IC12 Depression Flashcards
RF for suicide
poor, elderly, lonely, man, comorbidities, previous attempts, triggering events, access to meds/firearms
Monoamine hypothesis
decrease NT in the brain — norepinephrine (NE/NA), serotonin (5HT), dopamine (DA)
medical conditions causing depression
- Endocrine disorders: hypothyroidism, T2DM (depression and T2DM affects each other)
- Deficiency states: anemia
- Infections
- Metabolic disorders: electrolyte imbalance, hepatic encephalopathy
- CV: CAD, HF, MI (MI pt more likely to have depression)
- Neurological: Alzheimer, Epilepsy, Pain, Parkinson, post-stroke
- Malignancy
drug induced depression
- Psychotropics: CNS depressants (benzodiazepines, opioids, barbiturates)
- Withdrawal from alcohol and stimulants
- Systemic corticosteroids
- Isotretinoin (very potent vit A)
- Interferon-ß-1a
Clinical Presentation of depression
In.SAD.CAGES
- Interest decr
- Sleep decr
- Appetite decr
- Depressed mood
- Concentration decr
- Activity decr
- Guilt
- Energy low
- Suicide
Dx of depression
A. ≥5 out of 9 sx for at least 2 weeks (of which one of them must be depressed mood or lost of interest)
B. significant distress/ functional impairment
C. not caused my other medical condition/ substance use
Adjustment disorder
sx occurs within 3mths of onset of stressor. sx do not persist if stressor is removed (eg booking in)
Acute stress disorder
sx occurs within 1mth of a traumatic event
what medical condition should be excluded before starting on antidepressants
mania
Depression vs deliruim/dementia
- cyclical onset (good and bad days)
- consciousness not impaired
- no memory loss
Goals to tx
remission, suicide prevention
- assessment tool = PHQ-2/9
Non-pharm
sleep hygiene, psychotherapy, neurostimulation (for severe depression)
When is antidepressants indicated
moderate to severe depression
- mild depression no need antidepressants
first line antidepressant
mirtazapine, SSRI, SNRI, bupropion
acute phase tx: what is an adequate duration?
4-8 weeks
physical sx of depression (sleep and appetite) improves in…
1-2 weeks
mood sx of depression improves in…
4-8 weeks
total duration of antidepressant tx
6-12mths
why does mood sx takes longer to improve?
takes time for presynaptic autoreceptor to down-regulate to have unopposed secretion of NT (intended effect)
eg of TCA
Amitriptyline, Clomipramine, Nortriptyline
eg of SSRI
Fluoxetine, Paroxetine, Sertraline, Fluvoxamine, Citalopram, Escitalopram
eg of SNRI
Venlafaxine, Duloxetine
MOA of mirtazapine
NaSSA: increase 5HT and NE
eg of MAOI used for depression
MAO-AI: moclobemide
MOA of bupropion
Block reuptake of NE and DA (no effect of 5HT)
bupropion should be avoided in which pt
psychosis (increase dopamine worsens psychosis), seizure, 2D6 substrates (bupropion is a 2D6 inhibitor)
which antidepressants have short half life
paroxetine, venlafaxine
which antidepressants have long half life
bupropion, fluoxetine
which antidepressant should be taken with food to increase absorption
sertraline
SE of TCA
- GI, sexual dysfunction
- M1: anticholinergic
- H1: sedation, weight gain
- a1: orthostatic hypotension
- arrhythmia, seizure
SE of SSRI
GI, sexual dysfunction
which SSRI has most anticholinergic SE
most anticholinergic, sedating, weight gain, short T1/2
which SSRI has QTc prolongation
citalopram, escitalopram
SE of SNRI
GI, sexual dysfunction
- venlafaxine: increase BP
SE of mirtazapine
increase appetite sedation, weight gain, reverse GI and sexual SE of SSRI/SNRI
does bupropion has GI/sexual SE?
no (no activity with 5HT)
adjunct for MDD
- SGA: Aripiprazole, Brexpiprazole, Quetiapine XR (for tx resistant/ bipolar depression: olanzapine + fluoxetine)
- Esketamine
- PRN hypnotics
Can St John Wort be used for depression
avoid due to DDI with antidepressants (St John Wort is a 3A4 inducer)
when should antidepressant be swithced?
Adequate trial for 2 weeks & no improvement → switch medications (no need to wait for 4-8 weeks)
Mx of partial/no response
- Switching antidepressants (washout period for MAOI necessary)
- Augmentation with antidepressant with different MOA (mirtazapine, bupropion) or SGA
Define tx resistant depression
no response ≥2 adequate trials of antidepressants
special populations mx
see specialist
- elderly (avoid TCA)
- hyponatremia usually occur with elderly (highest risk with SSRI)
pt <24yo should be counselled for
suicide
drug of choice: underweight + depression
mirtazapine
drug of choice: neuropathic pain + depression
duloxetin
serotonin syndrome
agitation, myoclonus, diaphoresis, confusion, coma
which antidepressants has highest risk of bleeding?
SSRI
avoid taking antidepressants with..
other CNS depressants, alcohol (space apart by 4-6hrs), anticholinergic drugs
1A4 inhibitors
fluvoxamine
2C19 inhibitors
fluvoxamine
2D6 inhibitors
fluoxetine, paroxetine, bupropion
3A4 inhibitors
grapefruit juice
3A4 inducer
rifampicin, carbamazepine, phenytoin, St John Wort
Antidepressants with the fewest DDI
mirtazapine, escitalopram, venlafaxine, desvenlafaxine, vortioxetine
Antidepressant discontinuation syndrome (this is NOT withdrawal) sx
FINISH
- Flu like sx (lethargy, fatigue, headache, sweating)
- Insomnia
- Nausea
- Imbalance (dizziness)
- Sensation tingling
- Hyperarousal (anxiety)
how to avoid Antidepressant discontinuation syndrome
gradually tapering of short acting drugs (paroxetine, venlafaxine)
- long acting drugs no need gradual taper (bupropion, floxetine)
