Unipolar depression and antidepressants Flashcards
What are the causes of treatment resistant depression
- Diagnosis- ?bipolar vs unipolar, personality
- Medication optimisatioin
- Noncompliance
- Substances- drugs + other medications (B-blockers, methyldopa, steroids)
- Psychosocial
- Organic
Differentiating factors in bipolar and unipolar depression
WHIPLASHED Worse or wired when on antidepressants Hypomania, hyperthymic temperament, mood swings Irritable, hostile, mixed features Psychomotor retardation Loaded family hx of mood swings, BPAD Abrupt onset Seasonal or post-partum Hyperphagia Early age onset Delusions, hallucinations or other psychotic features
Management of mild depression
- Watchful waiting
- Guided self help
- Psychological interventions - brief CBT, problem solving and supportive counselling
- Structured and supervised exercise program duration 10-12 weeks, 3/weeks
- Sleep and anxiety management
- Antidepressants not advised for mild, but may be used if past history of severe depression and if persists after all the above
Pharmacotherapy for psychotic depression
- Sertraline + olanzapine
- Fluoxetine + olanzapine
- Venlafaxine + quetiapine
- Amitriptyline + haloperidol
Management of treatment-resistant depression
Assess risk
Setting of treatment
Investigations
If severely psychotic, not eating or drinking or suicidal- then ECT
Treat physical conditions- concurrent dehydration, infection, vitamin deficiencies
Optimise medication
For psychotic- TCA, AP, if no response ECT before lithium augmentation
Best augmentation with lithium
Add T4
High dose venlafaxine
Combine with BCT/IPT
STARD- Buspirone and bupropion
STARD- MAOI or combination venlafaxine and mirtazapine (California rocket feul)
NICE guidelines- mirtazapine + SSRI
recent evidence of augmentation with AP
Social interventions- accommodation, befriending, employment
What are the indications for ECT
Major depression with features of melancholia, psychosis and suicide risk Schizophrenia w/ acute features Mania NMS Parkinson's disease Treatment- resistant bipolar depression
What are the high risk conditions in which caution is advised
No absolute contraindications HTN MI Bradyarrythmias Cardiac pacemakers Epilepsy Raised ICP
What factors will you consider if a patient does not respond to course of ECT
ECT factors: Electrode placement Energy delivered Quality of seizure Number of treatments Factors affecting seizure
Patient factors:
Incorrect diagnosis
Organic impairment
D’Ella position
Non-dominant unilateral ECT at 2-5 times seizure threshold
Risk factors for PND
Edinburghs PND scale Previous depression antenatal depression, +levels ON stress Stressful life events Poor social/financial Young, single, multi, FHx, unintended Fear. poor physical health, personality Anxiety, poor sleep, seasonal
5 x risk when Past hx perinatal depression
2x risk when non-perinatal depressioin
Factors that increase seizure threshold
Old age Dehydration Improper electrode placement Previous ECT Use of concomitant drugs (Benzo's, anticonvulsants)
Important medication interactions in ECT
AD- some evidence of augmentation
TAC- seizures, and caution with concomitant cardiac illness
SSRI’s prolonged seizures
Benzodiazepine- increase seizure threshold, cease prior
Mood stabilisers- consult neuro if epileptic. May need to stop 24-48 hrs prior ECT
Lithium increases risk of post ECT delirium, balance with risk of ECT induced mania
Mechanism of mirtazapine
NASSA, alpha 2 antagonist, 5HT2A/2C antagonist
Side effects of SSRI
Initial anxiety Sleep disturbances GIT Headache Sexual dysfunction Hyponatremia GI bleeding
Risk factors for hyponatremia with SSRI
Female Old age Lower body weight Low baseline sodium Concomitant drugs- diuretics, NSAIDS, carbamazepine Reduced renal function Hx of hyponatremia Warm weather
Consider noradrenegric drugs for depression- reboxetine, lofepramine, nortryp
Side effects of TCAs
Anticholinergic: dry mouth, constipation, urinary retention, blurred vision
Alpha blockade: first dose hypertension
Most noradrenergic TCA
Nortryptiline and imipramine more noradrenergic, therefore less sedating
Side effects of venlafaxine
Similar to SSRI
Sexual dysfunction
Hypertention at doses >225mg
Greater risk of discontinuation syndrome on abrupt cessation
Important drug interactions to remember with SSRIs
SSRI enzym inhibitors, therefore increased levels of clozapine, olanzapine, benzo’s , TCAs and methadone
Do not prescribe SSRI’s with MAO’s
Paroxetine, sertraline, fluoxetine and fluvoxamine are potent inhibitor
Citalopram and escitalopram are not potent inhibitors)
What are the sexual side effects of antidepressants
Anorgasmia or delayed Erectile dysfunction Decreased libido Reduced lubrication in women Ejaculatory dysfunction
Lithium and NSAIDS
Increased lithium levels
Propranolol + SSRIs
reduce propranolol dose
High fibre diet + TCA
increase TCA dose
Opioids and SSRI
avoid co-administration
warfarin + fluoxetine or fluvoxamine
reduce dose and monitor warfarin
donepezil + SSRI
reduce dose of donepezil
chemotherapy
avoid TCA and carbamazepine
Pharmacotherapy options in CVD
SSRIs are first choice
Mirtazepine safe in arrythmias
Lithium can cause ECG changes
Avoid TCA’s
Pharmacotherapy options in hepatic
Low dose paroxetine, citalopram, escitalopram, desvenlafaxine
Avoid lofepramine, nefazodone, sertraline
Avoid TCAs- risk hepatic encephalopathy
Avoid MAOi’s hepatic toxicity
Pharmacotherapy options in renal
Citalopram and sertraline reaosnable choices
Pharmacotherapy options in DM
SSRIs may reduce glucose
TCA can increase
Amitryptilline, imipramine can be used in diabetic neuropathy
Pharmacotherapy options in post stroke dementia
SSRI or nortryp
Pharmacotherapy options in parkinson’s
TCAs good for anticholinergic effects
SSRIs caution with selegiline
Lithium and valproate may exacerbate tremor
Risk factors for developing depression in late life
Individual: physical illness sensory impairment dementia- early with retained insight female medication (steroid, AP) personal or fhx of depression
Psychosocial:
recent bereavement
feeling lonely
What are the differences between early onset and late life depression
in late life, more common: reduced expression of sadness more psychomotor retardation apathy more motivation late onset neurotic sx hypochondriasis, somatic complaints greater incidence of completed suicide less familial risk
anatomical: vascular disease. Alexopoulos 1997- damage to fronto-subcortical circuits can predispose, precipitate and perpetuate late onset depression
Relationship between vascular disease and vascular depression
Increased PLT aggregation
Both depression and ischemia may be secondary to atherosclerosis
Recurrent depression across lifespan may increase risk of vascular pathology
Damage to end arteries supplying subcortico triato-pallido-thalamo-cortical pathways may disrupt the neurotransmitted circuits involved in mood regulation, causing or predisposing to depression
Risk factors for suicide in the elderly
Older, physically unwell+ pain, male, living alone, widowed (bereavement), alcohol misuse, hx psychiatric illness, previous suicide attempt
Main components of CBT
- Guided discovery through socratic questioning= establish core dysfunctional assumptions about self, the world and future
- Identifying negative thoughts and schemas using thought diaries
- Modify negative automatic thoughts, restructure core beliefs and schemas. Use thought challenges worksheet to challenge extreme and unhelpful thoughts
- Behavioural deficits- behavioural activation, pleasant event scheduling, graded task assignment, self reward
- Graded exposure- mainy for panic and anxiety disorders
- Problem solving
- Relaxation
- Sleep hygeine
- Homework tasks
- Compliance therapy
- Relapse prevention
Components of interpersonal therapy
Unresolved grief
Role disputes
Role transitions
Interpersonal deficits
Evidence of rTMS
indicated only if patients choice, or prior response
Side effects- tension muscle headache, discomfort at site, scalp tenderness, seizures
MST ?
magnetic seizure therapy
VNS?
Vagal nerve stimulation
useful in low to moderate treatment resistance
How to differentiate grief and MDD
In depressive:
Guilt other than steps that could have been done
Thoughts of death other than wanting to be with the deceased
Marked psychomotor retardation
Hallucinatory experiences other than thinking he or she hears the voice/ sees images of the deceased
Delayed reaction- mummification, feeling stuck
Prolonged and marked functional impairment
According to DSM5:
In grief feelings are emptiness and loss, no depressed mood/inability to anticipate happiness or pleasure
Dysphoria in grief is likely to decrease in intensity over days and weeks, occurring in waves. In depression, depressed mood in more pervasive.
Grief may be accompanied by positive emotions and humour as opposed to pervasive unhappiness
Grief- preoccupations with thoughts and memories of the deceased, rather than self critical ruminations
In grief self esteem preserved. Derogatory feelings in grief are associated with perceived failings, related to the deceased
If bereaved think about dying, it the possibility of “joiging the deceasd”
DSM acute stress disorder
A. 1+ Threat of death witnessing learned repeated exposure B. 8+ 1. Intrusion sx 2. Negative mood 3. Dissociative sx 4. Avoidance 5. Arousal Occurs for 3+ day, lasting <1 month after traumatic event
DSM PTSD
A: stressor 1+ direct witnessing learning repeated B. intrusive sx 1+ memories nightmares dissociative prolonged distress avoid exposing to reminders \++physiologic response after exposure to stimuli C. avoidance 1+ trauma related thoughts/feeling trauma related external D. negative mood/cognitions inability to recall key features of traumatic event persistent (often distorted) negative beleifs and expectations about oneself or the world blame of self / others negative trauma related emotions diminished interests alienated from others constricted affect E. altered arousal 2+ irritable/aggression Self-destructive/reckless hyper-vigilance exaggerated startle problems in concentration sleep disturbance F. duration > 1 month
% initially diagnosed with unipolar depression, actually have BPAD
10%
Epidemiological statictics
1 in 10 patients in primary care present with depressive sx
Lifetime risk of depression is 15% and 12 month prevalence is 4.1%
2:1 female:male
Illness characteristics
Mean age onset 27, 40% have first episode by age 20
>80% of those affected by depression will experience at least 2 episodes of illness in their lifetime
Treatment responsiveness
54% recover within 6 months, 70% within a year
12-15% fail to recover and develop an unremitting chronic illness
