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RANZCP exam preparation > Unipolar depression and antidepressants > Flashcards

Unipolar depression and antidepressants Flashcards

1
Q

What are the causes of treatment resistant depression

A
  1. Diagnosis- ?bipolar vs unipolar, personality
  2. Medication optimisatioin
  3. Noncompliance
  4. Substances- drugs + other medications (B-blockers, methyldopa, steroids)
  5. Psychosocial
  6. Organic
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2
Q

Differentiating factors in bipolar and unipolar depression

A 
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
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3
Q

Management of mild depression

A
  1. Watchful waiting
  2. Guided self help
  3. Psychological interventions - brief CBT, problem solving and supportive counselling
  4. Structured and supervised exercise program duration 10-12 weeks, 3/weeks
  5. Sleep and anxiety management
  6. Antidepressants not advised for mild, but may be used if past history of severe depression and if persists after all the above
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4
Q

Pharmacotherapy for psychotic depression

A
  1. Sertraline + olanzapine
  2. Fluoxetine + olanzapine
  3. Venlafaxine + quetiapine
  4. Amitriptyline + haloperidol
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5
Q

Management of treatment-resistant depression

A

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

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6
Q

What are the indications for ECT

A 
Major depression with features of melancholia, psychosis and suicide risk
Schizophrenia w/ acute features
Mania
NMS
Parkinson's disease
Treatment- resistant bipolar depression
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7
Q

What are the high risk conditions in which caution is advised

A 
No absolute contraindications
HTN
MI
Bradyarrythmias
Cardiac pacemakers
Epilepsy
Raised ICP
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8
Q

What factors will you consider if a patient does not respond to course of ECT

A 
ECT factors:
Electrode placement
Energy delivered
Quality of seizure
Number of treatments
Factors affecting seizure

Patient factors:
Incorrect diagnosis
Organic impairment

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9
Q

D’Ella position

A

Non-dominant unilateral ECT at 2-5 times seizure threshold

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10
Q

Risk factors for PND

A 
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

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11
Q

Factors that increase seizure threshold

A 
Old age
Dehydration
Improper electrode placement
Previous ECT
Use of concomitant drugs (Benzo's, anticonvulsants)
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12
Q

Important medication interactions in ECT

A

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

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13
Q

Mechanism of mirtazapine

A

NASSA, alpha 2 antagonist, 5HT2A/2C antagonist

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14
Q

Side effects of SSRI

A 
Initial anxiety
Sleep disturbances
GIT
Headache
Sexual dysfunction
Hyponatremia
GI bleeding
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15
Q

Risk factors for hyponatremia with SSRI

A 
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

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16
Q

Side effects of TCAs

A

Anticholinergic: dry mouth, constipation, urinary retention, blurred vision
Alpha blockade: first dose hypertension

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17
Q

Most noradrenergic TCA

A

Nortryptiline and imipramine more noradrenergic, therefore less sedating

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18
Q

Side effects of venlafaxine

A

Similar to SSRI
Sexual dysfunction
Hypertention at doses >225mg
Greater risk of discontinuation syndrome on abrupt cessation

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19
Q

Important drug interactions to remember with SSRIs

A

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)

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20
Q

What are the sexual side effects of antidepressants

A 
Anorgasmia or delayed
Erectile dysfunction
Decreased libido
Reduced lubrication in women
Ejaculatory dysfunction
21
Q

Lithium and NSAIDS

A

Increased lithium levels

22
Q

Propranolol + SSRIs

A

reduce propranolol dose

23
Q

High fibre diet + TCA

A

increase TCA dose

24
Q

Opioids and SSRI

A

avoid co-administration

25
Q

warfarin + fluoxetine or fluvoxamine

A

reduce dose and monitor warfarin

26
Q

donepezil + SSRI

A

reduce dose of donepezil

27
Q

chemotherapy

A

avoid TCA and carbamazepine

28
Q

Pharmacotherapy options in CVD

A

SSRIs are first choice
Mirtazepine safe in arrythmias
Lithium can cause ECG changes
Avoid TCA’s

29
Q

Pharmacotherapy options in hepatic

A

Low dose paroxetine, citalopram, escitalopram, desvenlafaxine
Avoid lofepramine, nefazodone, sertraline
Avoid TCAs- risk hepatic encephalopathy
Avoid MAOi’s hepatic toxicity

30
Q

Pharmacotherapy options in renal

A

Citalopram and sertraline reaosnable choices

31
Q

Pharmacotherapy options in DM

A

SSRIs may reduce glucose
TCA can increase
Amitryptilline, imipramine can be used in diabetic neuropathy

32
Q

Pharmacotherapy options in post stroke dementia

A

SSRI or nortryp

33
Q

Pharmacotherapy options in parkinson’s

A

TCAs good for anticholinergic effects
SSRIs caution with selegiline
Lithium and valproate may exacerbate tremor

34
Q

Risk factors for developing depression in late life

A 
Individual:
physical illness
sensory impairment
dementia- early with retained insight
female
medication (steroid, AP)
personal or fhx of depression

Psychosocial:
recent bereavement
feeling lonely

35
Q

What are the differences between early onset and late life depression

A 
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

36
Q

Relationship between vascular disease and vascular depression

A

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

37
Q

Risk factors for suicide in the elderly

A

Older, physically unwell+ pain, male, living alone, widowed (bereavement), alcohol misuse, hx psychiatric illness, previous suicide attempt

38
Q

Main components of CBT

A
  1. Guided discovery through socratic questioning= establish core dysfunctional assumptions about self, the world and future
  2. Identifying negative thoughts and schemas using thought diaries
  3. Modify negative automatic thoughts, restructure core beliefs and schemas. Use thought challenges worksheet to challenge extreme and unhelpful thoughts
  4. Behavioural deficits- behavioural activation, pleasant event scheduling, graded task assignment, self reward
  5. Graded exposure- mainy for panic and anxiety disorders
  6. Problem solving
  7. Relaxation
  8. Sleep hygeine
  9. Homework tasks
  10. Compliance therapy
  11. Relapse prevention
39
Q

Components of interpersonal therapy

A

Unresolved grief
Role disputes
Role transitions
Interpersonal deficits

40
Q

Evidence of rTMS

A

indicated only if patients choice, or prior response

Side effects- tension muscle headache, discomfort at site, scalp tenderness, seizures

41
Q

MST ?

A

magnetic seizure therapy

42
Q

VNS?

A

Vagal nerve stimulation

useful in low to moderate treatment resistance

43
Q

How to differentiate grief and MDD

A

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”

44
Q

DSM acute stress disorder

A 
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
45
Q

DSM PTSD

A 
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
46
Q

% initially diagnosed with unipolar depression, actually have BPAD

A

10%

47
Q

Epidemiological statictics

A

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

48
Q

Illness characteristics

A

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

49
Q

Treatment responsiveness

A

54% recover within 6 months, 70% within a year

12-15% fail to recover and develop an unremitting chronic illness

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