MDD Flashcards
what are some differences between depressive disorders
duration, timing, etiology
T or F: treating parental depression has no effect on psychiatric symptoms in children
F- lowered psyc sx in children
T or F: MDD is the second leading cause of global disabiltiy
T
which of the following does not describe MDD diagnosis
1. you must have 5 symptoms from criteria A
2. patients often present with physical symptoms
3. criteria B states that the sx could not be from something else
4. diagnosis is 5 sx from criteria A, then B + C in addition
3- criteria B = clinically sig distress/ impaired functioning
C = not from substance/ other med condition
what are the 9 criteria from criteria A for MDD? What are the 2 points that the pt must have at least 1 of?
2 points: loss of interest, depressed mood
change in appetite and weight, fatigue, changes in sleep, psychomotor agitation or retardation, slowed thought process, feelings of worthlessness/ guilt, thoughts of suicide/ death
what is considered mild MDD
few if any sx if excess + distressing but manageable and minor fxn impairment
what is considered severe MDD
many sx in excess + seriously distressing and impacting function
how can medical conditions be associated with MDD through physical/ chemical mechs
shared sx
MDD causes bio changes that leads to other sx
other sx has bio effects that promotes MDD
name 3 clinical RF for MDD
Hx/ FamHx of depression
Psychosocial adversity
Higher users of med system
Chronic med conditions (esp CVD, DM, neuro)
Other psych conditions
Times of hormonal challenge (ex- peripartum)
name 3 symptom RF for MDD
Unexplained physical sx
Chronic pain
Fatigue
Insomnia
Anxiety
Substance abuse
Using rating scales can improve outcomes like ________ and _______
sx remission
adherence
what is the 2 question screen
in the last month, have you been bothered by little interest/ pleasure in doing things + have you been feeling down/ depressed/ hopeless → yes to either = further assessment
what are some clinician rated symptom rating scales
HAM-D, MADRS, IDS, GDS
what are some patient rated symptom rating scales
PHQ-9, IDS-SR
onset of MDD
any age, risk increases with puberty, peaks in 20s but late onset is not uncommon
regarding the disease course of MDD
1. most patients are episodically depression and hypomanic
2. most patients feel well between MDEs
3. the duration of episodes increases with age
4. the pattern is more frequent in females
2
Partial remission: sx of prev MDE present but _________(or ____without any sig sx of MDE following end of an episode)
full criteria not met
<2mths
________: no sig sx of MDE in last 2 mths (or 1-2sx to no more than a mild degree)
Full sx remission
Full sx remission: no sig sx of MDE in_______(or ___________ degree)
last 2 mths
1-2sx to no more than a mild
which of the following does not apply to psychotherapy
1. more frequency sessions may have beneficial results, esp in the acute phase
2. less than 2 sessions are not proven to be beneficial
3. psychotherapy + AD is more effective than AD alone
4. 1+2
2
3 NHPs for MDD
st john’s wort
omega 3s
SAM-e
st john’s wort indication in MDD
1st line mono tx for mild-mod MDD
AEs of st john’s wort
serotonin sx
hypomania when combined with ADs- CYP3A4 inducer
st john’s wort is a CYP3A4 ___
inducer
waht is first line for mild MDD
psychoeducation, self management, psyc tx, pharm tx (consider + SDM)
what is first line for mod-severe MDD
2nd gen AD
what are some first line SSRIs
citalo/escitalopram, fluoxetine, fluvoxamine
what are some first line SNRIs
desvenlafaxine, venlafaxine, duloxetine
what is a first line NDRI
bupropion
first line adjunctive drugs to ADs
aripiprazole, quetiapine, risperidone
ketamine is a __________ that _______- pick from the following list
- selective or nonselective
- ______ receptor agonist/ antagonist
- decreases/ increases ___________
nonselective NMDA receptor antagonist
decreases glutamate
what limits the use of NMDA outside of psyc spec
hallucinogenic/ abuse potential
what is considered early improvement from AD
> 20-30% improvement from baseline after 2-4wks at target dose
what is considered a response to AD tx? what about a partial response or a nonresponse?
> 50% improvement in 6-12wks
partial: 25-49%
nonresp: <25%
what is considered a remission from MDE
no sig s/s in the last 2 mths
or based off a predefined cut off
or 1-2 sx that are mild
at 6-12wks
if there is no early improvement, but no AEs at 2-4wks, what should you do?
optimize dose and wait another 2-4wks
if at 2-4wks dose is maxed and there is still no early improvement, ….
switch or adjunct
a patient has had 3 AD trials in the past, doses are maxed, and no early improvement is seen at 4wks. what should you do?
switch to a second line or third line AD
when should you switch ADs?
first AD trial
AEs felt
no response <25% improvement
no time crunch
pt pref to switch
when should you adjunct ADs
=>2 AD trials
no/ mild AEs
AEs may be targeted by other tx
partial response >25% improvement
time crunch
pt pref adj
what should you do after a pt has been at target dose for 4 weeks and early improvement of 30% is seen
continue tx for 6-8wks
after 8 wks of continued tx, a pt is not in remission. what should you do?
make sure target dose is achieved- if already achieved, switch/ adjunct
after 6-8 wks of maintenance, sx are in remission, what should you do now?
RF present = conmt for =>2yrs
no RF = cont for 6-9mths
list 3 RF for remission
Early age of onset
Greater number of prev episodes
Severity of initial episode (# of sx, suicidal ideation, psychomotor agitation)
Disruptions of sleep-wake cycle
Presence of comorbid psychopathology (esp persistent depressive disorder/ dysthymia)
FamHx of psych illness
Presence of negative cognitions
High neuroticism
Poor social support
Stressful life events
treatment resistent depression is defined as
inadequate response to =>2 AD
discontinuation syndrome from ADs happens in _______ after stopping/ dramatic dose reduction and resolves in ______ with no intervention
happens in 1-7days
resolves in 1-3wks
list 3 acute withdrawal sx
Somatic sx: dizziness/ incoordination, lethargy, N/V/D, headache, fever/ sweating/ chills, malaise, insomnia, vivid dreams
Neuro sx: myalgia, paresthesias, electric shock like sensations, dyskinesias, visual discoordination
Psychological sx: anxiety, agitation, crying, irritability, confusion, slowed thinking, disorientation
how to prevent discontinuation sx
lower by no more than 25%/wk
fluoxetine can be faster due to long hafl life
how to manage discontinuation sx
can add back some drug + taper more slowly
or substitute limited doses of fluoxetine
what is a direct AD switch? when is it recommended?
stop 1st AD, start new AD next day. Recommended if 1st AD <6wks and/or switching to AD with similar MOA
what is a taper, stop, switch? when is it recommended
gradually taper 1st AD, start new AD immediately after d/c. Recommended if 1st AD >6wks
what is a taper, stop, washout, switch
gradually taper 1st AD, start new AD after washout period
what is a cross taper
add on new AD and taper up, when at lowest effective dose then decrease dose of first AD
usually takes 1-2 weeks or longer
when is a washout period required in switching AD
when you have any switch involving a MAOi or RIMA
washout period from fluoxetine to RIMA or MAOi
5wks`
washout period from other SSRI to RIMA/MAOi
2wks
washout period from SNRI, NDRI, NaSSA, SARI, TCA to a RIMA or MAOi
1wk
washout from RIMA to any other AD
1-2d
washout period from MAOi to any other AD
2wks
if a pt stops AD due to unfortunate start, they have a ____ chance of relapse
2x higher
N/V from AD are due to
5HT receptors in GIT activated by SSR
which of the following is false
1. N/V from AD usually goes away in 1-2wks due to desensitization of 5HT3R
2. constipation from SSRIs is usually continuous
3. GI bleed from SSRIs is due to increased 5HT uptake by platelets, resulting in less clotting and more GI acid production
4. diarrhea from SNRIs are dose dependent and transient
3- DECREASED 5HT uptake by platelets
when does N/V stop from ADs
1-2wks
what increases risk of GI bleed from ADs, what decreases it?
↑RF with antiplatelets, anticoagulants, NSAIDs// ↓ R with PPIs
sleep changse from ADs usually resolve in
1-2wks
what are 3 more sedating ADs
mirtazapine and trazodone low dose, TCAs
what are 3 ADs that cause insomnia/ anxiety
bupropion, SSRIs, SNRIs
rank the following based on weight gain
TCAS, SNRIs, SSRIs, mirtazapine
mirtazapine >TCAs >SSRIs >SNRIs
symptoms of serotonin syndrome usually start within ________ and resolves within ___________
24hrs of increased dose
resolves in 24hrs after d/c
mild serotonin syndrome sx
HPTN, tachy, dilated pupils, sweating/ shivering, tremor/ myoclonus/ hyperreflexia, afebrile
mod serotonin syndrome sx
hyperthermia, hyperactive bowel sounds, ocular clonus, agitation, hypervigilance, pressured speech
severe serotonin syndrome sx
dramatic changes in pulse/ BP, delirium, muscle rigidity
May result in complications + death
what are some sx of sexual dysfunction on AD
↓interest/ libido, ED or ↓ arousal (clitoris), ↓ ability to achieve orgasm (anorgasma)
does sexual dysfunction from AD improve over time?
no
what are some lower risk AD options for sexual dysfunction
bupropion (1st line), mirtazapine, moclobemide, vortioxetine, vilazodone
what are the 2 ADs that are most likely to cause sexual dysfunction
SSRIs (esp paroxetine) >SNRIs
treatment options for sexual dysfunction from ADs
adjunctive buproprion (for anorgasma) or PDE5i fro both sexes
when should you refer before starting an AD due to TdP risk
if prolonged QTc interval >500ms
which ADs are most associated with increased QTc interval
Citalopram/ escitalopram, TCAs, mirtazapine, venlafaxine
does prolonged Qtc interval resolve on its own
no
which AD cause HPTN? under what circumstances?
MAOi (HPTN crisis with tyramine foods), SNRI (esp venlafaxine), bupropion, mirtazapine
which AD are most likely to cause orthostatic hypotension
MAOi, TCAs, trazodone, buproprion
T or F: SSRIs can increase suicidality in adolescence
both,,, is associated with higher risk, but may just be because we’re only giving them to the highest risk youth
list the 3 potent CYP2D6 inhibitors
paroxetine, fluoxetine, buproprion
what is a CYP 2C9, 2C19, and 3A4 inducer
st john’s wort
st john’s wort is a P-gp pump ____
1. inhibitor
2. inducer
inducer- decreases effect by pumping out of brain
MAOi + serotonergic or sympathomimetic drugs = _____ risk
HPTN crisis
T or F: there is no single order set to cover AD regimens
T- depends on each therapy regimen
what is first line for childhood MDD
fluoxetine and SSRIs
what is second line for childhood MDD
escitalopram/ citalopram, sertraline
in childhood MDD, start at a low dose and increase after a minimum of ______, then once remission is achieved, treat for
- _____ if no prev hx
- _________ if hx of 2 or more MDE or 1severe/ chronic episode
min 4wks
6-12mths if no prev hx
>1yr if hx
how long is maintenance tx for MDD in peripartum
6-12mths after remission, longer for higher risk
first and second line tx for perinatal depression
first: CBT, IPT
second: citalo/escitalopram, sertraline
what are some SEs on the newborn from ADs
↓BW, Apgar score, gestational duration
↑cortisol lvls, spontaneous abortion, potential discontinuation sx
what type of ADs should be pref in breastfeedign
those with shorter half lives
what is considered late life depression
MDD in >60yrs old
how to screen for late life depression
using the Geriatric depression scale (GDS)
which of the following is false about late life depression
1. trials of AD must be for 10-12wks instead of the usual 2-4wks
2. outcomes are generally better
3. maintanence treatment may go on for longer than average
4. must use caution with antiACh agents
2- worse
