Major Depressive Disorder - General Concepts

Question 1

MDD risk factors:

Answer 1

1. genetics (blood relatives suffering/suffered from MDD, bipolar, alcoholism, suicide)
2. traumatic/stressful life experiences
3. predisposing personality traits (e.g. low self-esteem, over-dependence on others, self-critical, pessimistic)
4. Medical comorbid conditions (e.g. HIV, anemia, MS, Parkinson’s cancer, etc.)

Question 2

What do we know about the pathophysiology of depression?

Answer 2

It’s complex, it involves amine hormones (5HT, NE, DA), it may involve brain-derived neurotrophic factor, and there’s likely structural/fn’al changes in the emotional processing parts of the brain

Question 3

Another name for MDD.

Answer 3

Unipolar depression

Question 4

Sx’s of depression

Answer 4

SIG E CAPS

Sleep changes (more or less of it)
Interest (loss)
Guilt (worthless)

Energy (lack)

Cognition/concentration (reduced)
Appetite (usually less)
Psychomotor (agitated or lethargic)
Suicide (ideation, attempt)

Question 5

Major meds assoc w/ inducing MDD

Answer 5

CV agents: clonidine, methyldopa

anticonvulsants: phenobarbital, topiramate, vigabatrin

Hormonal agents: CS’s, GnRH agonists, tamoxifen

Immunologic: interferon

Beta blockers: lipophilic ones

Question 6

Name a valid scale used to assess for the presence of MDD:

Answer 6

PHQ-9
QIDS
BDI
HAM-D
MADRS

Question 7

Objective findings in pts with MDD.

Answer 7

Poor hygiene
Changes in wt
Social isolation

(No lab tests/imaging studies avail to confirm dx)

Question 8

Who is at more risk of suicide: an ind who has suffered from 1 episode of depression or an ind who has suffered from 2?

Answer 8

the person who suffered from 2 (risk of suicide increases w/ each episode of depression)

Question 9

T of F: Depression paradoxically reduces the risk of suicide.

Answer 9

F

Depression always increases the risk of suicide, esp if left untx’ed

Question 10

Suicide risk factors:

Answer 10

IS PATH WARM

Ideation
Substance use
Purposelessness (nothing to live for - no kids, spouses, etc.)
Anxiety
Trapped (feelings of no way out)
Hopelessness
Withdrawal
Anger
Recklessness
Mood changes (dramatic)

Question 11

Median time it takes to treat an episode of MDD?

Answer 11

20 weeks (this is IF it’s tx’ed) (~4 months)

Question 12

How long can MDD last if not tx’ed?

Answer 12

6+ months

Question 13

As number of MDD episodes increase, chances of relapse _____.

Answer 13

increase

Question 14

What’s the overall goal of acute MDD tx?

Answer 14

Sx remission + restoration of premorbid psychosocial fn’ing

i.e. we want their psychiatric health to go back to normal

Question 15

What’re the 2 landmark MDD papers?

Answer 15

STAR*D 2006 and Cipriani Network Meta-analysis 2018

Question 16

In the STAR*D trial, what was studied?

Answer 16

How often remission is achieved in MDD pts.

Question 17

According to the STAR*D trial, did switching or augmenting appear to induce more remissions?

Answer 17

Switching

Question 18

Why can’t we conclude for sure that switching is better than augmenting MDD tx according to the STAR*D trial?

Answer 18

Because the augmentation and switching groups were not directly compared

Question 19

Bottom line of the STAR*D trial?

Answer 19

The odds of getting better (MDD remission) diminishes w/ every additional tx strategy (augmentation or switching) needed

Question 20

Which meds were assoc w/ inferior responses and higher dropouts in the Cipriani meta analysis?

Answer 20

1. fluvoxamine
2. reboxetine
3. trazedone

Question 21

What did the Cipriani meta analysis indicate regarding antidepressants?

Answer 21

That they were all similarly effective

Question 22

CANMAT pharmacological 1st line interventions for mod-severe depression.

Answer 22

pharmacotherapy (SSRIs, SNRIs, buproprion, mirtazapine, vortioxetine)

Question 23

CANMAT pharmacological 2nd line interventions for non-response to first line interventions

Answer 23

switch to a diff 1st line antidepressant

Question 24

CANMAT 2nd line pharmacological interventions for partial response to first line interventions

Answer 24

augment w/ 1st line adjunct (aripiprazole, quetiapine, risperidone)

Question 25

Non-pharm tx’s for MDD

Answer 25

1. exercise/eating healthy
2. Physical interventions (e.g. acupuncture, massage, Yoga, Tai Chi)
3. psychotx/counseling
4. ECT
5. bright light tx
6. music tx
7. vagal nerve stimulation
8. transcranial magnetic stimulation (TMS)

Question 26

How is psychotx utilized in MDD?

Answer 26

1. monotx for mild-mod depression

2. combination w/ pharm for severe depression

Question 27

Indications for ECT?

Answer 27

1. severe dep

2. depression w/ psychosis/catatonic features

Question 28

ECT effectiveness for MDD?

Answer 28

80-90%

Question 29

T or F: Younger pts have better outcomes w/ ECT.

Answer 29

F (older pts do)

Question 30

What meds should we absolutely avoid/reduce before ECT tx?

Answer 30

1. anticonvulsants (we WANT seizures to occur)

2. benzos

Question 31

Indication for transcranial magnetic stimulation?

Answer 31

refractory depression

Question 32

Indication for vagal nerve stimulation?

Answer 32

Used as add-on tx for long-term chronic or recurrent depression lasting longer than 2 yrs and no response to 4+ trials of antideps

Question 33

What’s the only natural product that has modest evidence for MDD tx?

Answer 33

St. John’s Wort

Question 34

What problems does St. John’s Wort have?

Answer 34

1. CYP450 inducer > lots of AEs

2. increases risk of serotonin syndrome