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CDM 4 Exam 2 > MDD > Flashcards

MDD Flashcards

1
Q

MDD typical onset age

A

Late 20s
sharp increase from 12-16, increase gradually in 40s

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2
Q

MDD risk factors

A

chronic medical conditions, family history, lower socioeconomic status, marital status, adverse life events

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3
Q

Brain structure abnormalities

A

Overactive amygdala and hippocampus, shrinks with each depressive episode

Enlarged lateral ventricles, smaller caudate and putamen, altered prefrontal cortex activity

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4
Q

Monoamine hypothesis

A

Decreased levels of 5-HT, DA, NE

Increases in neurotransmitters happens rapidly with antidepressant initiation

However, clinical effect is delayed

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5
Q

Dysregulation Hypothesis

A

Depression due to dysregulated NT altering pre- and post-synaptic receptors

Adaptive changes in receptor sensitization or downregulation

Normalization of receptors after antidepressant therapy explains delay

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6
Q

Chronic stress model

A

Increase in substance P
HPA axis secretes glucocorticoids and cortisol
Decrease in BDNF

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7
Q

Diagnostic Evaluation

A

PMH: anemia, stroke, Parkinsons, infection, HIV/AIDs, vit D deficiency, hypothyroidism, cancer, epilepsy, diabetes, HD

Meds: isotretinoin, anticonvulsants, BB, ACEi, CCB, clonidine, steroids, montelukast, substance-related

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8
Q

Common rating scales

A

PHQ-9
HAM-D
MADRS
BDI

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9
Q

MDD DSM-V definition

A

≥ 1 depressive episode with no history of mania
≥ 5 of the following present nearly every day for ≥ 2 wks
-depressed mood (important)
-reduced interest (important)
-weight loss/gain
-sleep disturbances
-psychomotor agitation
-fatigue
-feeling worthless
-difficulty concentrating
-suicidal thoughts

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10
Q

MDD SIG E CAPS

A

S –> sleep disturbances
I –> Interest (loss of)
G –> Guilt
E –> Energy (reduced)
C –> Concentration (impaired)
A –> Appetite changes
P –> Psychomotor agitation/retardation
S –> Suicidal thoughts

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11
Q

Treatment goals: Response

A

50% decrease in symptoms in 4-8 weeks

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12
Q

Treatment goals: Remission

A

few to no symptoms over ≥ 3 weeks

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13
Q

Duration of episode

A

20 weeks with treatment to recovery
≥ 6 months if untreated

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14
Q

Acute phase

A

6-12 weeks
goal is remission
optimize dose/regimen

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15
Q

Continuation phase

A

4-9 months
goal is to prevent relapse
continue agent/dose that led to remission

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16
Q

Maintenance phase

A

13-36 months
goal to prevent recurrence
recommended if ≥ 3 depressive episodes or symptoms

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17
Q

Treatment first line

A

Psychotherapy + first line therapy
SSRI, SNRI, bupropion, mirtazapine, vortioxetine
x 4-8 weeks

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18
Q

Treatment after adequate response

A

continue at optimal dose and re-evaluate at 6, 8, 12 weeks

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19
Q

Treatment with persistent symptoms

A

increase dose, switch, augment or consider 2nd generation + psychotherapy

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20
Q

if < 50% improvement after 8 weeks,

A

consider switching medications

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21
Q

Key takeaways from STAR*D trial

A

There are conflicting theories about increasing dose, switching, and augmenting as the best strategy

Maximizing dose is important

8-12 weeks necessary to determine effectiveness

Switch is possible

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22
Q

Strategies for partial/non-response

A

Switching (cross taper 1-2 weeks)
Augmentation

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23
Q

Treatment Resistance

A

failure to respond to 2 separate trials of diff. antidepressants of adequate dose and duration

Switch to another AD
Augment with lithium, triiodothyronine, SGA

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24
Q

Psychotherapy

A

Talk therapy -CBT, IPT, group psychoeducation

25
Q

Direct Current Therapy

A

vagus nerve stimulation
ECT
rTMS

26
Q

non-pharm other options

A

Exercise
Bright light therapy

27
Q

Rank SSRI by 1/2 life: Citalopram, Sertraline, Fluoxetine, Fluvoxamine, Escitalopram, Paroxetine

A

Longest
Fluoxetine
Citalopram
Escitalopram
Sertraline
Paroxetine
Fluvoxamine
Shortest

28
Q

MDD medications

A

SSRI, SNRI, Bupropion, Mirtazapine, TCA, MAOi, Mood stabilizers, Antipsychotics

29
Q

Increases serotonin, norepinephrine availability within synapses

A

SSRI, SNRI, TCA

30
Q

Increase dopamine and serotonin

A

bupropion

31
Q

inhibition of alpha-2 receptors

A

mirtazapine

32
Q

inhibition of MAO which breaks down neurotransmitters

A

MAOi

33
Q

modulation of serotonin receptions with partial agonism

A

trazodone, vortioxetine

34
Q

St. Johns Wart

A

“efficacy” at 600-1200 mg PO daily divided in 3 doses
Lots of DDI
SE: dry mouth, nausea, itching, photosensitivity, fatigue, dizziness, insomnia, headache
Serious ADE: infertility, worsening of underlying psychiatric conditions
ONLY for young healthy adults taking no other meds

35
Q

Lithium Augmention

A

In combo with TCA
Response within 48-72 hours

36
Q

Triiodothyronine Augmentation

A

May lead to hyperthyroidism

37
Q

Antipsychotic Augmentation

A

Aripiprazole
Brexpiprazole
Quetiapine

38
Q

Buspirone

A

mixed efficacy
useful in concomitant anxiety

39
Q

Stimulants (modafinil, methylphenidate

A

fatigue and apathy

40
Q

Hormone supplementation

A

Testosterone no benefit seen unless concurrent hypogonadism

Estrogen some effect on depression if perimenopausal vasomotor symptoms

41
Q

NMDA receptor antagonists

A

Mechanism includes alterations to inhibitory tone of interneurons and/or direct modulation of glutamate neurotransmission action on postsynaptic NMDA receptor

Ketamine, Dextromethorphan

42
Q

Esketamine

A

NMDA antagonist
CI: history of intracerebral hemorrhage, aneurysms, or arteriovenous malformations
BBW: risk of sedation and dissociation, potential for misuse

43
Q

Esketamine

A

NMDA antagonist
CI: history of intracerebral hemorrhage, aneurysms, or arteriovenous malformations
BBW: risk of sedation and dissociation, potential for misuse

44
Q

Dextromethorphan/bupropion (Auvelity)

A

non-selective, uncompetitive NMDA receptor antagonist and sigma-1 receptor agonist

45
Q

Cardiac risk of QT prolongation

A

Preferred: Sertraline
Avoid: citalopram, escitalopram, TCA

46
Q

Tobacco Use

A

Preferred: Bupropion
Avoid: No CI

47
Q

Seizure disorder

A

Preferred: No
Avoid: Bupropion, TCA

48
Q

Peripheral neuropathy or pain

A

Preferred: Duloxetine, high-dose venlafaxine, TCAs
Avoid: No CI

49
Q

Pregnancy

A

Preferred: No meds, if severe citalopram, escitalopram, sertraline
Avoid: paroxetine, MAOi, vortioxetine

50
Q

Daytime Sedation

A

Preferred: fluoxetine, bupropion, vorioxetine, duloxetine
Avoid: paroxetine, mirtazapine, trazodone

51
Q

Cognitive dysfunction

A

Preferred: Vortioxetine, bupropion, duloxetine, SSRI
Avoid: anticholinergic meds

52
Q

Insomnia

A

Preferred: mirtazapine
Avoid: activating medications later in the day

53
Q

Sexual dysfunction

A

Preferred: bupropion, mirtazapine, vortioxetine
Avoid: SSRI, SNRI, paroxetine, venlafaxine

54
Q

Weight gain

A

preferred: SSRI (not paroxetine) or SNRI
Avoid: paroxetine and venlafaxine

55
Q

polypharmacy

A

Preferred: escitalopram, sertraline, mirtazapine
Avoid: fluoxetine, paroxetine, MAOi

56
Q

Suicide risk

A

Preferred: SSRI, mirtazapine
AvoidL TCA, MAOi, citalopram used with caution

57
Q

Special populations: Pregnancy

A

All SSRI are Category C, except paroxetine (D)
All TCA are Category C, except maprotiline (B)
All SNRI, mirtazapine, bupropion are Category C
Avoid MAOI – teratogenic in animal studies

58
Q

Special populations: Lactation

A

Monotherapy with sertraline or paroxetine at lowest effective dose preferred

Imipramine or nortriptyline may also be recommended

Doxepin, St. John’s Wort are contraindicated
All SSRI and TCA (except doxepin) are low risk
Bupropion and SNRI are not well studied, variable risk

CDM 4 Exam 2 (13 decks)

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