Depressive disorders Flashcards
Depressed mood OR loss of interest/pleasure PLUS four associated symptoms for at least 2 weeks
Decreased interest Weight or appetite changes Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feeling worthless or guilty Decreased ability to concentrate SI or other thoughts of death
Major depressive disorder
Major depressive disorder should have depressed mood OR loss of interest/pleasure for two weeks… plus 4 other sxs from this list… which is?
Decreased interest Weight or appetite changes Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feeling worthless or guilty Decreased ability to concentrate SI or other thoughts of death
Easy way to remember major depressive disorder?
Depressed mood or loss of interest PLUS 4 of these S- Sleep I- Interest G- Guilty E- Energy C- Concentration A- Appetite P- Psychomotor S- SI/HI
Essential feature is at least 2 weeks of a depressed mood “sad” “hopeless” “down in the dumps” “discouraged” etc…
Sxs need to be present most of the day for nearly everyday
Fatigue or insomnia is a common presenting complaint
MDD
Psychomotor sxs are less common but if present, indicate a greater overall severity
Appetite changes can be an increase or decrease
Sleep changes can be insomnia or hypersomnia
Psychomotor changes must be severe enough to be noticed, not just subjective reports
MDD
Associated with high mortality
Suicidal thoughts range from:
Passive thoughts of death
Others being better off if they were dead
Contemplating suicide
Plans to commit suicide
MDD
Biggest risk factor for suicide attempt?
history of suicide attempts
Male sex, living alone, being single, prominent feelings of hopelessness
Presence of Borderline Personality DO markedly increases risk
suicide risks in MDD
MDD who is actively suicidal?
Probably shoudn’t prescribe antidepressants…. Pt shouldn’t leave observation
(point is… consider the black box warning for antidepressants and their likelihood of increasing suicide risk)
MDD non-pharm tx?
Cognitive behavioral therapy = Key to a good plan for depressed patients! All patients should have some form of this
Electroconvulsive therapy:
Indicated when medications can’t be used and/or extreme suicidality
Risks include memory disturbances and headache
Causes a generalized seizure
Works best when used for severe depression
Phototherapy
Major Depressive Disorder pharmacological tx?
SSRI
Typically well tolerated
Starting dose is typically therapeutic
Lower lethality in overdose
Adjunctive bupropion
Trial new medication
(Sertraline should be used for patients with acute MI or unstable angina)
[Also consider SNRIs]
In MDD patient who experience sexual dysfxn, consider?
trial of oral PDE5 inhibitors (sildenafil)
Adjunctive bupropion
Trial of new med
Antidepressant
Associated w/ less sexual dysfxn than other ADs
BUT CI in patients at risk for seizures, hx of anorexia/bulimia, or use in withdrawal from ETOH/BZDs
bupropion (NDRI)
Most activating SSRIs?
fluoxetine
Sertraline
(avoid in patients having trouble sleeping… dose in the morning)
Most sedating SSRIs?
paroxetine
fluvoxamine
(dose in evening)
SNRI?
Duloxetine
Venlafaxine
Aside from SSRIs/SNRIs, what are other pharmacologic options for MDD?
TCA (but use with caution/avoid in pts w/ cardiac condition… they can produce life threatening arrhythmias and delirium, coma, seizures, psychosis)
A “3rd line” option would be MAOIs
For a pt w/ MDD, what do you do if the response to an initial medication is poor?
(remember, response to a SSRI/SNRI can take 3-8 weeks…)
Reassess diagnosis
Trial a second medication is appropriate
Allow time for a medication “wash-out” if switching drug classes (consult pharmacist…)
Adjunct if needed (e.g., lithium, busipirone, thyroid hormone)
When considering adjunctive therapy (w/ lithium, buspirone, thyroid hormone) in a MDD pt who’s unresponsive to initial, what’s a consideration?
strongly consider getting sub-specialty help or transfer patient’s care to sub-specialist
For MDD pts, when should you consider full dosage indefinitely?
Consider need for full dosage indefinitely if
First episode before 20 or after 50,
over 40 w/ 2 episodes
one episode after 50, 3 episodes over a lifetime
Depressed mood, most of the day, more days than not, for at least 2 years PLUS 2 things
Sleep Concentration Hopelessness Appetite Low self-esteem Energy
2 consecutive years without at least a 2 month remission
Persistent Depressive Disorder
Persistent Depressive Disorder in children/adolescents… what’s the stipulation for them?
Children/adolescents mood can be irritable, and only for 1 year
Essential feature is depressive mood for at least 2 years
These symptoms are frequently considered part of their daily life and limit them from seeking help
Persistent Depressive Disorder
Difference between PDD and MDD?
MDD needs to have those 5 things!
PDD doesn’t quite have 5 of those thing (depressed + 2 other things NOTE THAT LOSS OF INTEREST ISN”T ON PDD)
PDD is a “long-term, less-severe version” of MDD
Note that patients can have MDD for longer than two years… so if a patient fits the MDD for longer than two years.. they’ve got MDD
not PDD…
How would you treat PDD?
Same as MDD
Mild depressive d/o (PDD, MDD)… tx plan?
So barely meets criteria, mostly self-controlled, NOT adversely affecting life….
Refer for behavioral health/non-medication mgmt
F/u as needed… add meds IF needed (start w/ daily meds and f/u and adjust as necessary)
Moderate depressive d/o tx plan…
So, more than meets criteria, mostly self-controlled, may/may not be adversely affecting life…
Refer for behavioral therapy (duh)
Consider starting daily med at this point (SSRIs, SNRIs)
Consider work restriction suggestions
Follow up as needed/scheduled and adjust prn
DOC for MDD patients w/ acute MI or unstable angina?
sertraline
Severe depressive d/o tx plan…
More than meets criteria, severe sxs, uncontrolled, adversely affected life…
Refer for therapy ALWAYS
Actively work with sub-specialist if possible
Consider starting daily medication at this point (SSRIs/SNRIs)
Consider work restriction suggestions
