ic12 depression (general) Flashcards
what are the secondary causes of depression (medical disorders)
endocrine: hypothyroidism, cushing, DM
deficiency states: anemia, wernicke’s encephalopathy
infection: CNS infections, STD/HIV, TB
metabolic disorders: electrolyte imbalance, hepatic encephalopathy
CV: CAD, CHF, MI
neurological: AD, epilepsy, PD, post stroke.
malignancy
what are the secondary causes of depression (psych disorders)
alcoholism, anxiety disorders, eating disorders, schizophrenia
what are the secondary causes of depression (drug induced)
1) lipid soluble beta blockers eg propanolol
2) psychotropics eg cns depressants (benzo, opioid, barbiturates, anticonvulsants)
3) withdrawal from alcohol/stimulants
4) corticosteroids (systemic)
5) isotretinoin
6) interferon beta 1a
dsm5 diagnostic criteria for MDD
5 symptoms in the same 2 week period: In SAD CAGES
interest
sleep
appetite
depressed mood
concentration
activity
guilt
energy
suicidal
and causing significant distress or impairment in social, occupational, or other important areas of functioning.
NOT caused by an underlying medical condition/substance.
differential diagnosis for MDD
1) adjustment disorder
- symptoms occur within 3 months of onset of a stressor, but once terminated, do not persist for an additional 6 months
2) acute stress disorder
- symptoms occur within 1 month of traumatic event and lasts 3 days - 1 month
- sx include intense fear, helplessness, horror, with dissociation, re-experiencing, avoidance, increased arousal.
3) persistent depressive disorder
- depressed mood + 2 other symptoms for 2 years (not fulfilling the MDD diagnosis)
GENERAL assessment for dementia
same as schizophrenia
exclude other medical conditions ESPECIALLY MANIA.
what is the non phx management for depression
1) sleep hygiene
2) psychotherapy
3) neurostimulation (mostly for psychosis)
- ECT for severe/refractory cases (good evidence for depression but affects large area of the brain).
- rTMS.
treatment alogrithm for depression
ACUTE PHASE
adequate dose for 4-8 weeks
counsel patient that there is delayed onset of effectiveness (due to gradual downregulation of pre-synaptic autoreceptors in the synapse)
- phy symptoms improve in 1-2 weeks (sleep, appetite)
- mood symptoms: 4-8 weeks to improve
CONTINUATION
1st episode of uncomplicated MDD = continue for another 4-9 months after acute phase treatment
TOTAL
6-12 MONTHS
what are the first line treatment options for depression in Singapore? include subsidised medication…
SSRI
- fluoxetine and fluvoxamine (subsidised)
SNRI
- venlafaxine (SDL2)
Mirtazapine
Bupropion
only consider MAOi and TCA if resistant to first line.
what antidepressants to consider for patients with low energy
bupropion: dopamine agonist = can help to increase energy (NDRI)
- note that it might affect psychosis (by increasing dopamine further) and seizure risk AND potent 2d6 inhibitor.
fluoxetine, escitalopram etc due to OM dosing (can help the patient be more alert
how to manage no response
1) SWITCH
if completely ineffective or intolerable to adequate dose in 2-4 weeks
- switch to another agent
- consider cross titration (combination = watch for serotonin syndrome)
how to manage partial response
2) AUGMENT
- combine a 2nd antidepressant with diff MOA
- e.g., mirtazapine, buproprion, T3 (liothyronine), lithium
OR adjunctive SGAs: quet XR, aripiprazole, brexpiprazole
cross-tapering
what, when, and why
if
- switching from serotonergic agent used daily for the past 2 months to non-serotonergic antidepressant (bupropion), consider cross-tapering
- decrease dose of the old agent while simultaneously increasing dose of the other
reason: reduce risk of antidepressant discontinuation syndrome
what is the washout period for MAOis
MAOi to antidepressant
- 24h washout
antidepressant to MAOi
- at least 1 week
- 5 weeks if fluoxetine
treatment resistant depression what and how to manage
if resistant ≥2 trials,
consider
1) ECT/rTMS
2) symbyax oral cap (olanzapine + fluoxetine)
3) spravator nasal (esketamine) adjunt to SSRI/SNRI
what to consider for pregnancy
nortriptyline for late pregnancy
what to consider for breast feeding
sertraline or mirtazapine
what to consider for post partum depression
brexanolone (gaba a modulator)
what to consider for renal impairment
vortioxetine
what to (avoid and) consider for hepatic impairment
avoid agolmelatine
if mild to moderate: vortioxetine
what to consider for post mi depression
sertraline
what to avoid for elderly patients
what is common in elderly patients taking antidepressants
TCA
SIADH = hyponatremia
- associated with all antidepressants esp SSRIs
elderly monitoring for antidepressants
SIADH
monitor serum sodium at baseline –> 2nd week, 4th week –> q3 mohtly
what antidepressants have less risk of SIADH/hyponatremia
agomelatine,
mirtazapine,
bupropion
what to consider in children and young adults taking antidepressants
risk of suicide
in patients ≤24YO
REQUIRE CONUNSELLING and close monitoring, regular review.
what are the sx of antidepressant discontinuation syndrome
FINISH
1) flu like symptoms: lethargy, fatigue, headache, ache, sweating
2) insomnia (w vivid dreams or nightmares)
3) nausea (maybe vomiting)
4) imbalance (dizziness, vertigo, light-headedness)
5) sensory disturbances (burning, tingling…)
6) hyperarousal (anxiety, irritation, agitation, mania, jerkiness).
what is antidepressant discontinuation syndrome? incl onset and duration, resolution
usually onset 36-72 hours,
worse if patient abruptly stops treatment (esp paroxetine, venlafaxine due to short half life)
for 3-7 days
usually resolves 1-2 weeks without treatment
how to avoid antidepressant discontinuation syndrome?
avoid by gradually tapering
- half tablet of lowest strength every 1-2 weeks if patient has been on regular dosing for ≥6-8 weeks.
may not be necessary for fluoxetine and bupropion due to longer half life (of drug/active metabolite)
patient counselling details
1) may take some time to help with symptoms, and at least a couple months for anxiety
2) do not take w alcohol, space 4-6h apart
3) inform dr or nurses other medicine you are taking
4) if condition is worsening, bothered by SE, or feel sucidal, inform doctor
possible side effects to be informed.
