Lecture 5: Depression & Anxiety Flashcards
What is wellness based on?
The integrated and coordinated function of many neurotransmitter systems
What is the broad definition of a disorder?
Imbalance impairing function and quality of life
What are psychiatric disorders?
CNS diseases characterized by disturbances in emotion, cognition, motivation, and socialization
True or false: psychiatric disorders are homogeneous syndromes, meaning they are the same in every case
False, they are heterogeneous syndromes, meaning they are different in every case/patient
How are psychiatric disorders diagnosed?
Clinical observations and criteria
How often do anxiety and sleep disorders co-occur?
Very often
What kind of neural flow is found in sleep disorders?
Stimulating more than calming
What are characteristics of NORMAL anxiety?
Adaptive and temporary
What are characteristics of EXCESSIVE anxiety?
Persistent, severe, and impairs function
What is anxiety good for?
Preparing for/reacting to environmental changes
What is the diagnostic criteria for generalized anxiety disorder (GAD)?
1) Excessive anxiety and worry, occurring more-days-than-not for at least 6 months, about a number of issues
2) Patient finds it difficult to control the worry
3) Exhibits 3 of the symptoms: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, or sleep disturbance
What are the stages of a sleep cycle?
Stage 1, 2, 3, 4, and REM
What is delta sleep?
The most restorative sleep; difficult to arouse; muscle atonia
How many sleep cycles does a typical person go through each night?
4-6
Where does the circadian rhythm come from?
Suprachiasmic nucleus
What is the target of the majority of sleep medications?
Alter sleep cycles
What triggers non-REM sleep?
Primary serotonergic tracts in medulla and dorsal raphe nucleus
What enables REM sleep?
Cholinergic tracts
What turns off REM sleep?
Noradrenergic areas
What 6 hormones produce an “alerting” effect?
1) Dopamine
2) Norepinephrine
3) Acetylcholine
4) Histamine
5) Substance P
6) CRH (cortisol)
What 4 factors can cause insomnia?
Situational, medical, psychiatric, or pharmacological factors
What are the common problems in sleep disorders?
- Difficulty falling asleep
- Difficulty maintaining sleep
- Non-restorative sleep
What is the ideal treatment for sleep disorders?
Improvement without medication
What are some situational causes of insomnia?
Stressors, jet lag, shift work
What are some medical causes of insomnia?
Cardiovascular, respiratory, pain, endocrine, GI, neurologic, pregnancy
What are some psychological causes of insomnia?
All disorders including substance abuse
What are some pharmacological causes of insomnia?
Anticonvulsants, adrenergic blockers, diuretics, SSRI, seriods, stimulants
What 4 conditions are all linked?
Anxiety, sleep disorders, chronic pain, and depression
What are 3 treatment targets in insomnia?
1) Address reversible causes and utilize sleep hygiene techniques
2) Enhance GABA and serotonin
3) Inhibit histamine, ACh, NE, dopamine, substance P and cortisol
What are 2 medications that are GABA agonists?
Benzodiazepines and zopiclone
What other medications besides GABA agonists can be used in the treatment of insomnia?
Antihistamines, antidepressants, and melatonin or related agonists
What types of drugs can cause anxiety?
Antidepressants, bronchodilators, steroids, herbals, thyroid, and stimulants
Withdrawal from ____ can cause anxiety
Sedatives
Describe the noradrenergic model of anxiety
ANS is overactive causing excessive NE and glutamate
Describe the GABA model of anxiety
Increased GABA can favourable impact 5HT, NE, and dopamine
Describe the serotonin model of anxiety
Increasing 5HT causes decreased LC firing and NE “excess”, which causes decreased overstimulation
What is the main goal of anxiety treatment?
Define condition and focus on reduction of reversible factors, as well as decrease duration and severity of symptoms to improve overall functioning
What are some physical symptoms of anxiety?
Restlessness, fatigue, muscle tension, sleep disturbance, and irritability
What type of treatment do physical symptoms of anxiety respond quickly to?
GABAa agonists
What type of treatment has better long-term effects for physical symptoms of anxiety, but what is the drawback to them?
- Antidepressants
- Can increase physical symptoms at first and benefits take time
What is a disadvantage to benzodiazepines in anxiety?
Have a dependence liability because of fast onset and rapid elimination
What are cognitive symptoms of anxiety?
Worries hard to control, on edge, poor concentration
What can cause quick easing of cognitive symptoms of anxiety?
Benzodiazepines
What is the treatment of choice for chronic anxiety symptoms?
Antidepressants
What non-pharm treatments are essential for optimal management of anxiety disorders?
Psychoeducation, psychotherapy, meditation, and exercise
What are properties of benzodiazepines?
Muscle relaxant, anxiolytic, sedative, and anticonvulsant
What is the main function of benzodiazepines?
GABA agonist (decreases CNS excitability by increasing GABA)
What does the onset speed of benzodiazepines correlate with?
Lipid solubility
What does a longer half-life mean?
Slower drug elimination and longer “hangover” effect
What does a shorter half-life mean?
Fast drug elimination and increased rebound symptoms, leading to a risk of dependency
What types of benzodiazepines have a short half-life?
Lorazepam and alprazolam
What is the role of pharmacists in sleep and anxiety disorders?
1) Educate about non-drug strategies
2) Educate about importance of thorough assessment and appropriate pharmacologic strategies
3) Educate about appropriate time-frames
4) Promote adherence
What does a major depressive episode cause?
Significant distress or dysfunction
What does NOT cause major depressive episodes?
Medication, mental illness, drug of abuse, or bereavement
What must be included in a major depressive episode?
Depressed mood and anhedonia (lack of pleasure in otherwise pleasurable activities) and must include 5 symptoms consistently in a 2 week period
What are the symptoms of a major depressive episode?
Depressed most of the day; anhedonia; weight loss; sleep disturbance; psychomotor changes; fatigue; feelings of worthlessness; inability to concentrate; suicidal thoughts
What is noticed in the neuropathology of anxiety disorders?
- Small decrease in hippocampal size
- Increased activation of amygdala (centre for emotions and motivation) by negative stimuli
- Decreased activation of nucleus accumbens by rewarding stimuli
How is depression diagnosed?
Validated questionnaires or scales to screen for and measure severity
What must be included in a medical workup for depression?
Thyroid function
What is the function of St. John’s Wort for depression?
Impacts many neurotransmitters
What is St. John’s Wort effective for?
Mild to moderate depression
What is a disadvantage to St. John’s Wort?
Potential for interacting with prescription medications
What are 10 potential sites for drug action?
Action potentials in presynaptic fiber; synthesis of neurotransmitter; storage; metabolism; release; reuptake into nerve ending or uptake into glial cell; degradation; receptor for the transmitter; receptor-induced increase or decrease in ionic conductance; retrograde signalling
What is the most common site of drug action in antidepressants?
Reuptake into nerve ending or uptake into glial cell
What does more storage mean?
More release
What does less metabolism mean?
More neurotransmitter
What does more release mean?
More signalling
What is degradation used for?
Treatment resistant patients because it has a number of side effects
How can you minimize side effects of an antidepressant?
Start with a low dose and work up
True or false: antidepressants cause addiction or dependency
False
What is needed for full and optimal benefits of antidepressants?
Long-term administration
What is serotonin involved in regulating?
Impulsivity, anxiety, irritability, sex, appetite, aggression, mood, emotion, and cognitive function
What is norepinephrine involved in regulating?
Energy, interest, motivation, anxiety, irritability, mood, emotion, and cognitive function
What is dopamine involved in regulating?
Drive, motivation, sex, appetite, agression, mood, emotion, and cognitive function
What are markers of poor outcomes of depression?
More severe presentation, longer time untreated, number of episodes, and frequency of relapse
What are factors that are consistent with better outcomes in patients with depression?
Access to supports, adherence to treatment, a history of “more rapid” response, and lower life stressors
Is adherence or compliance more important?
Adherence
What are 4 factors that impact our “psychiatric immune system”?
1) Psycho-social elements like feeling connected, valued, supported, threatened, and vulnerable
2) Life events and stressors
3) Socio-economic factors
4) Overall physical and mental health
