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PR3136 > Treatment of Depression > Flashcards

Treatment of Depression Flashcards

1
Q

MDD

A

Major Depressive Disorder

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2
Q

Diagnosis of MDD

A
  • at least 5 out of 9 symptoms (In.S.A.D.C.A.G.E.S)
  • must have In & D
  • for most of the same 2 week period
  • causing significant distress or functional impairment
  • symptoms are not drug-induced / secondary to other medical conditions
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3
Q

Goal of therapy

A
  1. Hamilton Rating Scale =< 7
  2. Remission of symptoms / symptoms free
  3. Treatment adherence
  4. Suicide prevention
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4
Q

Non-pharmacological therapy (4)

A
  1. Sleep hygiene
  2. Psychotherapy
    - cannot monotherapy in moderate-severe MDD
  3. Electroconvulsive Treatment (ECT) (more severe & refractory MDD)
  4. Repetitive Transcranial Magnetic Stimulation (rTMS) (less invasive)
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5
Q

Pharmacological therapy + Adjunctives

A
  1. Anti-depressants
    - SSRI, SNRI, Mirtazapine (NaSSA) & Bupropion
    > Agomelatine & Vortioxetine
    > TCA
    > MAOi
  2. Adjunctive medications
    - anxiolytics
    - hypnotics
    - short course, PRN
    - only if needed
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6
Q

Duration of antidepressant treatment

A

Acute phase
- 4-8 weeks (max 12 weeks)

Continuation phase
- 4-9 months

Total duration : at least 6-12 months

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7
Q

Duration for physical symptoms treatment (eg poor sleep)

A

1-2 weeks

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8
Q

Duration for mood symptoms treatment

A

> 6 weeks

  • due to downregulation of pre-synaptic autoreceptors to prevent negative feedback regulation of neurotransmitter secretion into synaptic space
  • leads to disinhibition & promotion of neurotransmitter release
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9
Q

Efficacy among antidepressants

A

All have similar efficacy for uncomplicated first episode of MDD

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10
Q

Duloxetine

A

SNRI

Also indicated for :

  • diabetic peripheral neuropathy
  • fibromyalgia
  • chronic musculoskeletal pain
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11
Q

All serotonergic agents (SSRI, SSRI, TCA, SMS) ADR

A
  1. GI effects

2. SD

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12
Q

Venlafaxine ADR

A
  • worsens HTN
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13
Q

Mirtazapine ADR

A
  • sedation

- weight gain (due to increased appetite)

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14
Q

Mirtazapine benefit

A

Reduce SD

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15
Q

Bupropion CI

A
  • history of seizures
  • psychosis
  • eating disorders
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16
Q

Bupropion benefit

A

No SD effect cos NDRI (no serotonergic effects)

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17
Q

TCAs ADR (6)

A
  1. Anticholinergic (dry mouth, blurred vision, constipation)
  2. Sedation
  3. Orthostatic hypotension
  4. Arrhythmias
  5. Seizures
  6. Fatal on overdose
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18
Q

Counselling point for all antidepressants to =<24y/o

A

Suicidality association

19
Q

Minimal CYP interactions (5)

A

MEVDV

  1. Mirtazapine
  2. Escitalopram
  3. Venlafaxine
  4. Desvenlafaxine
  5. Vortioxetine
20
Q

Significant PD interactions

A
  1. Serotonin Syndrome (RDTSMCCD)
    - multiple serotonergic agents used tgt
  2. CNS depression
21
Q

Discontinuation of antidepressant

A
  • taper dose gradually over 4 weeks
  • 10-25% every 1-2 weeks
  • if used daily for >=2months
22
Q

Withdrawal syndrome of antidepressants

A

FINISH

Flu-like symptoms (fatigue, muscle aches, headaches)
Insomnia
N/V
Imbalance (dizziness)
Sensory (paresthesia, electric shock sensations)
Hyperarousal (anxiety, agitation)

23
Q

Lifetime prevalence of MDD

A

5.8%

24
Q

Correlation with MDD

A

Physical illness & mental illness

25
Q

Risk factors for suicide in a general population (6)

A
  1. Poor
  2. Lonely
  3. Elderly
  4. Man
  5. Physical & mental illnesses
  6. Previous attempts
26
Q

3 independent predictors of suicide

A
  1. Coexisting physical illness
  2. Delusion
  3. History of attempted suicide with using highly lethal means
27
Q

Theory for depression

A

Monoamine theory

  • decrease neurotransmitters in the brain
  • NE, 5-HT and dopamine
28
Q

Secondary causes of depression (3)

A
  1. Medical conditions
    - CVD
    - endocrine disorders
  2. Drug induced / iatrogenic
  3. Psychological disorders
29
Q

General assessments prior to diagnosis and treatment (2)

A 
1. Psychiatric history 
eg maniac or hypomaniac episodes
2. Mental state exam (MSE)
- assess for suicidal/homicidal ideations and risks
- reassess on every interview
30
Q

SSRI examples (6)

A
  1. Fluoxetine
  2. Fluvoxamine
  3. Escitalopram
  4. Citalopram
  5. Sertraline
  6. Paroxetine
31
Q

SNRI examples (3)

A
  1. Venlafaxine (worsens HTN)
  2. Desvenlafaxine
  3. Duloxetine
32
Q

Function of presynaptic autoreceptors

A
  • negative feedback regulation
  • down-regulation of presynaptic autoreceptors lead to disinhibition of the release of neurotransmitters into synaptic space
33
Q

Antidepressants with long half life

A
  1. Vortioxetine
    - 66h (2-3 days)
  2. Fluoxetine
    - 4-6 days

Less concern about withdrawal symptoms (FINISH)

34
Q

MAOi ADR

A
  • hypertensive crisis
35
Q

Hypnotics

A

Benzodiazepines

  • diazepam
  • lorazepam
  • 2-4 weeks, short course, PRN
36
Q

Switching methods (2)

A
  1. Cross-titration
    - recommended if daily use of serotonergic agents to non-serotonergic agents (cos need to taper dose gradually) to prevent serotonergic withdrawal syndrome
    - careful of serotonergic syndrome
  2. Direct switch
    - complete washout required for MAOi
37
Q

Advice for patients taking alcohol and antidepressants

A
  • space apart 4-6h

eg benzodiazepines & opioids = increased mortality

38
Q

Benzodiazepines discontinuation

A
  • gradual discontinuation of long-term high dose use
39
Q

DDI (4)

A
  1. Fluvoxamine
    - CYP1A2 inhibitor
    - CYP2C19 inhibitor
  2. Fluoxetine & Paroxetine
    - CYP2D6 inhibitor
  3. Bupropion
    - CYP2D6 inhibitor
  4. Grapefruit juice
    - CYP3A4 inhibitor
40
Q

Augmentation of antidepressants

A 
- add 2nd antidepressants with another MOA
eg Mirtazapine (NDRI)
41
Q

Adjunctive SGAs (3)

A
  1. Aripiprazole
  2. Brexpiprazole
  3. Quetiapine XR
42
Q

Treatment resistant depression

A
  • no response to 2 adequate trials of antidepressants
43
Q

Treatment resistant depression management (2)

A
  1. Electroconvulsant Therapy (ECT)
    - more invasive
    - refractory & more severe cases
  2. Repetitive Transcranial Magnetic Stimulation (rTMS)
44
Q

Antidepressants with short half life (2)

A
  1. Paroxetine

2. Venlafaxine

PR3136 (19 decks)

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