Lecture 2 - Major Depressive Disorder Flashcards
DSM-V definition of depression
> 1 major depressive episode w/ no hx of mania or mixed mood episodes
need to have > 5 of criteria, nearly every day for > 2 weeks
** Must include Depressed mood or reduced interest/pleasure ** among them
SIG E CAPS
Sleep disturbance (insomnia/hypersomnia)
I interest
G guilt (excessive)
E Energy (reduced)
C concentration (impaired)
A appetite changes (inc/dec)
P psychomotor agitation/retardation
S suicidial thoughts/attempts
Treatment response is…
50% reduction in symptoms
usually 4-8 weeks
Remission is….
Few to no symptoms over > 3 weeks
Return to previous lvl of functioning
Acute Phase Txm info
Goal = remission
Agents selected based on pt specific factors, preference, prior response, FH, SE, comorbidities, DI
Optimize Dose/regimen
6-12 weeks
Continuation Phase Txm info
Goal = revent relapse
Continue agent/dose that led to remission
Relapse risk = 20-85% if txm not continued
4-9 months
Maintenance Phase Txm info
Goal = prevent recurrence
Recommended if > 3 depressive episodes
duration can be indefinite or lifelong
13-36 months
General Txm approach depression
Psychotherapy + 1st line = SSRI, SNRI, bupropion, mirtazapine, vortioxetine for 4-8 week
If Adequate Response (50% symptom reduction) continue at optimal dose and re-eval 6,8,12weeks
If persistent symptoms = inc dose or switch or augment with alt or with SGA +/- psychotherapy
** if < 50% improv after 8 wks, consider switch **
What to do for subclinical depression
psychotherapy recommended
Takeaways from STAR*D trial
switch possible if no response to one SSRI
maximizing dose is important
trial of 8-12wks before determine med ineffective
When should you do follow-up for depression treatment
every 1-2wks after initiating
re-eval 2-4wks, then again 8-12wks
strategies for partial/non-response
Switching = cross taper over 1-2weeks, 1 down other up
Augmentation with another antidepressant or SGA
Treatment Resistance
Defined as failure to respond to 2 sep trials of dif antidepressants of adequate dose/duration
Switch to another AD, augment with lithium, triiodothronine
Rank SSRI by half life (longest to shortest)
- Fluoxetine
- Citalopram
- Escitalopram
- Sertraline
- Paroxetine
- Fluovoxamine
St.Johns Wort info
Bunch of DDI and SE
Not really recommended for anyone
Only for someone who is healthy, young, no other meds, no money for meds, etc
When is Lithium used for augmentation?
usually with TCA but not really used
** monitor lvls & renal function **
When is Triiodothyronine (T3) used for augmentation?
use if not dependent on thyroid function/status
May lead to hyperthyroidism
Ketamine
rapid improvement in treatment-resistant depression (exp, off label)
given IV up to 3 times per week
Esketamine (Spravato)
NMDA antagonist
given intranasally
REMS program associated, monitored for atleast 2hrs..has to be reg with company
Done in healthcare setting
Dextromethorpahn/bupropion (Auvelity)
req renal dose adjustments
Taken twice daily, SE mostly Bupropion associated
If pt has cardiac/risk of QT prolongation, preferred med is….
Sertraline
Avoid those with high risk or high dose
If pt is using tobacco, preferred agent is….
Bupropion
If pt has seizure disorder/risk of seizures, Hx of active eating disorder then preferred agent is….
None preferred
CI = Bupropion, TCA
If pt is pregnant, preferred agent is….
Psychotherapy, if severe then Citalopram, Escitalopram, Sertraline
CI = Paroxetine, MAOIs, vortioxetine
