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3153 Psychiatry > IC11 Major Depressive Disorder > Flashcards

IC11 Major Depressive Disorder Flashcards

1
Q

What is the patho of MDD?

A

Possible cause pathophysiology of MDD:
- Monoamine hypothesis: ↓NTM in brain –> ↓NE, 5-HT, DA

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2
Q

How to diagnose MDD? What are the symptoms to look out for?

A

Diagnosis:

  • At least 5 out of 9 symptoms of InSADCAGES (at least 1 is depressed mood or loss of interest) over the most of the same 2-week, causing significant distress or functional impairment
    o Interest: ↓Interest and pleasure
    o Sleep: insomnia, hypersomnia
    o Appetite: ↓appetite, weight loss
    o Depressed
    o Concentration impaired
    o Activity: retardation, agitation
    o Guilt
    o Energy low
    o Suicidal thoughts
  • Rule out:
    o Drug-induced e.g. beta-blockers, CNS depressants like BZDs, opioids, alcohol withdrawal, substance abuse, corticosteroids
    o Medical conditions e.g. hypothyroidism, HF, MI, alcoholism etc.
    o Bipolar
    o By doing labs and test: vital signs, weight, BMI, FBC, U/E/Cr, LFTs, TFTs, ECG, fasting blood glucose, lipid panel, urine toxicology
  • Goal of therapy: remission of symptoms, treatment adherence, suicide prevention
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3
Q

What are the RF of suicide?
What are the common causes of suicide?
What re the 2 things you need to look out for in a person with risk of suicide?

A

Suicide:

  • Risk Factors: poor, elderly, lonely, men, physical/mental comorbidities, previous attempts
  • Common causes: schizophrenia, major depression, alcohol-use disorders
  • Risk assessment: ask about 1) ideation 2) suicide plan
  • If yes to any of the questions, refer to behavioral health counselling/ contact crisis lines
  • If very high risk, seek immediate help, contact behavioral health intake, go to emergency room, call 995
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4
Q

What is the onset, consciousness, and memory of people with MDD? VS Delirium, Dementia, Withdrawal

A

Depression:
Cyclical
Generally unimpaired
Intact

Delirium:
Acute
Impaired
Poor

Dementia:
Step wise
Clear until later stages
Poor

Withdrawal:
Acute
Unimpaired to impaired
Intact

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5
Q

What are the non-pharm for MDD?

A

Non-pharmacological Management (monotherapy for mild depression):

  • Sleep hygiene
  • Psychotherapy
  • Counselling
  • ECT for severe depression / refractory cases
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6
Q

Which level of severity then start antidepressants?

A

mod-severe

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7
Q

What are the 1st line for MDD? Based on what criteria are the meds chosen?

A
  1. Antidepressant
    a. For mod-severe depression
    b. Do NOT use alone for bipolar (risk of maniac switch)
    c. 1st line Choices: mirtazapine, SSRI (e.g. fluoxetine, fluvoxamine, escitalopram), SNRI (e.g. venlafaxine, duloxetine), bupropion, agomelatine >TCA>MAOi
    i. Choose based on target symptoms, interactions (DDI/drug-disease interactions), prior response, patient preference
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8
Q

What is the acute phase treatment duration?
Give the timeline of improvement in symptoms.

A
  1. Acute Phase Treatment
    a. 4-8 weeks on adequate dose
    i. Physical symptoms (sleep, appetite) –> 1-2wks to improve
    ii. Mood symptoms (depress) –> >6wks to improve
    iii. Delayed onset of effectiveness due to gradual down regulation of pre-synaptic autoreceptors in the synapse, in turn facilitates NTM release
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9
Q

Why is there a delayed onset of effect when using antidepressant?

A

iii. Delayed onset of effectiveness due to gradual down regulation of pre-synaptic autoreceptors in the synapse, in turn facilitates NTM release

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10
Q

After the acute phase, what is the minimum total duration of treatment needed for MDD?

A

Continuation Phase Treatment

  • Total of at least 6-12 months
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11
Q

What are some adjunctive therapy to be used with antidepressants for MDD?

A
  1. Adjunctive therapy
    a. Short course (1-2 weeks) of PRN hypnotics/anxiolytics
    b. For MDD –> SGA e.g. Aripiprazole, brexpiprazole, quetiapine XR + antidepressants
    c. For MDD insomnia –> BZDs, z-hypnotics, antihistamines PRN
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12
Q

How to manage partial/no response?

A

Managing partial/no response:

  • If partial response in 2wks
    i. ↑dose / add 2nd antidepressant with diff mechanism e.g. mirtazapine, bupropion, adjunctive SGAs
  • If no response in 2wks, change med
    i. switch SSRI to dual mechanism e.g. SNRI, mirtazapine, bupropion, agomelatine, vortioxetine
    ii. can stop SSRI totally if the next med is serotonergic
    iii. need to gradually taper over several weeks to reduce antidepressant discontinuation syndrome if change to non-serotonergic agent
    iv. watch for serotonin syndrome if add serotonergic agents
    v. wash out period is necessary for MAOIs
    Switch from moclobemide to another anti-depressant: 24hrs
    Switch from anti-depressant to moclobemide: at least 1wk / 5wks if stopping fluoxetine
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13
Q

What are the options for treatment-resistant MDD?

A

Treatment-resistant depression
1. ECT
2. Olanzapine + Fluoxetine capsule
3. Esketamine + SSRI/SNRI

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14
Q

Which TCA can be used for OCD?

A

Clomipramine

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15
Q

Why are TCAs not 1st line?

A

A lot of side effects

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16
Q

What are the ADRs of TCAs?

A

(↑NE, 5-HT; ↓H1, a-adrenergic; anticholinergic)

1) GI, sex dysfunction
2) Anticholinergic
3) Sedation, weight gain
4) orthostatic hypotension
5) Arrhythmias
6) Seizures
7) Fatal on overdose

17
Q

What are the ADRs of SSRIs?

A

1) GI, sex dysfunction
2) Insomnia (fluoxetine)
3) Hyponatremia (SIADH)
4) Bleeding risk
5) sedation
6) serotonin syndome

18
Q

Which SSRI has long t1/2? What is the implication of this?

A

Fluoxetine (4-6days) –> no need to taper when stop

19
Q

Which SSRI has a short t1/2?

A

Paroxetine –> Need to taper when stopping to prevent anti-depressant discontinuation syndrome

20
Q

Which SSRI can lead to QTc prolongation at high doses in elderly?

A

Escitalopram, citalopram

21
Q

What is the addtional ADR of paroxetine that is not favourable compared to the rest of the SSRIs?

A

Most anticholinergic, sedating, weight gain

22
Q

What are the ADRs of venlafaxine?

A

1) GI, sex dysfunction
2) HTN

23
Q

What are the ADRs of duloxetine?

A

1) GI, sex dysfunction
2) Urinary hesitancy

24
Q

What is the additional indication of duloxetine that is approved by the FDA?

A

Chronic Pain (e.g. diabetic peripheral neuropathy, urinary incontinence, fibromyalgia, & chronic musculoskeletal pain)

25
Q

What are the ADRs of vortioxetine?

A

GI, sex dysfunction

26
Q

What are the NTM mirtazapine increases or decreases?
What are the ADRs of it?

A

(↑NE, 5-HT;
antagonizes 5-HT2&3, H1, a2-adrenergic)

1) Somnolence/sedation
2) ↑appetite, weight gain

1) GIVE IF no appetite/insomnia /underweight
2) REVERSE / minimal GI & sex dysfunction
3) GIVE IF hyponatremia
4) Lower risk of bleeding

27
Q

What are the 5 specific occasions when mirtazapine should be considered?

A

1) GIVE IF no appetite/insomnia /underweight
2) REVERSE / minimal GI & sex dysfunction
3) GIVE IF hyponatremia
4) Lower risk of bleeding

Linked to the ADRs:

  • Somnolence/sedation
  • ↑appetite, weight gain
28
Q

What are the 3 CI of bupropion?

A

1) Seizures
2) Psychosis
3) eating disorder

29
Q

What are the ADRs of bupropion?

A

1) Seizures
2) Insomnia
3) Psychosis
4) CI in eating disorder
5) worsen HTN

30
Q

What are the 4 occasions when bupropion should be considered?

A

2) GIVE IF no energy (avoid if have insomnia)
3) Minimal sexual dysfunction since no 5-HT effects
4) GIVE IF hyponatremia
5) Lower risk of bleeding

31
Q

What are the 3 ocassions to consider agomelatine?

A

1) Minimal sexual dysfunction
2) GIVE IF hyponatremia
3) Lower risk of bleeding

32
Q

What is trazodone mostly used for?
What is the trazodone’s ADR that we should look out the most?

A

Indication: Insomnia

1) GI, sex dysfunction
2) Sedation
3) Orthostatic Hypotension

33
Q

Which are the fastest antidepressants?

A

PO mirtazapine/PO escitalopram

34
Q

Which group of patients are at the higher risk of suicidality?

A

Suicidality esp. with <24y/o –> need to counsel patients and caregivers

35
Q

Which antidepressant as the fewest CYP (1A2, 2D6) interactions?

A

a. Minimal CYP (1A2, 2D6) interactions: mirtazapine, escitalopram (but still increase hypertension), venlafaxine, desvenlafaxine, vortioxetine

36
Q

What are the significant pharmacodynamic interactions/DDI? there are 4.

A

Significant PD interactions:

  1. CNS depression
    - (alcohol, BZDs)
    - Separate alcohol from antidepressants 4-6hrs apart
  2. Serotonin syndrome e.g. insomnia, anxiety, nausea, diarrhea, HTN, tachycardia, hyper-reflexia, agitation, myoclonus, tremor, confusion, death etc.
    - (tramadol, fentanyl, pethidine, triptans, MAOI, linezolid, ritonavir, other serotonergic antidepressants)
  3. SSRIs: ↑risk of bleeding
    - (NSAIDs, warfarin, aspirin, steroids –> add PPI; stop taking SSRI 2wks before surgery if high bleeding risk)
    - Agomelatine, bupropion, mirtazapine safest
  4. Excess anticholinergic effects
    - Anticholinergic agents
37
Q

What is the herb that should not be taken with antidepressant?

A

St John’s Wort (significant increase in serotonin; thus can cause serotonin syndrome)

38
Q

How to avoid antidepressant discontinuation syndrome?
Which drugs are most at risk with this?
Which drug is not at high riskl of this?
What are the symptoms of this syndrome?

A

Discontinuation of antidepressants
a. Gradual tapering over several weeks after long term use.
b. Discontinuation symptoms least likely with fluoxetine (due to long t1/2)
c. but most likely with paroxetine and venlafaxine (due to short t1/2)
d. FINISH Symptoms
i. Flu like sx e.g. lethargy, fatigue, headache
ii. Insomnia
iii. Nausea
iv. Imbalance
v. Sensory disturbances e.g. electric like sensation
vi. Hyperarousal e.g. anxiety

3153 Psychiatry (10 decks)

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