IC11 Depression Flashcards
What are the main etiological classes of MDD? (6)
- Biological → hormonal increases (increased secretion of cortisol) and monoamine hypothesis (decreased neurotransmitters (NE, 5-HT and DA) in the brain
- Psychological → loss, negative self-evaluation
- Psychosocial → isolation, lack of social support (5 basic appetites of food/water, sleep, work, hobbies and sex)
- Genetics
- Medical → secondary to medical disorders like DM, CVA and cancer
- Pharmacological → drug-induced
Which medical disorders can be secondary causes for depression? (7)
- Endocrine (hypothyroidism)
- Deficiency states (anemia)
- Infections
- Metabolic d/o (electrolyte imbalance)
- CV (CAD, CHF, MI)
- Neurological (AD, epilepsy)
- Malignancy
Which states or drug classes can induce depression? (3)
- Withdrawal from alcohol or stimulants
- Psychotropics
- Systemic corticosteroids
What are the 3 broad points in DSM-5 classification for depression?
- At least 5 sx present during the same 2-week period and represent a change from previous functioning (present for most of the week or almost everyday) where one of the symptoms must be depressed mood or loss of interest
- Sx cause significant distress or impairment in social, occupational or other important areas of functioning
- Sx not caused by an underlying medical condition or substance (reversible)
What are the symptoms that depressed patients exhibit (At least 5 sx from DSM-5)?
In.SAD.CAGES
- Interest: decreased interest and pleasure in normal activities
- Sleep: insomnia or hypersomnia (less than 3h of sleep with normal function is a cause for worry)
- Appetite: decreased appetite, weight loss (especially things they usually like eating)
- Depressed: depressed mood (in adults)
- Concentration: impaired concentration and decision making
- Activity: psychomotor retardation or agitation
- Guilt: feelings of guilt or worthlessness
- Energy: decreased energy or fatigue (possible link to metabolic disorders)
- Suicidal thoughts or attempts
Describe adjustment d/o
sx occur within 3 months of onset of a stressor but once stressor is terminated, sx do not persist for another 6 months
Describe acute stress d/o
sx occur within 1 month of a traumatic event and last 3 days to 1 month, including intense fear, helplessness, horror, dissociation, re-experiencing, avoidance and increased arousal
(becomes PTSD if prolonged)
Which clinical-rated tool can be used for MDD and what score indicates remission?
HAM-D
score of ≤ 7 indicates remission
Which self-rated tools can be used in MDD?
PHQ-2 (screening tool)
PHQ-9 (assessment tool)
Which 2 questions should be asked for PHQ-2, where a positive answer to either warrants administering PHQ-9?
(1) little interest in doing things and (2) feeling down, depressed or hopeless
What scores for PHQ-9 warrant antidepressant therapy?
10 and above
What are the non-pharmacological treatment options for depression? (3)
- Sleep hygiene
- Psychotherapy (not suitable as monotx)
- Neurostimulation and light therapy
What are the first-line drugs for depression? (4)
Mirtazapine
SSRIs
SNRIs
Bupropion
What is an adequate trial in the acute phase of treatment?
adequate dose and duration of 4-8 weeks
How long should continuation phase treatment for depression last for first episode of uncomplicated MDD?
for first episode of uncomplicated MDD, continue for at least another 4-9 months after acute-phase treatment
total 6-12 month treatment at least (if stop before 6 months, high likelihood of relapse)
Name some (1) TCAs, (2) SSRIs, (3) SNRIs
TCA: amitryptyline, clomipramine, imipramine, nortryptyline
SSRI: fluoxetine, fluvoxamine, escitalopram, citalopram, paroxetine, sertraline
SNRI: venlafaxine, duloxetine
Which 2 half-lives are important to note for antidepressants?
- Fluoxetine (SSRI) has a half life if 4-6 days (very long)
- Vortioxetine (SMS) has a half life of 66h (longer than most)
Explain the MOA of TCAs
Blocks reuptake of NE and 5HT and has anticholinergic and H1 and α-adrenergic antagonism
What are the side effects of TCAs? (3+5)
- GI SE (5HT-3)
- Sexual dysfunction (5HT-2)
- Anticholinergic SE
Other SE: sedation, weight gain, orthostatic hypotension, arrhythmias and seizures
Can be fatal on overdoses
Explain the MOA of SSRIs
Blocks reuptake of 5HT selectively
What are the side effects of SSRIs? (2)
GI and sexual dysfunction
Which is the most anticholinergic SSRI
paroxetine is the most anticholinergic with short half-life and causes the most sedation, weight gain
Explain the MOA of SNRIs?
blocks reuptake of NE and 5HT
What is the additional SE of venlafaxine?
Hypertension
What else is duloxetine indicated for?
diabetic peripheral neuropathy, fibromyalgia and chronic musculoskeletal pain
Explain the MOA of mirtazapine (NaSSA)?
increases 5-HT and NE, additional 5-HT (2, 3) and H1 antagonism (opposite effects to serotonin)
Can be used to reverse the GI and sexual SE of SSRI/SNRIs
What are the side effects of mirtazapine? (3)
increased appetite, weight gain, somnolence
Explain the MOA of bupropion (NDRI)
blocks reuptake of NE and DA
What are the side effects of bupropion? (4)
seizures, insomnia, psychosis, not suitable for eating disorder (due to high risk of seizures)
Explain the MOA of moclobemide?
Reversible Inhibitor of MAO-A
Why aren’t irreversible MAOIs used?
Can result in hypertensive crisis
Which main class of medication (3 examples) can be used as adjunct for MDD?
SGAs (aripiprazole, brexpiprazole, quetiapine XR)
Which other medications can be given as adjunct for MDD?
- Benzo (lorazepam)
- Z-hypnotics (zolpiclone)
- Antihistamines (promethazine, hydroxyzine)
- Melatonin
What are the important doses to remember for TCAs? (2)
Amitriptyline max 300mg a day
Clomipramine max 300mg a day
How is fluoxetine dosed?
Fluoxetine start at 20mg OM, max 80mg a day
How is desvenlafaxine dosed?
Desvenlafaxine usually dosed 50mg a day
How is mirtazapine dosed?
Mirtazapine usually dosed 15-45mg a day
What should be done when switching antidepressants for cross-titration and direct switching?
For cross-titration avoid combinations of serotonergic agents
If direct switch, can stop one SSRI completely and initiate another serotonergic agent
When should washout period be observed when switching antidepressants?
Necessary for MAOIs (eg. when switching from moclobemide to another antidepressant or vice versa)
Which antidepressants can be added on for augmentation?
mirtazapine or bupropion SR
(use antidepressant with a different MOA)
How is treatment resistant depression defined and what should be done?
If there is no response to ≥ 2 adequate trials on antidepressants, consider other means like neurostimulation (electroconvulsive therapy)
What should you look out for in elderly?
Hyponatremia (drowsiness, confusion, convulsions)
Which 2 classes of drugs should be avoided in elderly and why?
TCAs and anticholinergics (risk of postural hypotension and cardiac SE)
What should be taken note of when starting antidepressant therapy in younger patients?
Association with suicidality in patients ≤ 24 years old, counselling should be given to all patients
What is the antidepressant of choice in underweight patients?
Mirtazapine due to side effect of increased appetite and weight gain
What is the antidepressant of choice in patients with chronic pain or neuropathy?
SNRIs or TCAs (duloxetine is licensed for DPN)
What are the clinically significant DDIs and what can be done to manage them if applicable? (4)
- Combination of 2 serotonergic agents can result in serotonin syndrome → try not to administer together
- SSRIs increase bleeding risk (especially for elderly on anticoagulants, antiplatelets and NSAIDs) → consider giving PPI
- Increased CNS depressant effect s alcohol and other CNS depressants → avoid combination or separate 4-6h apart
- Anticholinergic agents can cause excessive anticholinergic effects
What are the mild, moderate and severe symptoms of serotonin syndrome?
Mild - insomnia, anxiety and nausea (IAN)
Mod - agitation, myoclonus, tremors, flushing (AMTF)
Severe - hyperthermia, respiratory failure, coma, death (HRCD)
What are the symptoms of antidepressant discontinuation?
- Flu-like symptoms
- Insomnia
- Nausea
- Imbalance
- Sensory disturbances (electric-like disturbances)
- Hyperarousal (anxiety)
How long does antidepressant discontinuation syndrome last and how can it be avoided?
Usually resolves over 1-2 weeks
Can avoid by gradually tapering by half a tablet of the lowest strength every 1-2 weeks
