MDD Flashcards
What is MDD characterized by?
Persistent low mood
and
Lack of positive affect
Anhedonia (Loss of interest in usually pleasurable activities) that is different from patient’s usual self
and
Causes significant distress or impairment for 2+ weeks
Which sex is MDD more common in?
Women > men
What does MDD co-occur with?
Other psychiatric and medical conditions
What does MDD contribute to?
Suicide - must assess
What does MDD impact?
Functioning and ability to work
What is MDD partially due to?
Genetics
Stress
Environment (biopsychosical model)
What hypothesis does MDD therapy focus on?
“Monoamine hypothesis”
or
“Biogenic amine hypothesis”
What is the monoamine hypothesis?
Deficiency/underactivity in serotonin, NE, DA, GABA, tryptophan, somatostatin, and thyroid hormones have all been impacted in causing MDD or depression
What are the RFs for MDD?
FH Other psychiatric illness Stress Female Meds Illness
What meds cause MDD?
Clonidine Oral contraceptives Corticosteroids AEDs Antipsychotics Varenicline Benzo EtOH Opioids
What is the first step in treating MDD?
Treating or removing underlying cause
How long will sx develop in MDD?
days-weeks
What is the onset of MDD?
Mid-20s
Is MDD recurrent or one time?
Recurrent
Are recurrent episodes of MDD variable or consistent?
Variable
When are longer periods of remission most common in MDD?
Early in course
What is a predictor or MDD persistence?
Severity of initial major depressive episode
Which assessments are used in MDD?
PHQ-9
HAM-D
What is PHQ-9 used for?
To screen for and diagnose depression
Can be completed in minutes
What is the HAM-D used for?
Monitoring
Decreasing score = improvement
How many sx must be present for how long in MDD?
5+ sx (at least one of the following: depressed mood or loss of interest/pleasure)
During the same 2 week period
What are the sx of MDD?
SIG E CAPSL Sleep (insomnia/hypersomnia) Interest (loss of interest/pleasure) Guilt (feelings of worthlessness or excessive/inappropriate guilt) Energy (fatigue/loss of energy) Concentration Appetite (change in appetite/weight) Psychomotor Suicidal thoguhts Low mood
What variation of MDD is experienced in elderly?
“pseudo-dementia”
What types of physical complaints are common?
Somatic - involves having a significant focus on physical sx to the point that it causes major distress and problems functioning
What is persistent depressive disorder?
2 years of impaired functioning secondary to MDD sx (5 or less)
What is considered a response to therapy of MDD?
50% reduction of sx
What is partial response to therapy of MDD?
Less than 50% reduction of sx
What is considered MDD remission?
A period of 2 or more months w/no sx
1-2 sx of mild degree
Primary goal of treatment
What is considered MDD recovery?
Sustained remission lasting > 6 months
What is considered MDD relapse?
Return of manifestations of a disease
What are common residual sx of MDD?
Insomnia Fatigue Painful physical complaints Difficulty concentrating Lack of interest
What are the least common residual sx of MDD?
Depressed mood
Suicidal ideation
Psychomotor retardation
What are key indicators of relapse of MDD?
Uncommon residual sx
What is considered recurrence of MDD?
Return of sx
What are the short term treatment goals of MDD?
Response
Decrease current sx
Limit SE/ADRs
Monitor SI
What are the long term treatment goals for MDD?
Remission
Restore fxn and QOL
Limite relapse/recurrence
What are the 1st line treatment options for MDD?
SSRI
SNRI
Mirtazapine
Bupropion
What are the 2nd line treatment options for MDD?
Try a different first line therapy
What are considerations when selecting therapy for MDD?
Patients tolerate and respond to medications differently
Clinically important differences exist between commonly prescribed antidepressants for both efficacy and acceptability
How is CBT used in MDD?
CBT has good evidence for use in MDD, and is acceptable first line monotherapy or combination therapy
How soon are physical sx improvement seen in MDD?
Sleep, and appetite in 1-2 weeks
How soon are emotional sx improvement seen in MDD?
Reduced sadness, increase pleasure in 2-4 weeks
How do we monitor efficacy of MDD treatment?
Adherence
Response
Functional status
QOL
What do we monitor in MDD therapy?
Drug SEs and Serotonin syndrome
What is important to remember about suicide risk and antidepressant use?
For most patients, antidepressant tx is better than no tx when considering SI and associated risk
What do we do for patients to help with SI and use of antidepressants?
Patients must be educated, and closely monitored
How long is considered an adequate trial for MDD therapy?
4-8 weeks at an appropriate dose
Should we exceed FDA max dose recommendations?
Does not improve efficacy
What do we do if non-response in MDD tx?
Re-evaluate patient and diagnosis
Change/switch to a different antidepressant (unless pt wishes to remain on therapy)
What do we do if there is a partial response in MDD tx?
Ensure optimized dose
Can either switch/augment therapy (should target remaining sx)
Augmentation is a better strategy when response is seen
What is the gold standard for MDD augmentation?
Lithium
What does Li do in MDD?
Reduces SI or thoughts in MDD
What augmentation agent for MDD is better in females?
T3 or T4
Can use in euthyroid
If AAP are used for MDD augmentation, what must we do?
Weight risk/benefit with SEs
Which AAPs are acceptable in MDD w/o psychosis?
Low dose SGAs Aripiprazole Quetiapine Olanzapine Brexpiprazole
How are stimulants used with augmentation/adjunct tx in MDD?
Controversial
May consider short course in severe depression (fatigue, not getting out of bed or if immediate response required)
May exacerbate anxiety
Abuse potential
How are Mood stabilizers/AEDs used in augmentation/adjunct tx in MDD?
May offer some benefit
Often used as a hail Mary
If mood stabilizers are effective at sx improvement, what is the next step in therapy?
Should screen patient for bipolar disorder
What is the DOT for first episode of MDD?
At least 12 months with the first episode for most patients
What is the DOT for patients with recurrent and/or severe MDD?
12-36 months
Indefinitely depending on severity
How should d/c be managed in MDD therapy?
Must be tapered over several weeks to prevent WD (sx are severe)
What are the sx of WD for antidepressants?
GI disturbance Flu like sx Anxiety Crying MDD re-emergence
Is it better or worse to treat pregnant women with MDD with antidepressants?
The risks of untreated psychiatric disorder to mother and child often outweigh the risks associated with antidepressants
How is the decision to treat pregnant women with MDD determined?
Shared decision making (mother to be to provider) necessary to determine whether or not to treat (start, continue, adjust, or stop)
What is 1st line treatment of MDD for pregnant women?
Zoloft
Celexa
Lexapro
