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445- Pain and Mental Health > MDD > Flashcards

MDD Flashcards

1
Q

what are some differences between depressive disorders

A

duration, timing, etiology

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2
Q

T or F: treating parental depression has no effect on psychiatric symptoms in children

A

F- lowered psyc sx in children

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3
Q

T or F: MDD is the second leading cause of global disabiltiy

A

T

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4
Q

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

A

3- criteria B = clinically sig distress/ impaired functioning
C = not from substance/ other med condition

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5
Q

what are the 9 criteria from criteria A for MDD? What are the 2 points that the pt must have at least 1 of?

A

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

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6
Q

what is considered mild MDD

A

few if any sx if excess + distressing but manageable and minor fxn impairment

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7
Q

what is considered severe MDD

A

many sx in excess + seriously distressing and impacting function

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8
Q

how can medical conditions be associated with MDD through physical/ chemical mechs

A

shared sx
MDD causes bio changes that leads to other sx
other sx has bio effects that promotes MDD

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9
Q

name 3 clinical RF for MDD

A

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)

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10
Q

name 3 symptom RF for MDD

A

Unexplained physical sx
Chronic pain
Fatigue
Insomnia
Anxiety
Substance abuse

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11
Q

Using rating scales can improve outcomes like ________ and _______

A

sx remission
adherence

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12
Q

what is the 2 question screen

A

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

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13
Q

what are some clinician rated symptom rating scales

A

HAM-D, MADRS, IDS, GDS

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14
Q

what are some patient rated symptom rating scales

A

PHQ-9, IDS-SR

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15
Q

onset of MDD

A

any age, risk increases with puberty, peaks in 20s but late onset is not uncommon

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16
Q

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

A

2

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17
Q

Partial remission: sx of prev MDE present but _________(or ____without any sig sx of MDE following end of an episode)

A

full criteria not met
<2mths

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18
Q

________: no sig sx of MDE in last 2 mths (or 1-2sx to no more than a mild degree)

A

Full sx remission

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19
Q

Full sx remission: no sig sx of MDE in_______(or ___________ degree)

A

last 2 mths
1-2sx to no more than a mild

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20
Q

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

A

2

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21
Q

3 NHPs for MDD

A

st john’s wort
omega 3s
SAM-e

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22
Q

st john’s wort indication in MDD

A

1st line mono tx for mild-mod MDD

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23
Q

AEs of st john’s wort

A

serotonin sx
hypomania when combined with ADs- CYP3A4 inducer

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24
Q

st john’s wort is a CYP3A4 ___

A

inducer

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25
Q

waht is first line for mild MDD

A

psychoeducation, self management, psyc tx, pharm tx (consider + SDM)

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26
Q

what is first line for mod-severe MDD

A

2nd gen AD

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27
Q

what are some first line SSRIs

A

citalo/escitalopram, fluoxetine, fluvoxamine

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28
Q

what are some first line SNRIs

A

desvenlafaxine, venlafaxine, duloxetine

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29
Q

what is a first line NDRI

A

bupropion

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30
Q

first line adjunctive drugs to ADs

A

aripiprazole, quetiapine, risperidone

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31
Q

ketamine is a __________ that _______- pick from the following list
- selective or nonselective
- ______ receptor agonist/ antagonist
- decreases/ increases ___________

A

nonselective NMDA receptor antagonist
decreases glutamate

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32
Q

what limits the use of NMDA outside of psyc spec

A

hallucinogenic/ abuse potential

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33
Q

what is considered early improvement from AD

A

> 20-30% improvement from baseline after 2-4wks at target dose

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34
Q

what is considered a response to AD tx? what about a partial response or a nonresponse?

A

> 50% improvement in 6-12wks
partial: 25-49%
nonresp: <25%

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35
Q

what is considered a remission from MDE

A

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

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36
Q

if there is no early improvement, but no AEs at 2-4wks, what should you do?

A

optimize dose and wait another 2-4wks

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37
Q

if at 2-4wks dose is maxed and there is still no early improvement, ….

A

switch or adjunct

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38
Q

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?

A

switch to a second line or third line AD

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39
Q

when should you switch ADs?

A

first AD trial
AEs felt
no response <25% improvement
no time crunch
pt pref to switch

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40
Q

when should you adjunct ADs

A

=>2 AD trials
no/ mild AEs
AEs may be targeted by other tx
partial response >25% improvement
time crunch
pt pref adj

41
Q

what should you do after a pt has been at target dose for 4 weeks and early improvement of 30% is seen

A

continue tx for 6-8wks

42
Q

after 8 wks of continued tx, a pt is not in remission. what should you do?

A

make sure target dose is achieved- if already achieved, switch/ adjunct

43
Q

after 6-8 wks of maintenance, sx are in remission, what should you do now?

A

RF present = conmt for =>2yrs
no RF = cont for 6-9mths

44
Q

list 3 RF for remission

A

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

45
Q

treatment resistent depression is defined as

A

inadequate response to =>2 AD

46
Q

discontinuation syndrome from ADs happens in _______ after stopping/ dramatic dose reduction and resolves in ______ with no intervention

A

happens in 1-7days
resolves in 1-3wks

47
Q

list 3 acute withdrawal sx

A

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

48
Q

how to prevent discontinuation sx

A

lower by no more than 25%/wk
fluoxetine can be faster due to long hafl life

49
Q

how to manage discontinuation sx

A

can add back some drug + taper more slowly
or substitute limited doses of fluoxetine

50
Q

what is a direct AD switch? when is it recommended?

A

stop 1st AD, start new AD next day. Recommended if 1st AD <6wks and/or switching to AD with similar MOA

51
Q

what is a taper, stop, switch? when is it recommended

A

gradually taper 1st AD, start new AD immediately after d/c. Recommended if 1st AD >6wks

52
Q

what is a taper, stop, washout, switch

A

gradually taper 1st AD, start new AD after washout period

53
Q

what is a cross taper

A

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

54
Q

when is a washout period required in switching AD

A

when you have any switch involving a MAOi or RIMA

55
Q

washout period from fluoxetine to RIMA or MAOi

A

5wks`

56
Q

washout period from other SSRI to RIMA/MAOi

A

2wks

57
Q

washout period from SNRI, NDRI, NaSSA, SARI, TCA to a RIMA or MAOi

A

1wk

58
Q

washout from RIMA to any other AD

A

1-2d

59
Q

washout period from MAOi to any other AD

A

2wks

60
Q

if a pt stops AD due to unfortunate start, they have a ____ chance of relapse

A

2x higher

61
Q

N/V from AD are due to

A

5HT receptors in GIT activated by SSR

62
Q

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

A

3- DECREASED 5HT uptake by platelets

63
Q

when does N/V stop from ADs

A

1-2wks

64
Q

what increases risk of GI bleed from ADs, what decreases it?

A

↑RF with antiplatelets, anticoagulants, NSAIDs// ↓ R with PPIs

65
Q

sleep changse from ADs usually resolve in

A

1-2wks

66
Q

what are 3 more sedating ADs

A

mirtazapine and trazodone low dose, TCAs

67
Q

what are 3 ADs that cause insomnia/ anxiety

A

bupropion, SSRIs, SNRIs

68
Q

rank the following based on weight gain
TCAS, SNRIs, SSRIs, mirtazapine

A

mirtazapine >TCAs >SSRIs >SNRIs

69
Q

symptoms of serotonin syndrome usually start within ________ and resolves within ___________

A

24hrs of increased dose
resolves in 24hrs after d/c

70
Q

mild serotonin syndrome sx

A

HPTN, tachy, dilated pupils, sweating/ shivering, tremor/ myoclonus/ hyperreflexia, afebrile

71
Q

mod serotonin syndrome sx

A

hyperthermia, hyperactive bowel sounds, ocular clonus, agitation, hypervigilance, pressured speech

72
Q

severe serotonin syndrome sx

A

dramatic changes in pulse/ BP, delirium, muscle rigidity
May result in complications + death

73
Q

what are some sx of sexual dysfunction on AD

A

↓interest/ libido, ED or ↓ arousal (clitoris), ↓ ability to achieve orgasm (anorgasma)

74
Q

does sexual dysfunction from AD improve over time?

A

no

75
Q

what are some lower risk AD options for sexual dysfunction

A

bupropion (1st line), mirtazapine, moclobemide, vortioxetine, vilazodone

76
Q

what are the 2 ADs that are most likely to cause sexual dysfunction

A

SSRIs (esp paroxetine) >SNRIs

77
Q

treatment options for sexual dysfunction from ADs

A

adjunctive buproprion (for anorgasma) or PDE5i fro both sexes

78
Q

when should you refer before starting an AD due to TdP risk

A

if prolonged QTc interval >500ms

79
Q

which ADs are most associated with increased QTc interval

A

Citalopram/ escitalopram, TCAs, mirtazapine, venlafaxine

80
Q

does prolonged Qtc interval resolve on its own

A

no

81
Q

which AD cause HPTN? under what circumstances?

A

MAOi (HPTN crisis with tyramine foods), SNRI (esp venlafaxine), bupropion, mirtazapine

82
Q

which AD are most likely to cause orthostatic hypotension

A

MAOi, TCAs, trazodone, buproprion

83
Q

T or F: SSRIs can increase suicidality in adolescence

A

both,,, is associated with higher risk, but may just be because we’re only giving them to the highest risk youth

84
Q

list the 3 potent CYP2D6 inhibitors

A

paroxetine, fluoxetine, buproprion

85
Q

what is a CYP 2C9, 2C19, and 3A4 inducer

A

st john’s wort

86
Q

st john’s wort is a P-gp pump ____
1. inhibitor
2. inducer

A

inducer- decreases effect by pumping out of brain

87
Q

MAOi + serotonergic or sympathomimetic drugs = _____ risk

A

HPTN crisis

88
Q

T or F: there is no single order set to cover AD regimens

A

T- depends on each therapy regimen

89
Q

what is first line for childhood MDD

A

fluoxetine and SSRIs

90
Q

what is second line for childhood MDD

A

escitalopram/ citalopram, sertraline

91
Q

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

A

min 4wks
6-12mths if no prev hx
>1yr if hx

92
Q

how long is maintenance tx for MDD in peripartum

A

6-12mths after remission, longer for higher risk

93
Q

first and second line tx for perinatal depression

A

first: CBT, IPT
second: citalo/escitalopram, sertraline

94
Q

what are some SEs on the newborn from ADs

A

↓BW, Apgar score, gestational duration
↑cortisol lvls, spontaneous abortion, potential discontinuation sx

95
Q

what type of ADs should be pref in breastfeedign

A

those with shorter half lives

96
Q

what is considered late life depression

A

MDD in >60yrs old

97
Q

how to screen for late life depression

A

using the Geriatric depression scale (GDS)

98
Q

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

A

2- worse

445- Pain and Mental Health (21 decks)

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