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
Brexpiprazole
- More or less works like aripiprazole with slightly more metabolic SE - More expensive - No evidence that it is superior
26
Olanzapine
-Avoid as initial choice due to worse metabolic complications
27
Quetiapine
- 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
Miscellaneous Treatment Options
- Lithium - Liothyronine - Buspirone - Pramipexole - Modafinil
29
Lithium
- 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
Liothyronine
-Be careful not to induce HYPERthyroidism
31
Buspirone
-No benefit unless concurrently diagnosed with GAD
32
Pramipexole
- Reasonable option for targeting apathy and anhedonia - Nausea (younger patients), orthostatic hypotension (older patients), and history of impulsive behaviors should be monitored
33
Modafinil
- FDA-approved for augmentation | - Good for excess fatigue and/or apathy
34
Prophylaxis for SE
- Prevent with proactive counseling | - Switching therapies is usually easiest if SE still occur
35
SE: Sexual Dysfunction Alternative
- 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
SE: Insomnia Alternatives
- 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
SE: Fatigue Alternatives
- Adjust timing of current medication - Modafinil - Bupropion can have a mild stimulant effect - Methylphenidate, ampehtamines, and aripiprazole are all valid options as well
38
Serotonin Syndrome
- 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
QT Interval Prolongation
- 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
smoking
- Aromatic hydrocarbons induce CYP1A2 | - Will significantly effect the levels of clozapine and olanzapine
41
CYP2D6
- Fluoxetine, bupropion, duloxetine, paroxetine are INHIBITORS - Watch out for use of meds metabolized by this enzyme
42
Psychotherapy
- 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
ECT
- 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
Repetitive Transcranial Magnetic Stimulation
- 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
Other Non-Pharm Options
- Animal-assisted therapy - Yoga - Tai chi - Qi gong - Aerobics
46
Why won't I feel better immediately?
- Neurogenesis takes 2-6 weeks to take effect | - Increased neurotransmitters will occur immediately
47
I've heard antidepressants work no better than placebos
- Mild depression tends to have high rates of natural remission - Moderate to severe depression still sees benefits from antidepressant use
48
Are antidepressants safe while pregnant?
- 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
Suicide Screening
- 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
Ketamine
- 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
Esketamine
- 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
Hydroxynorketamine
- Likely antidepressant metabolite from ketamine | - Enhances AMPA signaling pathway under an unclear mechanism