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Depression > Module > Flashcards

Module Flashcards

1
Q

what est % of diagnosed depressed pts reported unexplained physical symptoms as their chief complaint?

A

69%

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2
Q

which pts have poorer outcomes than those without depression?

A

pts with diabetes, ischemic heart disease, stroke, or lung disorders

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3
Q

what % of pts with severe mood disorders die from suicide?

A

15%, one study showed 20% visited their PCP the same day they committed suicide

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4
Q

what is the risk of having depression if pts first degree relative has recurrent major depression?

A

1.5-3 times higher
27% of children with one parent with a mod disorder will develop the disorder themselves, and 50-75% if both parents are affected

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5
Q

what is mood?

A

a range of emotions that a person feels over a period of time

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6
Q

what is affect?

A

how a person displays his or her mood

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7
Q

what is pseudodementia?

A

severe cognitive impairment due to depression

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8
Q

when should depression screening be highly considered?

A

pts with:
personal previous history of depression or bipolar disorder, first degree biologic relative with history of depression or bipolar disorders, chronic dz, obesity, chronic pain, impoverished home environment, financial strain, experiencing major life changes, pregnant or postpartum, socially isolated, multiple vague and unexplained symptoms, fatigue or sleep disturbance, substance abuse, loss of interest in sexual activity, elderly age

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9
Q

what is the USPSTF recommendation on screening for depression?

A

screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow up is recommended
-without access to these resources there is fair evidence that the screening will not improve outcomes

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10
Q

what is lack of improvement in depression most related to?

A

lack of treatment NOT insufficient case identification

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11
Q

what are some of the formal screening tools available?

A

Zung self assessment depression scale, Beck depression inventory, General Health Questionnaire, Center for epidiologic study depression scale and the patient health questionaire (PHQ2) the USPSTF does not recommend one screening test over another

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12
Q

what PHQ9 score is needed for diagnosing depression?

A

> 10, 88% sensitivity and 88% specificity

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13
Q

what is the DSM IV criteria for Major Depressive Episode?

A 
at least 5 of the following symptoms present in a two week period nearly everyday and an impairment, one of them must be anhedonia or depressed mood 
P: psychomotor retardation or agitation
W:worthlessness 
A: Anhedonia
D: Depression
C: Concentration 
A: Appetite
F: fatigue
S: suicidality 
S: sleep
symptoms not accounted for by a mood disorder due to a general medical condition, substance induced mood disorder or bereavement 
and are not accounted for by a psychotic disorder
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14
Q

What types of special features can be associated with a major depressive episode?

A

melancholic, psychotic, or atypical

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15
Q

how will patients with depression with melancholic features present?

A

mainly anhedonia, must have three of the following: diurnal variation (depression worse in the morning), pervasive and irremediable depressed mood, marked psychomotor retardation or agitation, significant weight loss or anorexia, excessive or inappropriate guilt and early morning awakening
-have the best response to pharmacotherapy

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16
Q

What do depressed pts with psychotic features typically have?

A

hallucinations and delusions

  • very high risk for suicide even if they deny suicidal ideation
  • should be hospitalized immediately
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17
Q

what do atpical depressed pts exhibit?

A

milder depressed symptoms, must experience mood reactivity and two of the following: leaden paralysis (enormous effort to walk or exert, hypersomnia, rejection hypersensitivity, overeating or weight gain
-respond less to tricyclic antidepressants

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18
Q

what initial lab testing might be helpful when first evaluating a pt for depression?

A

TSH, CBC, and chem panel

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19
Q

what prescription drugs can casue substance induced depresion?

A

blood pressure meds (reserpine, propanolol, anticholinergics, steroids, oral contraceptives, psychotropic medications and antieoplastic drugs

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20
Q

what is dysthymic disorder?

A

chronic form of depression, signs and symptoms are milder but can cause much distress and dysfucntion, more chronic an dunremitting, less responsive to pharmacotherapy

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21
Q

what is the DSM IV criteria for dysthymic disorder?

A

depressed mood for most of the day for more days than not, for at least two years (kids and adolescentas 1 year)
with:
A: poor appetite or overeating
S:sleep-insomnia or hypersomnia
F:fatigue
S:low self esteem
C: poor concentration
H:hopelessness
-never without symptoms for more than two months at a time
not MDE present during first two years of disturbance,
-never been a manic, mixed episode or hypomanic episode, and not cyclothymic, does not occur during the course of a chronic psychotic disorder like schizo or delusional,
-not due to a durg or medical condition
-must cause significant distress or impairment in social, occupational or other importnat areas of functioning

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22
Q

when should bereavement resolve?

A

usually resolve within 2 months (do not require pharmacotherapy) but if persist major depression should be considered

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23
Q

what is adjustment disorder with depressed mood?

A

pt has depressive symptoms or complaints within 3 months of an identifiable psychosocial stressor, stressors may include academic failure, job loss, or divroce, the stressor causes depressed symptoms that do not meet the criteria for major depression or dysthymic disorder
treatment is psychotherapy over pharmacologic

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24
Q

what are seasonal affective disorders?

A

major depressive episodes that have a seasonal pattern

  • dx not made if there is a clear psychosocial stressor related to the change in season
  • respond to standard antidepressants and psychotherapy
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25
Q

what is poor neonatal adaptation?

A

irritability, tachypnea, hypoglycemia, thermal instability, and weak or absent cry usually mild and transient lasting no more than two weeks, caused by use of SSRIs in thid trimester

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26
Q

what are the agents of choice in treating pregnant pts with depression?

A

SSRIs, or psychotherapy if mild/.moderate sx
paroxetine use in first trimester may increase risk for congenital malformations particularly cardiac
-mood stabilizers (phenytoin, VPA, carbamazepine are teratogenic

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27
Q

which pts recommended to remain on their medication through pregnancy?

A

bipolar, suicide attempts, recurrent MDD, or psychotic disorders

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28
Q

what is postpartum depression?

A

occurs within one month of giving birth can begin as soon as 24 hrs post delivery

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29
Q

what are some risk factors for depression in elderly adults?

A

history of depression, chronic medical illness, male sex, being single or divorced, brain disease, alcohol abuse, use of certain medications and stressful life events

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30
Q

what are common complaints in elderly patients

A

insomnia, anorexia, and fatigue

-SSRIs can be useful

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31
Q

which pts are at higher risk for developing chronic and recurring depression?

A

pts who are elderly wehn they have their first episode of depression and young
-it may take longer to achieve remission in older pts

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32
Q

what are the symptoms of pseudodementia?

A

marked psychological distress, inability to concentrate or complete daily tasks, marked cognitive dysfunction

  • usually exhibit profound concern about their impaired cognitive dysfunction
  • pts with dementia tend to minimize their disability
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33
Q

what is a manic mood characterized by? hypomania?

A

irritability or abnormal euphoria, hypomania is a lesser degree of mania that lasts for a shorter duration, usually can contiue on with normal life and do not require hospitalization

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34
Q

what is the DSM IV criteria for a manic episode?

A

distinct period of abnormally and persistently elevated, expansive, or ittitable mood lasting 1 week,
during the period 3 or more persist:
-grandiosity, inflated self esteem
-decressed need for sleep
-more talkative
-flight of ideas
-distractibility
-excessive involement in pleasurable activites taht have a high potential for painful consequences
-increase in goal oriented activity
*symptoms must not meet the criteria for a mixed episode,
*mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activites or relationhips with other, or to necessitate hospitalizaion
*not due to a substance of a medical condition

35
Q

what is the DSM IV criteria for a hypomanic episode?

A

distinct period of elecated, expansive or irritable mood lasting at least 4 days that is clearly different form the usual non depressed mood
during the 4 days, 3+ have persisted
-graniosity, inflated self esteem
-decreased need for sleep
-more talkative
-flight of ideas
-distractibility
-increase in goal directed activity
-excessive involement in pleasureable activites that have a high potential for consequences
*change in fxn
*observable by others
*not severe enough to cause marked impairment or not needing hospitalization
*not due to another substance or medical condition

36
Q

which antidepressants are more lethal in overdose?

A

tricyclics (cardiotoxicity, convulsions)

-risk of suicide in all pts who are recovering from major depression may increase during initial treatment

37
Q

which antidepressant is used in children and adolescents?

A

fluoxetine (SSRIs)

38
Q

what is the average risk of suicide in general with antidepressants? with placebo?

A

antidepressants 4%

placebo 2%

39
Q

what are the steps in planning a treatment regimen for a pt?

A
  1. perform a diagnostic evaluation to determine if the diagnosis of depression is warranted or it other psychiatric or medical conditions exist
  2. evaluate for the safety of the pt and of others*
  3. evaluate functional impairment (relationships, work, living conditions, health and medical related needs)
  4. determine a treatment setting (safest and most effective)
  5. establish and maintain a therapeutic alliance
  6. continue to montior the patient’s psychiatric status and safety
  7. provide patient education and, it appropritae to the pts family
  8. enhance treatment adherence
  9. work with the pt to address early signs of relapse
40
Q

what is a contraindication for tricyclic antidepressant use?

A

cardiac disease

block H1 receptors, block parasympathetic cause tachycardia, urinary retention, dry mouth

41
Q

what are the three phases of treatment?

A

acute phase: remission is induced (min 6-8 weeks)
continuation phase: remission is preserved and relapse prevented (usually 16-20 weeks in duration)
maintenance phase: susceptible patients are protected against recurrence or relapse of subsequent major depressive episodes (duration varies with frequency (duration varies with frequency and severity of previous episodes)

42
Q

what is remission?

A

return to the pts baseline level of symptom severity and runctioning

43
Q

what is relapse?

A

the re-emergence of significant depressive symptoms or dysfunction after remission has been achieved

44
Q

what is the goal of the acute phase of treatment?

A

to induce remission

45
Q

what should initial therapy be?>

A

pharmaco therapy or pharmacotherapy and psychotherapy

46
Q

when should pts be seen after starting antidepressants?

A

within 1-2 weeks for re assessment

47
Q

when is readjustment of meds considered?

A

if after the initial 4-8 week trial ther eis not a moderate im provement in baseline symptoms in the acute phase, medication can be increased, if after another 4-8 weeks there is still no moderate improvement of symptoms another review should occur

48
Q

what dose is used in the continuation phase?

A

same dose in the acute phase that achieved remission

49
Q

how often should a pt be seen in the continuation phase?

A

once every 2-3 months if stable, can vary though

if in active psychotherapy may be seen several times a week

50
Q

who can be considered candidates for discontinuation of treatment?

A

pts who remain stable throughout the continuation phase and who ar enot candidates for the maintainence phase (eg recurrent relapsing chronic depression)

51
Q

what is the minumim total length in treatment of an uncomplicated pt for their first MDE?

A

6 months (6 weeks acute 16-20 weeks continuation)

52
Q

what % of pts with a single MDE will have another?

A

50-85%

53
Q

what is the goal of maintenance treatment>

A

to prevent relapse

54
Q

what treatment should be used in the maintenance phase?

A

same treatment that was effective in the acute and continuation phase, optimal length unknown

55
Q

what are the factors that should be considered when deciding if pt can dc treatment?

A

frequency and severerity of recurrent episodes, dysthymic symptoms between episodes, the presence of other psychiatric disorders, the presence of chronic general medical disorders or patient preference

56
Q

how should maintenance pharmacotherapy be discontinued?

A

tapered over several weeks

57
Q

what are discontinuation syndromes?

A

mood disturbances, sleep, energy, appetite appear like relapses but due to lack of tapering medications
-more likely in short acting medications

58
Q

which is the most effective medication for depression?

A

all classes are equally effective

59
Q

what is the general order of use of antidepressants?

A
  1. SSRIs
  2. dual action reuptake inhibitors venlafaxine, buproprion
  3. tricyclics
  4. MAOis
60
Q

which antidepressants may be more effective in severe depression or depression with melancholic features?

A

TCAs and NRIs or depression that has predominant physical symptoms or pain

  • have cardiac conduction effects
    contraindications: cardiac effects, BPH, urinary retention and closed angle glaucoma
61
Q

how do venlafaxine, milnacipran and duloxetine work?

A

serotonin-NE reuptake inhibitors

-less cardiac effects

62
Q

which antidepressants are useful in treating chronic pain and diabetic neuropathy?

A

duloxetine and paroxetine

63
Q

what is buproprion?

A

inhibits NE and dopamine but not serotonin

  • less diarrhea, nausea, somnolescence and sexual side effects
  • can be used in smoking cessation
64
Q

How do MAOIs work?

A

nonselectively block Mao A and B isoenzymes

-need to adhere to a low tyramine diet to prevent HTN crisis

65
Q

which class of sntidepressants are used for atypical depression?

A

MAOis

atypical: extremem fatigue, sensitivity to rejection, troubled relationhips, mood reactivity

66
Q

what is nefazodone?

A

blocks 5HT receptors, efficacy similar to SSRIs and tends to be sedating

67
Q

what is mirtazapine?

A

adrenergiv receptor, specific serotonin receptors and histamine recetprs to enhance NE in synaptic cleft. wight gain, sedating

68
Q

what are some of the adjunct medicaiton?

A

lithium-mood stabilizer, can prevent manic and depressive edpisodes in bipolar pateitns,
-antipsychotic

69
Q

what is used to treat anxiety and depression?

A

SSRIs (anxiety initially worsened) and benzos

  • improve antidepressant response but can cause sedation, memory loss and dependence and withdrawal syndromes
  • be careful in those with alcohol abuse, older pts who cant metabolize well,
70
Q

when is psychotherapy considered for first line?

A

for mild depression, particulary if associated with psychosocial stress, interpersonal problems, or with concurrent development or personality disorders

71
Q

when is psychotherapy most effective?

A

in the acute phase of treatment, and in preventing relapse during continuation phase

72
Q

what are the most effective forms of psychotherapy?

A

those with structured and brief approaches-CBT, interpersonal therapy, certain problem solving therapies

73
Q

what is cognitive behavioral therapy CBT?

A

targets thoughts and behaviors that need to be changed, goal to recognize what triggers certain thoughts and behaviors and to alter routines through direction and action

  • teach pts to substitute healthy thoughts for negative ones-behaviour change is the primary goal with internal change as the byproduct
  • emphasis on present rather than on past
74
Q

what is interpersonal therapy?

A

based on belief that depression is caused by problems in important interpersonal relationships,

  • compiling an interpersonal history examining all of the pts relationships
  • pts taught to identify and deliberately tolerate feelings
  • does not involve formal homework like CBT
75
Q

what is problem solving therapy?

A

brief, focused form of cognitive therapy that focuses on the problems a person is currently facing and on helping to find solutions to these problems
-link between poor problem solving abilities and the etiology and maintenance of psychological disorders
-can change ones situation with oneself of changing ones reaction to something
-individuals are taught to identify, discover and invent effective responses for specific problematic situations
provide tools on how to effectively manage life’s stress in order to decrease distress, enhance sense of control and improve quality of life
-can be in group or individual sessions

76
Q

when is electroconvulsive therapy considered first line?

A

in severe depression with psychotic features, psychomotor retardation or resistance to medications
-suicidal and pregnant pts may have rapid benefits from ECT

77
Q

how is ECT used? Is it effective?

A

6-12 treatments 2-3 times a weeek
remission rates around 60-80 % in severe major depressive disorders
relapse rate more than 50%
-most start prophylactic treatment with antidepressants and adjuvants medications like lithium

78
Q

is St Johns wart effective?

A

not effective in treatment of major depression
unknown if effective when used in combination therapy
-contraindicated in HIV pts taking antiretroviral therapy

79
Q

what do most pts suffering form depression complain of?

A

anhedonia or vague unexplained symptoms

80
Q

when does having a first major depression episode usually lead to higher lieklihood of developing chronic and recurring depression?

A

pts who are older higher chance of having chronic and recurring depression

81
Q

who has a better prognosis for recovery old or young adults?

A

same, but older pts may take longer to achieve remission (elderly usually start at lower doses)

82
Q

what situations require referral to psychiatrist?

A

suicide risk, bipolar disorder or manic episode, psytchotic symptoms, severe decrease in level of functioning, recurrent depression and chronic depression, depression that is refratory to treatment, cardiac diease taht requires TACs, need for ECT lack of available support system and any diagnostic or treatment questions

83
Q

when is psychotherapy condisered for first line?

A

in mild depression , or in mild to moderate–> most effective in the acute phase and in presenting relapse during the continuation phase,

84
Q

what do PHQ 9 scores mean?

A

1-4 minimal depression

Depression (1 decks)

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