EM Psych 5: Depression

Question 1

most common mental health complaints presenting to the ED

Answer 1

Mood disorders, which include depressive disorders and bipolar disorders (50%)

behind anxiety and substance use disorders (about 25% each)

Question 2

most common mental health disorder overall

Answer 2

Anxiety

Question 3

Criteria for MDD diagnosis

Answer 3

The patient needs to have at least 5 out of 9 symptoms for 2 weeks; one symptom has to be depressed mood or anhedonia

Symptoms cannot be due to substance abuse or a medical condition.

Symptoms must be significant enough to impair normal functioning

Question 4

two simple questions to screen for depression

Answer 4

1. During the past month, have you been bothered by feeling down, depressed, or hopeless?
2. During the past month, have you been bothered by little interest or pleasure in doing things?

Question 5

the most important part of the evaluation of depression is

Answer 5

the assessment of suicide risk

Question 6

remarks on antidepressant therapy

Answer 6

Antidepressants take about 2-3 weeks to have clinical effects and may initially place a patient at increased risk of suicide.

Ideally, ED antidepressant prescriptions should be discussed with the follow-up practictioner and should include an arranged visit within a week

Question 7

Black box warning for SSRIs

Answer 7

Antidepressants may increase suicide risk in patients <25 years old

Question 8

Examples of SSRIs

Answer 8

Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertralinee

Question 9

Examples of SNRIs

Answer 9

Duloxetine
Venlafaxine
Desvenlafaxine

Question 10

Examples of atypical antidepressants

Answer 10

Bupoprion
Mirtazapine
Trazodone

Question 11

Examples of heterocyclics

Answer 11

Amitriptyline
Nortriptyline

Question 12

Examples of drugs that may trigger serotonin syndrome

Answer 12

Metoclopramide
Ecstasy, Cocaine
Tramadol
Ondansetron
Dextromethorphan
St John’s wort

Question 13

Treatment of serotonin syndrome

Answer 13

Discontinuing the affecting agents
Benzodiazepines
Supportive care

Question 14

Remarks on Bupoprion

Answer 14

a dopamine reuptake inhibitor
also used for smoking cessation

Question 15

Remarks on Trazodone

Answer 15

a serotonin antagonist and reuptake inhibitor
more sedating than other depressants with less anticholinergic effects
commonly used as a sleep aid

Question 16

Remarks on Mirtazapine

Answer 16

related to the heterocyclic antidepressants
tends to cause weight gain
has a more rapid onset of action of about 1 week

Question 17

remarks on heterocyclic antidepressants

Answer 17

low therapeutic index
side effects are mainly anticholinergic related and cardiotoxic, including prolonged QTc interval and AV block

Question 18

remarks on MAO inhibitors

Answer 18

Monoamine oxidase inhibitors - rarely used first line in treating depression because of potentially lethal drug-drug and dietary interactions

Monoamine oxidase inhibitors block oxidative deamination of tyramine and may precipitate a sometimes FATAL hypertensive crisis when certain drugs (or tyramine-containing foods) are co-ingested:
- sympathomimetic amines
- levodopa
- narcotics
- heterocyclic antidepressants

Question 19

Disposition of the depressed patient

Answer 19

based on the assessment of:
-harm to self or others
-ability to care for one’s self
-level of supportive environement at home
-complicating medical or substance abuse problems

Any combination of the above may require psychiatric consultation for admission evaluation

Question 20

commonly prescribed for chronic or neurogenic pain

Answer 20

Amitriptyline