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825 > Treating Depression (Cut off for Exam 4) > Flashcards

Treating Depression (Cut off for Exam 4) Flashcards

1
Q

Partial Response

A

At least a 50% reduction in reported symptoms

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2
Q

Remission

A

Resolution of symptoms (screens as if no depressive symptoms present)

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3
Q

Pleiotropic

A

In the context of drug therapy, unanticipated effects (usually beneficial)

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4
Q

Augmentation

A

Addition of a second or third medication to achieve greater resolution of symptoms

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5
Q

Severity of Depressive Disorder

A
  • Ideally ranked severity mirrors level of functional impairment in everyday life
  • Mild: 4 symptoms, at least one core (depressed mood or loss of interest)
  • Moderate: 5-6 symptoms, at least one core but likely meets at least 2
  • Severe: 6+ symptoms (likely meets all core requirements)
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6
Q

VA Guidelines

A
  • Depression screening recommended for all patients not currently on therapy for depression
  • Recommendations vary depending on depression severity
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7
Q

Mild-Moderate Depression Recommendations

A
  • Psychotherapy (strong recommendation): ACT, IPT, CBT, PST, MBCT
  • Pharmacotherapy (strong recommendation): SSRI, SNRI, mirtazapine, bupropion
  • Partial response: combo of psycho and pharm therapy, alternative monotherapy, augmentation with second medication
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8
Q

Psychotherapy Abbreviations

A
  • ACT: Acceptance and commitment therapy
  • IPT: interpersonal therapy
  • CBT: cognitive behavioral therapy
  • PST: problem-solving therapy
  • MBCT: mindfulness-based cognitive therapy
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9
Q

Severe Depression Recommendations

A
  • Use combination of psychotherapy and pharmacotherapy to start
  • Consider ECT
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10
Q

Other ECT Indications

A
  • Catatonia
  • Psychotic features
  • Patient preference
  • Pregnancy
  • Intolerable SE with medication
  • Need for rapid resolution
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11
Q

All Depression Levels Recommendations

A
  • Continue pharm therapy for at least 6 months after achieving remission
  • Treat longer, 12 month to indefinitely, if high risk of relapse
  • Consider psychotherapy if stopping pharm and patient is at high risk of relapse
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12
Q

Pregnancy + Depression Recommendations

A
  • Use psychotherapy first

- If stable on med before pregnant, weigh risks/benefits of continuing therapy

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13
Q

Elderly + Depression Recommendations

A
  • 65 y.o.+

- Use psychotherapy first

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14
Q

Patients with SAD

A

-Light therapy

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15
Q

Treatment Resistance Recommendations

A
  • Defined as failure to achieve remission with at least two adequate pharm therapy trials
  • Try MAOI or TCA
  • Evidence not strong for ketamine
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16
Q

Other/Alternative Treatments for Depression

A
  • Acupuncture, yoga, tai chi, qi gong as mono or add-on therapy (insufficient evidence)
  • Exercise and patient education
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17
Q

Herbals/Supplements

A
  • Not enough evidence for Vitamin D or fish oil as monotherapy
  • If patient insists, use standardized St. John’s Wort extract
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18
Q

American Psychiatric Association Guidelines

A
  • Greater focus on diagnosis than VA guidelines
  • More detail for non-pharm therapies
  • Little difference in actual treatment recommendations for any level of depression
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19
Q

The Campbell Method

A

-Target the greatest number of presenting symptoms
Avoid the most SE
-Maximize the list of comorbid conditions treated
-Minimize polypharmacy
-Work with patient/caregiver on choice of therapy

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20
Q

Options if First Lines Don’t Work

A
  • Consider referral/consult for diagnosis clarification
  • Run the usual lists of trouble-shooting: med compliance, drug-drug/drug-food interactions
  • Dose titration: not universally accepted process, SNRI/SSRI/atypicals saw no additional benefit from titration
  • Switching agents: mixed evidence on best modality
  • Augmentation Strategies
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21
Q

Augmentation Strategies

A
  1. Second Antidepressant
  2. Atypical antipsychotics
  3. Miscellaneous
22
Q

Second Antidepressant Options

A

Bupropion

  • Can use with SSRI, SNRI, TCA, mirtazapine, or nefazodone
  • Best option if experiencing sexual dysfunction with SSRI
  • Avoid dosing after 3-4 PM

Mirtazapine

  • Best option if also having insomnia or poor appetite
  • Lower doses are MORE sedating
23
Q

Atypical Antipsychotic Options

A
  • Best evidence currently for augmentation with atypical antipsychotics after failing second antidepressant trial
  • Usually use lower doses than if treating a psychosis
  • Aripiprazole, Brexpiprazole, Olanzapine, and Quetiapine are all options
24
Q

Aripiprazole

A
  • Least sedating

- Low metabolic risk

25
Q

Brexpiprazole

A
  • More or less works like aripiprazole with slightly more metabolic SE
  • More expensive
  • No evidence that it is superior
26
Q

Olanzapine

A

-Avoid as initial choice due to worse metabolic complications

27
Q

Quetiapine

A
  • Usually use IR
  • Major active metabolite acts as a potent NE reuptake inhibitor
  • Highly sedating
  • Orthostatic hypotension common in older adults
  • Metabolically less favorable, better than olanzapine though
28
Q

Miscellaneous Treatment Options

A
  • Lithium
  • Liothyronine
  • Buspirone
  • Pramipexole
  • Modafinil
29
Q

Lithium

A
  • Go to agent for years
  • Concerns or renal toxicity with long term use
  • Requires biannual monitoring or ECG, renal fxn, CBC, and lithium levels
  • Generally well-tolerated at doses used for augmentation
  • One or two medications to REDUCE suicide risk
30
Q

Liothyronine

A

-Be careful not to induce HYPERthyroidism

31
Q

Buspirone

A

-No benefit unless concurrently diagnosed with GAD

32
Q

Pramipexole

A
  • Reasonable option for targeting apathy and anhedonia
  • Nausea (younger patients), orthostatic hypotension (older patients), and history of impulsive behaviors should be monitored
33
Q

Modafinil

A
  • FDA-approved for augmentation

- Good for excess fatigue and/or apathy

34
Q

Prophylaxis for SE

A
  • Prevent with proactive counseling

- Switching therapies is usually easiest if SE still occur

35
Q

SE: Sexual Dysfunction Alternative

A
  • Vague term, clarify exact symptoms with patient/provider
  • Erectile dysfunction: sildenafil, tadafil, etc
  • Loss of libido/inability to reach orgasm: add bupropion
  • Any form of sexual dysfunction: CHANGE medication
  • Bupropion, mirtazapine, and nefazodone have lowest rate of sexual dysfunction as monotherapies
36
Q

SE: Insomnia Alternatives

A
  • Adjust timing of current medication
  • Add mirtazapine (7.5 mg) or trazodone (12.5-25 mg) at LOW dose
  • Quetiapine (12.5-100 mg) is second-line due to SE
37
Q

SE: Fatigue Alternatives

A
  • Adjust timing of current medication
  • Modafinil
  • Bupropion can have a mild stimulant effect
  • Methylphenidate, ampehtamines, and aripiprazole are all valid options as well
38
Q

Serotonin Syndrome

A
  • Can occur from excessive serotonin activity form taking too many serotonergics
  • Exceedingly rare
  • Treatment: withdrawal of offending agents
  • Cyproheptadine also recommended, direct 5HT antagonist
39
Q

QT Interval Prolongation

A
  • Most every medication prolongs QT to some extent
  • Aripiprazole is rare exception: SHORTENS QT interval
  • Duloxetine neutral effecton QT inteval and is a good option if baseline prolongation is present
  • Effect is additive
  • Solution: monitor with regular ECGfs, use caustion is QT > 450 msec, stop/taper meds if QT > 500 msec
40
Q

smoking

A
  • Aromatic hydrocarbons induce CYP1A2

- Will significantly effect the levels of clozapine and olanzapine

41
Q

CYP2D6

A
  • Fluoxetine, bupropion, duloxetine, paroxetine are INHIBITORS
  • Watch out for use of meds metabolized by this enzyme
42
Q

Psychotherapy

A
  • Many different forms exist
  • CBT is most widely used and studied form
  • Can be done face-to-face or in a computer based way
43
Q

ECT

A
  • Most effect treatment for depressive disorders (70-90% see positive response)
  • Safest treatment in existence
  • SE: transient anterograde amnesia, permanent retrograde amnesia
  • One of the fastest treatments
  • Best if 2-3 treatments over 6-12 weeks
  • Virtually no CI except Lithium
  • Lithium can cause prolonged delirium after procedure, reduce or stop dosing to avoid this SE
  • Avoid/taper off most anticonvulsants if possible
44
Q

Repetitive Transcranial Magnetic Stimulation

A
  • rTMS
  • Utilizes brief magnetic pulses directed at specific regions of cerebral cortex
  • Pulses delivered repetitively between 10-20 Hz
  • Approved for those failing to response to at least one antidepressant
  • Response rate is variable
45
Q

Other Non-Pharm Options

A
  • Animal-assisted therapy
  • Yoga
  • Tai chi
  • Qi gong
  • Aerobics
46
Q

Why won’t I feel better immediately?

A
  • Neurogenesis takes 2-6 weeks to take effect

- Increased neurotransmitters will occur immediately

47
Q

I’ve heard antidepressants work no better than placebos

A
  • Mild depression tends to have high rates of natural remission
  • Moderate to severe depression still sees benefits from antidepressant use
48
Q

Are antidepressants safe while pregnant?

A
  • SSRIs and septal heart defects are root of public concern
  • SSRIs do not appear to have associated congenital heart defects
  • Risk of untreated depressant shown to have a larger risk of this defect than SSRIs
  • Use during first trimester is the greatest association with risk
49
Q

Suicide Screening

A
  • ALL health care professionals should ask
  • Full risk assessments require qualified providers
  • Be blunt: are you considering harming or killing yourself?
  • Normalize the situation with facts (10% consider suicide in their lifetime)
50
Q

Ketamine

A
  • Infusions can be done at facilities and psychiatric offices
  • Use lower doses than used for anesthesia
  • 40-minutes infusions
  • Similar treatment schedule to ECT
51
Q

Esketamine

A
  • Spravato
  • Nasal spray
  • Approved for use with oral antidepressants
  • Dose: 28-84 mg intranasally
  • Requires 2 hours of observation and a driver home afterwards
  • Shown to increase time until relapse when taken with antidepressant than when antidepressant is taken as monotherapy
52
Q

Hydroxynorketamine

A
  • Likely antidepressant metabolite from ketamine

- Enhances AMPA signaling pathway under an unclear mechanism

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