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PR3153 CNS > Therapeutics - MDD > Flashcards

Therapeutics - MDD Flashcards

1
Q

What is the aetiology of MDD?

A

Biological (neuroendocrine theories)
- Hormonal influences: increases secre of cortisol (major stress hormone)

Psychological
- Loss, -ve self ev
Pyschosocial
- Isolation, lack of social support
Psychiatric disorders
- Alcoholism
- Anxiety disorders
- Eating disorders
- Schizophrenia

Genetics
- Polymorphism in 5HTT gene: SLC64A on chr 17q11.2-12, indi w “S” allele of the promoter region of SERT gene more vulnerable to depression, more resistant to treatment

Endocrine disorder (hypothyroidism), Cushing syndrom, T2DM in women
Def states: anaemia, Wernicke’s encephalopathy
Infections: CNS infections, STD/HIV, TB
Metabolic disorders: electrolyte imbal, hepatic encephalopathy
CV: CAD, CHF, MI
Neuro: Alzheimer’s epilepsy, pain, PD, post-stroke
Malignancy

Drug
- CNS depressants
- Lipid sol BB
- Psychotropics: CNS depressants (benzos, opioids, barbiturates), anticonvulsants, tetrabenazine
- Withdrawal from alc, stimulants
- Corticosteroids (systemic)
- Isotretinoin
- Interferon-B-1a

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2
Q

What is the physiology of MDD?

A

Monoamine theory. Insuff monoamine (norepinephrine, 5HT, dopamine) rece activation

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3
Q

What are the risk factors for suicide?

A

Poor, elderly, isolation, man, other comorb, Hx of attempts, delusions

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4
Q

Describe the epidemiology of MDD?

A

20% lifetime incidence
280mil persons suffer from deoression worldwide
1 in 13 adults in SG

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5
Q

What are the signs and symptoms of MDD?

A

A. At least 5 of the following sx, where one is either depressed mood or decreased interest
Interest - decreased
Sleep - decreased or increased from usual
Appetite - >5-7% from baseline
Depressed mood
Concentration
Activity - psychomotor retardation or agitation
Guilt
Energy - low
Suicidal thots or attempts

B. Sx cause distress or impair social, occupational or other impt areas of fning
C. Not caused by other underlying medical conditon or sub

Retardation of thot and action
Loss of libido

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6
Q

What are some differential Dx for MDD?

A

Dysthymia = Depressed mood +2 sx for at least 2y but not fulfilling MDD Dx
Adjustment disorder = sx within 3mo of stressor but upon removal of stressor, sx do not last more than 6mo
Acute stress disorder- within 1mo of traumatic event & last 3d-1mo, incl fear, horror, w dissoc, re-xp, avoidance, increased arousal
Bipolar disorder

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7
Q

What are the agents used in MDD management?

A

Antidepressants

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8
Q

What considerations are made for underwt pts?

A

Consider mirtazapine. Avoid bupropion

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9
Q

What considerations are made for pts w eating disorders?

A

Consider fluoxetine. Avoid bupropion

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10
Q

What considerations are made for obese pts?

A

Consider bupropion, SSRI, SNRI. Avoid mirtazapine, TCAs, MAOIs

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11
Q

What considerations are made for CVD?

A

Consider setraline. Avoid TCAs, escitalopram, citalopram

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12
Q

What considerations are made for CVA?

A

Caution w antithrombotics

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13
Q

What considerations are made for chronic/neuropathic pain?

A

Consider SNRIs/TCAs

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14
Q

What considerations are there for renal insuff?

A

Consider paroxetine, escitalopram. Avoid agomelatine, duloxetine

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15
Q

What are the considerations for pts w DM?

A

Avoid TCAs, paroxetine, duloxetine, bupropion

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16
Q

What are the considerations for HTN?

A

Avoid TCAs, SNRIs

17
Q

What are the considerations for seizures?

A

Consider SSRIs, SNRIs. Avoid bupropion, TCAs

18
Q

What are the considerations for elderly?

A

Avoid TCAs, antidepressants w alpha adrenergic, histaminergic, anticholinergic S/E

19
Q

What are the considerations w tamoxifen?

A

Avoid CYP2D6 inhib (req CYP2D6 conversion of tamoxifen –>active): fluoxetine, paroxetine, bupropion

20
Q

What are the considerations for pregnancy?

A

Avoid paroxetine, bupropion (nortriptyline in late preg may be considered), monitor suicide risk

21
Q

What are the considerations for smoking?

A

Use bupropion

22
Q

What are the considerations for BPH, angle closure glaucoma?

A

Avoid TCAs, paroxetine, venlafaxine

23
Q

What is an adequate trial?

A

Adequate dose + duration 4-8 weeks, max 12 weeks

24
Q

What is the time course of treatment response?

A

Physical symptoms: 1-2 weeks
Mood symptoms: 4-8 weeks

25
Q

Describe the washout required with MAOIs.

A

Switching from MAOI to other antidepressants: 24h washout

Switching from other antidepressants to MAOI: 1 week washout. (If switching from fluoxetine 5weeks)

26
Q

When do we switch antidepressants?

A

When completely ineffective or intolerable to adequate dose in 2-4 weeks
If cross titration: watch out for serotonin syndrome if combining serotonergic agents
If direct switch: stop SSRI totally and ini next serotonergic agent
If switching from serotonergic antidepressant used daily for past 2mo to a non-serotonergic agent: gradual cross tapering over several weeks to reduce risk of antidepressant discont syndrome

27
Q

If there is partial resp, what is the recommendation?

A

Combine 2nd antidepressant (w diff MOA) to existing
E.g. mirtazapine + bupropion SR or nortriptyline, T3 (liothyronine), Li

28
Q

What is the recommendation for treatment resistant depression?

A

Neurostim
Symbax PO capsule (olanzapine 6mg + fluoxetine 25mg)
Spravato nasal spray (Esketamine 28mg /vial) as adjunct to SSRI/SNRI

29
Q

What is treatment resistant depression?

A

Non-resp to >= 2 adequate trials of antidepressants

30
Q

What are the adjunct treatment for MDD?

A

SGA: aripiprazole, brexpiprazole, quetiapine XR
NMDA rece antagonist: esketamine
prn hypnotics (refer to anxiety, sleep disorders): benzos, Z-hypnotics, antihistamines

31
Q

What is the duration of treatment for continuation phase of MDD?

A

Cont min 4-9mo after acute phase treatment (TOTAL 6-12mo)

32
Q

What are the non-pharm reco for MDD?

A

Psychosocial treatment
Sleep hygiene
Exercise, relaxation techniques
Neurostim
- ECT
- Repetitive transcranial magenetic stim (rTMS)
Light thera
Nut
- Vit B12
- L-methylfolate
- Vit D
- S-adenosylmethionine (SAMe)
- Omega-3-FA
- 5-hydroxytryptophan (5HTP_

Do NOT take St John’s Wort (DDI + potentiate serotonin syndrome

PR3153 CNS (13 decks)

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