Depressive Disorders Flashcards
What must be evident in the patients medical history to make a diganosis of “due to another medical condition”?
Causal relationship
Besides medical condtions, what other causes must be considered?
Substance induced depressive disorders
What medical conditions cause ONLY depression?
Parkinson Hypothyroid Hyperparathyroid Hypoparathyroid Cushing Addison SLE RA Folate def. HIV
What medical conditions casue ONLY mania?
Wilson
Temporal lobe epilepsy
Which medical conditions cause either depression or mania?
Huntington CVA Cerebral tumor Cerebral trauma Encephalitis MS Hyperthyroid Uremia B12 def.
What can clue the clinician into metabolic changes that might be causing depression?
Weight gain without a change increased appetite
- Atypical depression will have increased appetite
What is the appropraite step if a patient presents with substance/medication induced depression?
- Stopping the substance is usually enough
- May take several weeks - Use of an antidepressant may be needed
- Substance abuse treatment
- Admit is SI, HI, or psychosis is present
What critera must be met to make a dx of S/M induced depression?
- Developed during use, intoxication, or withdrawal
- May occur up to 1 month after use has stopped - Subtance is known to cause depression
What disorders overide S/M induced depression?
Any depressive disorder not caused by a substance/medication
What symptoms, if present, disqualifies S/M induced depression?
Delirum
What are the signs and symptoms of cocaine withdrawal?
Fatigue
Low energy
Hypersomnia
Increased appetite
What kind of most is most likely to be present during cocaine use or intoxication?
Mania
- Depression occurs most often during withdrawal
What nonpsychiatric medications can cause mood distrubance?
- Antihypertensive agents
- Beta blockers - Interferon
- Cytotoxic agents
What other conditions should be ruled out if someone present with S/M induced depression?
- Primary mood disorder
- MDD - Depressive disorder due to another medical condition
- Bipolar disorder
When treating someone with co-occurring depression and cocaine use, what medication may be superior to an SSRI?
TCAs
How many attempts do patients usually need at substance abuse treatment before being successful?
10
What physical exam findings indicated the use of opioids?
Miosis
Slurred speech
Drowsiness
What physical exam findings indicate a patient has been using phencyclidine?
Nystagmus
Hypertension
Muscle rigidity
What physical exam findings indicates a patient has been using cannabis?
Conjucntival injection
Increased appetite
Dry mouth
What physical exam findings indicates a patient is going through opiod withdrawal?
Mydriasis
Gooseflesh
Rhinorrhea
Muscle aches
What are some substances that can induce depression?
Cocaine
Alcohol
Methamphetamine
Spray paint
What is the appropriate treatment plan for a patient who has MDD with severe features and mood-congruent psychosis?
- Offer psychiatric admission
- Start with an SSRI
- Add an atypical antipsychotic
- Discharge when stable
- Weekly follow-ups for 4 weeks after discharge
What symptoms would tip a diagnosis toward MDD vs Adjustment disorder?
- Vegetative symptoms
- Suicidal ideation
- Auditory hallucinations
How do children and adolescents with MDD typically describe their mood?
Angry or mad
What things need to be considered inorder to “commit” somone to the unit for depression?
- Are they an imminent danger to themself or others?
2. Can they take care of themselves?
How many symptoms are need to meet criteria for MDD?
5
How long do the symptoms need to be present to meet critera for MDD?
2 week period
One of which two symptoms must be present to meet criterai for MDD?
Depressed mood or Anhedonia
What other areas are impacted by MDD (SiG E CAPS)?
Si- SI
G- Guild or worthlessness
E- Energy- Decreased
C- Concentration - Impaired
A- Appetite/Weight - Increased or decreased
P- Psychomotor - Retardation or agitation
S- Sleep - Increased or decreased
What other conditions supersede MDD?
- Bipolar disorder
- Due to medical illness or substance
- Not normal bereavement
What are “mood-congruent delusion or hallucinations” for a patient with MDD?
Pertaining to being:
- Defective or deficient
- Diseased
- Guilty and deserving of punishment
What is the key aspect of psychosis?
Ability to assess reality is impaired
What are the three catagorial symptoms present during depression?
- Vegetative
- Cognitive
- Emotional
What are vegetative symptoms?
Anything related to body function
What cognitive symptoms?
- Poor concentration
- Low self-esteem
3.
What are emotional symptoms?
Crying speels
What are predictors of MDD in childhood and adulthood?
- Genetics
- Loss of a parent before the age of 11
- Adverse early life experiences
How do children usually present with MDD?
- Anger or irritability
- Anhedoina
- Decreased energy
- Poor grades
- Staying up late
- Social isolation
Why are patients often diagnosed with a depressive disorder before bipolar disorder?
The patient often goes through several depressive episodes before mania occurs
- Important to review clinical and family history of BP disorder
How long must a patient abstain from a substance before a diagnosis of S/M induced or MDD can be confirmed?
Several weeks
What are some indications that bereavement may be becoming MDD?
- Guilt
- Patient feels they caused the death
- SI
What is a common symptom of bereavemnt in children?
Hallucinatory phenomena
- Usually reassuring and comforting
What type of hallucinations are usually more common with MDD?
Hostile accusatory hallucinations
At what point should an atypical antispychotic be tapered off?
3 months
At what point should an antidepressant be tapered off?
6 to 12 months
- Taper over 2 to 3 months
What type of therapy is most effective for MDD?
CBT
- Interpersonal therapy
At what time point does bereavement need to be evaluated as MDD?
Bereavemnt can present with all the same symptoms of MDD (excpet psychosis or SI/HI). If symptoms are still there after 4 months, MDD may be considered an appropriate dx.
According to the AACAP, what is the appropiate pharmacotherapy for a patient with MDD and psychosis?
SSRI and atypical neuroleptic
- Taper to effect, max dose, or side effects become an issue
What SSRIs are available for MDD?
Sertaline Citalopram Fluoxetine Fluvoxamine Paroxetine
What SNRIs are available for treating MDD?
Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran
What other treatments for MDD are available?
Bupropion
Mirtazapine
What are the most common side effect of SSRIs?
GI upset Sleep disturbances Tremor Dizziness Increase prespiration Sexual dysfunction
What treatment for MDD is not associated with sexual dysfunction?
Bupropion
What side effect of TCAs can be leathal?
Cardiac arrhythmias
What is the time requirement to meet critera for MDD?
2 weeks
How many symptoms need to be present to meed MDD?
5+
What other conditions supersede MDD?
Bipolar disorder S/M induced Medical condition Schizophrenia Schizoaffective Delusional disorder Other psychotic disorder Bereavement
What critera qualify bereavement as MDD?
Symtpoms last longer then 2 months
Marked functional impairment
SI
Psychotic symptoms
What other conditions can SSRIs be used to treat?
Eating disorders
Panic attack disorder
OCD
Borderline personality
What other condtions can be treated with an SNRI?
GAD
What is the MOA of bupropion?
Blocks uptake of NE and DA
What conditions can be treated with bupropion?
Anxiety associated depression
Smoking
What is the MOA of mirtazapine?
TCA
Acts on noradrenergic and serotonergic mechanisms
Does not block uptake
What other conditions can be treated with mirtazapine?
Anxiety
Insomnia
How many people in the US will suffer from depression at some point in their life?
1 in 7
What are some warning signs of suicide?
Patient becomes quite and less agitated after a previous expression of SI
Making a will
Giving away personel property
What are risk factors for suicide?
Older age Alcohol or drugs dependence Prior suicide attempts Male gender Family history
What needs to be monitored in MDD patients being treated with an antidepressant?
Worsening depressed mood and suicidality
- First couple of months
- Whenever there is a dosage change
What are the key symptoms of the “baby blues”?
Sadness
Strong feelings of dependency
Frequent crying spells
Dysphoria
How long do the “baby blues” typically last?
Days to 1-week
Can antidepressants get into the breast milk?
yes
What is the lifetime recurrence rate for MDD?
85%
What is the 1-year recurrence rate for MDD?
40%
What conditions increase the risk of MDD recurrance?
Residual symptoms between episodes
Comorbid psychiatric disorders
Chronic medical conditions
What not medical options are avaliable for the treatment of MDD?
ECT
Transcranial magnetic stimulation
Which two antidepressants are most commonly associated with sexual dysfunction?
SSRIs
Venlafaxine
What are the major side effects of TCAs?
Anticholinergic effects
Orthostasis
Cardiac effects
Why are MAOIs not used very often?
DDI
Dietary restrictions
What is the best indication for what medication will work in a patient with recurrent MDD?
Whatever medication put them in remission before
At what point does sexual dysfunction become an issue for patients taking SSRIs?
Weeks to months after being on the medication
What is the best medical therapy for persistent depressive disorder?
SSRI SNRI Bupropion Mirtazapine TCA MAOIs
What is the time critera for persistent depressive disorder?
Depressed mood on most of the day, for most of the days
At least 2 years
1 year in children and adolescents
No longer then 2 months symptoms free
How many symptoms need to be present to meet critera for PDD?
2+
What are the symtpoms for PDD?
CHASES
Concentration Hopelessness Appetite Self-esteem Energy Sleep
What conditions superscede PDD?
Bipolar
Cyclothymia
Any psychosis
Substances or Medical condition
Which medical conditions often coexist with PDD?
MDD
Anxiety- Especailly panic disorder
Substance abuse
Borderline personality disorder
What are important differences between PDD and MDD?
PDD - Earlier onset (Teenage to early adulthood) - More chronic course - Less intense and longer lasting MDD - Later onset - Episodic - More severe
What is the concept of “double depression”?
When PDD has an episode of MDD
- Poor prognosis
What non-medical therapy is available for PDD?
CBT
Insight-oriented therapy
Interpersonal therapy
What are key signs of serotonin syndrome?
Headache
Rapid heartbeat
Fever
Chills
What medications can be used to manage PMDD?
SSRI are 1st line
What is the timeline requirement to meet critera for PMDD?
Majority of menstrual cycles 1 year Start the week before Improve within days after onset Minimal to absent postmenses
What two areas are assessed to determine critera for PMDD?
Mood
Associated symptoms
How many symptoms are required to meet critera for PMDD?
5+
What are the mood symptoms of PMDD?
- Depression, hopelessness, and self-deprication
- Affective instability, mood swings, and rejection sensitvity
- Increased irritablity, anger, or interpersonel conflicts
- Significant anxiety and tension
What are the associated symptoms of PMDD?
- Anhedonia
- Concnetration
- Sleep disturbance
- Energy
- Overwhelmed
- Appetite or specific craving
- Weight gain, bloating, muscle/joint pain, breast tenderness, or swelling
What conditions supercede PMDD?
Substance or medication
Medication condition
What is affective lability?
Rapid change in affect (ie mood swings)
PMDD is a significant risk factor for what condition?
Postpartum depression
What conditions can manifest similar to PMDD?
Thyroid dysfunction
Fibromyalgia
IBS
What type of therapy is often prescibed for symptoms of PMDD, that can actually make it worse?
Exogenous hormones
What is the difference between PMS and PMDD?
PMS has fewer symptoms and is usually without mood changes
Which symptoms are most severe with PMDD?
Mood swings and irritability
When can SSRIs be taken to treat PMDD?
Continuously or only during the luteal phase
What is the only TCA that has shown any effectiveness in treating PMDD?
clomipramine
What type of therapy is useful for PMDD?
CBT
