatment
History of discontinuation syndrome

85
Q

How long after remission of MDD should you take meds?

A

12 months

If you’ve had 3 or more MDD episodes, you need lifelong meds

86
Q

Persistent depressive disorder (dysthymia)

A

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
Q

Dysthymia in children

A

It’s equal among boys and girls

Only requires a 1 year history

Mood is often irritable instead of sad

88
Q

Grief and Bereavement

A

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
Q

Meds for Grief

A

Benzos
Nonbenzo hypnotics like zolpidem
TCAs
Antihistamines

90
Q

Premenstrual dysphoric disorder

A

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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