Major Depressive Disorder & Psych Intro Flashcards
What is mental health?
state of well-being and can cope with normal stressors
DOES NOT Mean not having a mental illness
True or Flase mental health means not having a mental illness
FALSE
What is the difference between mental health disorders and mental health problem?
Disorder= significant changes in emotional state, behavior or ability to function- psychiatric diagnosis
problem=does not meet diagnostic criteria but may disrupt life
What is a brief timeline of the evolution of mental illness?
punishment/possesion
fluid imbalance
emotions then with christian back to punishment
natural physical causes
psychological and social stress
bio and social and psychological causes
Who is the father of psychiatry?
Emil Kraepelin- ‘invented’ mental illness being biological
What is the issue with being too focused on the biological causes of mental illness?
very subjective and not fully understood rn with current biological theories.
How many people have had or will have a mental illness by age 40?
50%
How many people do not seek out treatment when having a mental health problem?
60%
Which sex has a higher rate of successful suicide?
men-more lethal means
How can culture influence mental illness?
Each culture has a different perspective on mental health or even level of concern for it, and how to treat
True or false: white people are less likely to seek treatment
False
What does the Medical Health Services Act do?
assist people suffering from serious in receiving treatment
encourage voluntary receipt of services
What are the three methods of involuntary hospitalization?
physician, police, court judge
need 2 G forms to be admitted
What 3 criteria for being involuntarily hospitalized
mental disorder needing inpatient care
not capable of making a decision
likely to harm self or others
What is the difference between physical vs mental health diagnosis?
Physical= signs and sx, history, labs
test
Psychiatry= impression on thoughts and feelings, use symptoms to cross-reference in diagnosis manual.
Problems with psychiatric diagnosis?
current= symptom x,y,z= schizo
may not have all sx
is criteria even valid?
no objective tests
Pros and cons of DSM-5
Pros= criteria, reliable diagnosis, standardized
Cons= some illnesses are close to normal(overdiagnose), based on opinion, oversimplified human behavior, misdiagnose, stigma
Components of psychiatric interview?
Patient demographics
chief complaint
history
past psychiatric/substance use
family history
social history
meds
risk assessment-suicide, murder
differential diagnosis
impression
plan
What is a mental status exam?
observe the patient- get a picture of the patient= look at appearance, thought process, mood, attention.
kind of like a physical exam
What does affect mean in the mental status exam?
takes mood terms and makes them objective
What are 3 questions to assess suicide risk?
Have you thought of suicide
What actions have you taken to prepare? (will, note)
Whether they have attempted
What are the core symptoms of depression (SIG E CAPS)
Sleep
Interest decrease
Guilt or worthless
Energy decrease
Concentration issues
Appetite disturbance
Psychomotor retard/agitate
suicidal
What is measurements-based care for mental illness?
systematic tools and scales to support decision-making and monitor progression
Give an example of a MBS
PHAQ-9
Barriers to MBS
underutilized
time effort and cost
negative attitudes toward test
sx may not be on scale
Problems with current psychotropic nomenclature?
based on arbitrary first indications of meds
flawed and misleading- can use antipsychotics in depression
outdated
confusing stigma
What is neuroscience-based nomenclature?
based on the method of action = SSRI’s
What is the problem with stigma?
fear of stigma delays treatment
won’t admit
How can we reduce stigma?
initiative- bell let’s talk
change language
nonjudgmental
What is the definition of major depressive disorder?
Persistent and abnormal low mood, sad, emptiness, and irritability accompanied by cognitive changes that significantly impact the capacity to function
Which gender is more likely to have depression?
female
What is the prevalence of depression?
11-18%
What risks are associated with depression?
increased CVD, morbidity, complications
lower QOL, social+ occupational
What is the typical age of onset of depression?
late 20’s
What is the monoamine hypothesis?
dysfunction in monoamine production= low 5HT (serotonin)
What is the neuroplasticity hypothesis?
low amount of BDNF= growth factor for survival of neurons, important for structural integrity
chronic stress may suppress DNF expression in hippocampus
What is the endocrine and immune system abnormality hypothesis?
higher cortisol= increased peripheral cytokine= hypothalamic-pituitary axis
higher release of stress hormones causes detrimental effects on the brain
What is the structural and functioning alterations hypothesis of depression?
reduced volume or reactivity in the prefrontal cortex, hippocampus, amygdala= causes brain functioning issues
MAY be modulated by monamines= some cross-over in hypothesis
True or false One hypothesis of depression is sufficient.
FALSE= very complicated
What new target is being explored for depression, specifically treatment-resistant depression?
glutaminergic transmitters= modulate through ketamine
What are the 5 common risk factors of MDD?
Genetics= blood relatives’ history of mental illness
Life experiences traumatic or stressful events
Personality disorders= traits such as low self-esteem, overly dependant, self critical
Substance use
Medical comorbidities= Anemia, HIV, Heart, hypothyroid, cancer, pain
What percentage of people with MDD have a medical comorbidity?
85%
What percentage of people with MDD also have a personality disorder?
30%
What is the DSM-5 diagnostic criteria for MDD?
Need at least 5 symptoms
at least 1 sx must be depressed mood or anhedonia (lack of pleasure)
not caused by a substance or other mental illness
NO manic episode
What is classified as mild MDD?
5 or 6 sx with minimal functional impairment
What is classified as severe MDD?
nearly all sx with significant impairment
What is a persistent depressive disorder?
depressive mood for >2 years with sx free period no greater than 2 months
need only 2 sx of depression
No MDD in first 2 years
What is a substance-induced depressive episode?
disturbance in the mood with diminished interest
caused by substance duh or even withdrawal
What other things could depression be other than MDD?
bipolar- mania with/or hypomania
anxiety- may cooccur
Other medical condition-hypothyroid, autoimmune, pain
grief
PMS
sad
irritable
What medications is associated with MDD?
Anticonvulsants (topiramate, phenobarbital), Hormonal agents (CS, tamoxifen), interferon alpha
Which beta-blocker may be associated with MDD?
propranolol
What are the 5 different MDD rating scales?
PHQ-9- Clinical practice
QIDS- Both
Beck Depression Inventory Both
HAM-D-research
MADRS-research
Which rating scales are done by the patient?
PHQ-9, QIDS, Beck
What is considered moderate on the HAM-D test? WHat is considered a response and remission?
14-18
Response- >50% reduction inscore
Remission= score <7 for at least 2 weeks
What is considered moderate on the PHQ-9 test? WHat is considered a response and remission?
10-14 Moderate
response is >50%
remission is <5
What is a quick screen for MDD in pharmacy?
PHQ-2= 2 questions
3+ score for positive screen
How does suicide rate change with each episode of depression?
increases with each episode
What is life time risk of suicide if MDD is untreated?
20%
What are the suicide risk factors? (IS PATH WARM)
Ideation
Substance use
Purposelessness
Anxiety
Trapped
Hopeless
Withdrawl
Anger
Recklessness
Mood changes (dramatic
WHat percentage of people dont achieve remission?
15%
How many people recover in 3 months, 6 months, 12 months?
3= 40%
6=60%
12=80%
When is first response and when is peak?
first response= 2 weeks
peak= 4-6 weeks but may be up to 12 weeks
True or false: Response declines with each subsequent treatment trial?
True
What is the difference between a relapse and a recurrence?
relapse is back into a depressive state when getting a response from the drug
recurrence is when they are back into a depressive state after remission
What is the criteria to be in recovery?
full remission for at least 2 months
What is the criteria to be chronic in nature?
> 2 years
What are the criteria for treatment resistance?
episode that has failed to respond to 2 separate trials of different antidepressants of adequate dose and duration.
What are the factors that predict remission of MDD?
female
white
higher level of education and income
employed
Give some non-pharmacological treatment for MDD.
+ life changes-diet,exercise, yoga, music
natural drugs-
psychological= counselling, psychotherapy
neurostimulation
What are some natural products that MAY (prob not) have an effect for MDD?
St Johns- good!
methionine
Omega 3’s
methylfolate
WHy are we worried about St johns wort?
OTC= maybe serotonin syndrome, BLEEDING
LOTS OF interactions because of CYP450
MOA of St johns wort?
MAO
True or false St johns wort can be used as first line for moderate to severe MDD
NO
only for mild-moderate
For people with MDD what should they always get as treatment?
ALWAYS PSYCHOTHERAPY
What are some psychological treatments that can be done?
CBT
BA
self help groups
What is Transcranial Magnetic Stimulation (TMS)? and what is it indicated for?
use magnetic fields to stim nerve cells in mood regions
for treatment resistance
What is the issue with TMS?
effective BUT lasts only for 4 weeks
What can be some side effects of TMS?
headache and scalp issues
What is electroconvulsive therapy ECT?
electrodes to stimulate and make a seizure
What is ECT indicated for and who does it work better in?
severe depression
Older people get more benefit
What are some side effects of ECT?
headache, confusion, memory issues
What should you not use while on ECT?
anticonvulsant meds should be minimal because it will minimize seizure
lithium should be minimal as it could prolong seizure
What did the Cipriani MA tell us?
all drugs new and old are effective
old is usually second line due to side effects and interactions
Even with Cipriani results which drugs GENERALLY may have higher response with decent tolerability?
escitalopram, sertraline, mirtazapine, venlafaxine, vortioxetine
From the Star study what did we learn?
First option= generally 1/3 remission
With each new addition or switch we see a decline in the rate that reach remission
Also no difference between switching or augmenting
True or false the more treatment steps someone has the more likely for relapse
True
What is the general time to see an response/remission from a medication for MDD?
5-7 weeks
Drugs Compared to placebo, what is the increase in response rates?
10%
What are the 1st line augmenters?
aripiprazole, quetiapine, risperidone
What are the 2nd line augmenters?
bupropion, lithium, mirtzapine, TCA, ketamine
What are the CANMAT 1st line agents?
SSRI’s, SNRI’s NDRI (bupropion), mirtazapine, vortioxetine
What are the SSRI’s?
Citalopram, escitalopram, fluoxetine, paroxetine, sertraline
What is MOA of SSRI?
inhibit 5-HT reuptake = more serotonin in cleft
What is the GENERAL onset of action of SSRI?
couple of days= help with agitation, anxiety, sleep, appetite
1-3 weeks= more activity, sex drive, memory
2-4 weeks= no more depress
What is s/e of SSRI (HANDS) and how long do they last for
headache
anxiety
nausea
diarrhea/Gi
Sleep change
ANTICHOLINERGIC
sex dysfucntion
blunting
first 2 weeks usually
If there is an issue with blunting with taking SSRI’s what can we do?
switch to bupropion or lower dose
What is the condition SSRI’s can cause and explain it?
SIADH
lethary, low sodium, pain, vomit
Which SSRI is more associated with SIADH and what can we do to stop it?
venlafaxine, d/c
Which drugs are we worried about QTc prolongation?
citalopram and escitalopram
What issues can arise for elderly with SSRI’s?
fracture risk
True or false SSRIs are generally non-sedating and have no weight gain?
True
Which SSRI can cause the most sedation and weight gain?
Paroxetine
Which SSRI can be stimulating?
fluoxetine
Which SSRIs are the most tolerable?
escitalopram and sertraline
Which SSRIs are we worried about interactions and which CYP do they affect?
Fluoxetine and paroxetine at CYP 1A2, 2D6
IS bleeding a significant contraindication of SSRI’s and NSAIDS/ other?
no
Which SSRI’s are we worried about in liver dysfunction?
fluoxetine, citalopram, sertraline
Which SSRI’s bioavailability increases with food?
sertraline
What drug can we give if sexual dysfunction is a problem?
Vortioxetine= less than SSRI’s
What is MOA of vortioxetine?
serotonin reuptake inhibitor PARTIAL agonist= potentially less side effects
What are the SNRIs and whats special about each
Venlafaxine= bind to serotonin at low doses both at high and even dopamine at higher
duloxetine= more NET inhibition and more anitcholinergic
What is MOA of SNRI’s
stop serotonin and norepinephrine reuptake
Why are SNRIs perhaps better than SSRIs?
more antidepressive action due to nor e and perhaps dopamine in cleft
What is SNRI onset of action and what could happen more than SSRIs?
exactly the same onset
maybe more agitation and anxiety
What is s/e of SNRIs compared to SSRI’s? HANDS
same as SSRIs
less sex issues in duloxetine
SAIDH worse in venlafaxine
more anticholinergic
more NE s/e
less blunting
no fractures
Which SNRI are we worried about if liver issues?
duloxetine
Why cant you just stop SNRIs?
because of norepinephrine harder and worse withdrawl
CI of SNRIs
HTN, urinary retention, alcoholic, liver problems
At what age can ALL AD increase the suicide rate?
<24
What is MOA of bupropion?
inhibit NE and DA NO 5-HT
What is bupropion’s place in therapy?
augment with SSRI and SNRI
for ADHD like sx
smoking
What are the s/e of bupropion?
more anxiety, agitate, insomnia, sweat= NE
MAYBE seizure
What is a condition you do NOT want to use bupropion in?
eating disorder because reduced appetite
kidney issues= how it is excreted
seizure
What is MOA of mirtazapine?
antagonize 5-HT, H receptors= more NE and 5HT
Causes calming effect
What patients would mirtazapine be good for?
insomnia, reduced appetite, sex problems
WHat side effects does mirtazapine cause?
sedation, weight gain,
What clearance mechanism are we worried about in regards to disease for mirtazapine?
none only caution at low function for both renal and hepatic
True or false mirtazapine loses its sedation at higher doses?
true
What is the overview of second-line agents for MDD?
TCA
SNRI-levmilnacipran
Moclobemide
trazodone
quetiapine
vilazodone
What are the main TCA?
amitriptyline-tertiary amine
nortriptyline-secondary amines
What is TCA MOA?
inhibit serotonin and NE reuptake
Which type of amine is more NE activity and better tolerated?
secondary amines- nortriptyline
WHat is the issue with TCA?
very dirtttttty (like Carter)
act on multiple receptors like Histamine muscarinic, sodium channels
When would we opt for TCA?
for insomnia, chronic pain (neuropathic)
When is TCA contraindicated?
liver impairment, CVD, qt prolongers, elderly
What do we need to do when we dispense TCA?
not too much as overdose is very lethal
only need 3 x max dose= low BP
What are the symptoms of anticholinergic activity?
hot, mydriasis, dry mouth, flushed, confused
What are some additional side effects of TCA?
weight gain, sex problems, rash, seizure, tremors
What drug causes urine discoloration?
amitriptyline
How does trazodone work?
inhibit sert and NET and serotonin receptors and others
S/E of trazodone
dizzy, sedate, headahce, prolong QT
What side effect is less in trazodone?
sexual dysfunction
How does moclobemine work?
reversible MAO inhibitors
What is the issue with moclobemine?
at higher doses the selectivity for MAOa goes down which is bad because over stim due to tyramine
What happens with too much NE?
hypertensive crisis
S/E of moclobemide
tachycardia, hypotension, sleep disturbance,
True or false moclobemide has more sexual dysfunction and anticholinergic effects than SSRIs?
false
What are some IRREVERSIBLE MAO inhibitors?
phenelzine, tranylcypromine (like METH)
How does ketamine work?
work on NMDA receptors, opioid and AMPA= more protein synthesis and restore synaptic connectivity
Which form of ketamine is available in Canada
racemic and S for nasal spray for treatment resistant MDD
What could be the advantage of R ketamine?
less potent but longer lasting and with fewer side effects
What are the side effects of ketamine?
headache, anxiety, dissociation, pee lots, blurred vision
What can we do if they have GI effects?
lower dose, food
Which drugs cause GI more often?
Venlafaxine SSRI,
When does Gi effects atart and how long can they last?
2 weeks and up to 3 months
Which drug causes the worst constipation?
paroxetine
When do we see a correlation with suicide for these drugs?
under 18 for first 3 months
At what age do we see protective effect of suicide for medications
> 25
Which drug has the lowest risk of sex dysfunction?
bupropion>mirtazapoine, trazadone, moclobemide
hich drug has the highest risk of sex issues?
SSRIs, TCA
What can we do if theres sex issues?
may fix by itself, reduce dose, drug holidays, add bupropion or mirt, PDE4
Which drugs are we reallhy worried about QTc interval prolongers?
TCA, citalopram, escitalopram, venlafaxine
What is serotonin syndrome?
-when multiple serotonin agents
get mental changes, autonomic hyperactivity, neuromuscular abnormalities in 6 hours
What is discontinuation syndrome? What is the worst culprit and what is the best?
feel like the flu
worst= venlafaxine, paroxetine
best= fluoxetine
What are the sx of discontinuation syndrome? (FINISH)
flu
insomnia
nausea
imbalance
sensory disturbances-shock sensation
hyperarousal-anxiety
When does discontinuation syndrome start and when can it resolve?
1-3 days after stopping medication
lasts for 1-2 weeks maybe months
How can we prevent discontinuation syndrome?
taper
or switch to fluoxetine
The patient comes in and is still not feeling better what should we do and what options are there?
are they taking it
has it been 6-8 weeks
switch or augment
GENERALLY when should we switch or augment medication?
switch if no response= <25% sx improve
augment if partial response
What is the definition of treatment resistant?
<20% improvement on 2 or more trials of meds
WHen do we need a washout period?
if starting a MAO
WHat should we do if we are switching drugs?
cross taper
What are the first line augmentor
s?aripiprazole, quetiapine, risperidone
What are the second line augmenters
bupropion, mirtazapine, lithium, t3
Is lithium a suitable option? How long to see the benefit?
yes
see in 3-4 weeks
Which is better lithium or T3
t3 has better tolerability
but lithium is better for CVD people
What is the difference between a continuation phase and a maintenance phase?
continuation phase= 4-9 months at same dosage
maintenance= lifelong
Patient comes in and is elderly, what is our go to drugs?
duloxetine, bupropion, sertraline
Patient comes in and is a child/adolescent, what drugs are our go tos?
fluoxetine, sertraline, cilaopram, escitalopram
When should a medication be given to a pregnant woman?
if moderate-sever
suicidal
Which drugs are we giving if needed in pregnancy?
SSRIs= sertraline, cilaopram, escitalopram
Which drugs if breastfeeding?
citalopram, sertraline, paroxetine= because less in milk
What drug causes cardiac malformations in fetus?
Paroxetine
Can fetus get withdrawl?
yes but is often self limiting
