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Psychology & Neuroscience of Affective Disorders > Psychiatric perspectives > Flashcards

Psychiatric perspectives Flashcards

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1
Q

What are the current depression treatment options?

A

> Pharmacological
- antidepressants and adjunctive treatments

> Non-pharmacological

  • psychotherapy (CBT, IPT, psychodynamic)
  • lifestyle changes and minfulness
  • phototherapy (use of bright light)

> Neurostimulation

  • ECT
  • Deep brain stimulation (DBS)
  • Vagus nerve stimulation
  • Repetitive Transcranial Magnetic Stimulation (rTMS)
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2
Q

What is the use of phototherapy?

A

Helpful for seasonal and non-seasonal affective disorders

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3
Q

Are the current treatments for depression exclusive?

A

No

- psychological + pharmacological therapy

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4
Q

What is the history of use behind antidepressants, antipsychotics and anti-convulsants?

A

Derived form other areas of medicine, then repurposed for mood disorders,
with sound evidence base

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5
Q

What do the rates of antidepressant prescriptions in England (2015) tell us?

A

2015: 61 million prescriptions written
- 8-10% receiving antidepressants

-> frequently used medication

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6
Q

What is the goal of treating depression?

A

Remission

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7
Q

What is remission?

A

Reduction of symptoms below a certain level

  • less than 8 on HAM-D scale
  • less than 10 on MADRS scale
  • less than 5 on QIDS-SR
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8
Q

What is a response to treatment?

A

50% reduction in symptoms from baseline QIDS-SR

  • self-inventory
  • designed to measure severity of depressive symptoms
  • based on DSM-IV

-> Measure of signal of efficacy rather than satisfactory treatment outcome

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9
Q

Why are residual symptoms relevant?

A

> Patients associated with higher residual symptoms have poorer outcomes and higher relapse rates compared to those without

> Residual symptoms associated with early relapse, even mild residual symptoms

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10
Q

What was the goal of the STAR*D study?

A

Set benchmark for our expectations of treatment

- STAR*D algorithm (Sequence Treatment Alternatives to Relieve Depression)

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11
Q

What did the STAR*D study consist of?

A

> Carried out in early 2000s in the US
- headed by Pr. John Rush

> Multi-level progressive treatment algorithm

  • Level 1: initial treatment: citalopram
  • Levels 2, 2A, 3
  • Level 4: switch to tranylcypromine or mirtazapine combined with venlafaxine (extended-release)
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12
Q

What did the STAR*D study (2007) show?

A

> Implementing all of the treatment strategies in the algorithm resulted in:

  • 2/3 participants remitting
  • 1/3 participants with persisting depressive symptoms

> Failure to achieve remission increased risk of relapse

> Switching treatment does not have to be within same class to have extra benefit

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13
Q

What are the current identified problems with antidepressants?

A

> Majority of patients with depression do not respond to, or do not achieve remission through first pharma treatment applied

> Chance of achieving remission reduces with each new treatment attempts

> Risk of relapse increases with each new treatment

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14
Q

What can be done if a patient does not remission?

A
  • Reconsider the diagnosis
  • Evaluate patient’s adherence to treatment
  • Consider increasing the dosage
  • Change treatment
  • Augment the treatment (adjunctive medication)
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15
Q

What is the evidence on increasing the dosage of an antidepressant?

A

Limited evidence, but should be considered especially if:

  • there are minimal side-effects
  • some improvement on the antidepressant
  • current antidepressant has possible dose response
  • evidence for venlafaxine, escitalopram and TCAs
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16
Q

When should you consider switching antidepressants?

A

> If there are troubling or dose-limiting side-effects, and/or no improvement

> Switch within or between antidepressant classes initially

> Consider different class after more than one failure with a specific class

e.g. Failure on 2 SSRIs -> first consider SNRI or other class, then consider venlafaxine

17
Q

When should you avoid switching antidepressant quickly?

A
  • If there’s potential drug interaction

- If there are potential drug discontinuation effects

18
Q

Which antidepressants have evidence of higher efficacy?

A
  • Venlafaxine (> 150mg)

- Escitalopram (20mg)

19
Q

When should you consider augmenting/combining pharmacological treatment?

A

> If there’s partial/insufficient response on current antidepressant but good tolerability

> If switching antidepressants has been unsuccessful

20
Q

What is necessary when augmenting/combining pharmacological treatments?

A

> Establish the safety of the proposed medication

> Choose the combination(s) with best evidence base first

21
Q

What did the CO-MED stud (Rush et al., 2011) show?

A

No significant benefits of combining antidepressants

22
Q

What are the guidelines for the augmentation of antidepressants?

A

> Consider adding an atypical antipsychotic

  • Quetiapine
  • Aripiprazole

> Consider adding lithium (monovalent cation)

> Other antipsychotics may be considered

  • Risperidone
  • Olanzapine
  • Trlodothyronine
  • Mirtazapine
23
Q

What is the evidence on the switching or augmentation of antidepressants in older patients?

A
  • Smaller evidence base
  • About 50% respond to switching or augmentation
  • Best evidence for lithium augmentation
24
Q

What are the guidelines on augmenting antidepressants for severely treatment resistant patients?

A

Consider
- multiple combinations concurrently

  • approaches with limited evidence
  • must be carried out in specialist centres with appropriate expertise and safeguards
25
Q

What is the evidence on augmenting antidepressant treatment with second-generation (atypical) antipsychotics?

A

Good evidence suggesting this should be a principal strategy for patients who haven’t responded to antidepressant monotherapy

26
Q

What is the evidence on the effectiveness of lithium compared to augmenting antidepressants with atypical antipsychotics?

A

When we add lithium to antidepressants, aim for blood level of minimum 0.6 mmol/L to maximise likelihood of response

Otherwise:
lithium+antidepressants is less efficacious than quetiapine+antidepressants
(evidence is not robust)

27
Q

What are the next-step physical treatment options for treatment resistant patients who failed to respond to a combination of lifestyle, psychological and pharmacotherapy options?

A

> ECT
- first-line physical treatment

> tDCS (transcranial direct current stimulation)

  • limited evidence of efficacy in resistant patints
  • not recommended in routine clinical practice
  • being examined in clinical trials

> rTMS

  • limited evidence of efficacy
  • could be considered for those who are intolerant to other treatments
  • limited availability

> Vagus nerve stimulation (VNS)

  • commonly used for epilepsy
  • limited but growing evidence of efficacy

> Deep brain stimulation (DBS)

  • implanted electrodes in brain
  • first used to treat Parkinsonism
  • 2 trials that failed

> Ablative surgery
- less than a dozen patients per year in the UK undergo this treatment

28
Q

When should vagus nerve stimulation be undertaken for treatment-resistant patients?

A
  • Only in specialist centres with prospective outcome evaluation
  • If long-term follow-up is available
29
Q

When is deep brain stimulation (DBS) be recommended?

A

Only for use in very specialist centres as part of ongoing research

Psychology & Neuroscience of Affective Disorders (16 decks)

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