Wk 27 - Depression Flashcards
What are the classifications for depression?
- Major depression (unipolar)
- Bipolar (manic)
What are the key symptoms of depression?
- Persistent sadness/low mood
- Marked loss of interest
What are the associated symptoms of depression?
- Disturbed sleep
- Dec/inc appetite
- Fatigue
- Agitation
- Poor conc
- Feelings of worthlessness
- Suicidal thoughts
What are subthreshold depressive symptoms?
Fewer than 5 symptoms of depression
What is mild depression?
Few symptoms in excess of 5 required to make diagnosis + symptoms result in minor functional impairment
What is moderate depression?
Symptoms or functional impairment are btw mild + severe
What is severe depression?
Most symptoms + symptoms markedly interfere w/ functioning. Can occur w/ or w/o psychotic symptoms
What is needed for GP active treatment?
- Past fam history
- No social support
- Associated social disability
What is needed for a referral to a mental health service?
- Poor or incomplete response to 2 interventions
- Recurrent episode w/in 1 year
- Relative referral
- Self neglect
What is needed for a psychiatric referral?
- Actively suicidal ideas or plans
- Psychotic symptoms
- Severe agitation w/ severe symptoms
- Severe self neglect
Outline the pathophysiology of depression
- Dysregulation of serotonin + NA in brain strongly associated w/ depression
- Dysregulation in spinal cord = inc pain perception among depressed patients
- Imbalance = emotional + physical symptoms
Outline the focus + nature of intervention in step 1 of the stepped care model
- Step 1: all known + suspected presentations of depression
- Assessment, support, psycho-education, active monitoring + referral for further assessment
Outline the focus + nature of intervention in step 2 of the stepped care model
- Step 2: persistent subthreshold depressive symptoms; mild to mod depression
- Low-intensity, psychosocial interventions, psychological interventions, meds + referral for further assessment
Outline the focus + nature of intervention in step 3 of the stepped care model
- Step 3: persistent subthreshold depressive symptoms or mild to mod depression w/ inadequate response to initial interventions; mod + severe depression
- Med, high intensity psychological interventions, combined treatment, collaborative care + referral for further assessment + interventions
Outline the focus + nature of intervention in step 4 of the stepped care model
- Step 4: severe + complex depression, risk to life, severe self neglect
- Meds, high intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multi professional + inpatient care
What is an SSRI?
- Safer in OD
- Don’t stim appetite
- Fewer antimuscarinic s/e than tricyclics + other NA uptake inhibitors
What are the uses for SSRIs?
- Depression
- Panic disorder (chronic anxiety + prophylaxis for panic attack)
- OCD
- Bulimia nervosa
- Seasonal affective disorder (esp carb craving + weight gain)
What are the adverse effects of SSRIs?
- GI disturbance
- Dry mouth
- Headache
- Insomnia
- Dizziness
- Sweating
- Erectile dysfunction
- Delayed orgasm
What are the drug interactions of SSRIs?
- TCA (SSRI inc plasma conc)
- Antiepileptics (inc risk of convulsions)
- Aspirin, warfarin + NSAIDs (risk bleeding
- MAOIs (inc risk of serotonin syndrome)
- Citalopram + Escitalopram prolong QT interval, avoid giving to existing QT interval prolongation (TCA, methadone, antipsychotics + erythromycin)
What are the contraindications of SSRIs?
- Hepatic + renal failure
- Epilepsy
- Manic phase
What is the maximum dose of citalopram?
- Adults: 40mg daily
- Elderly: 20mg
- Hepatic impairment: 20mg
Outline the important points to remember when taking SSRIs
- 2-4wks for effect
- Review every 1-2 wks for at least 4 wks
- Continue for at least 6 months
- Recurrent depression patient - 2 years
- W/drawal slow
What are the uses of TCAs?
- Depressive illness
- Atypical oral + facial pain
- Prophylaxis of panic attack
- Phobia anxiety
- OCD
- Nocturnal enuresis
What are the adverse effects of TCAs?
- Arrhythmias
- Anxiety
- Dizziness
- Dry mouth
- Urinary retention
- Hyponatremia in elderly (sodium deficient)
What are the drug interactions of TCAs?
- MAOI (risk of hypertensive crisis + hyperpyrexia)
- Antiepileptics (red seizure threshold)
- Alcohol + antihistamines (inc sedation)
- Antihistamines + anticholinergic (inc antimuscarinic effect)
What are the contraindications of TCAs?
- Recent MI
- Arrhythmias
- Epilepsy
- Mania
- Severe liver disease
Outline the important points to remember when taking TCAs
- OD fatal due to cardiac arrhythmias
- Symptomatic improvement after 2 wks
- Vary in sedation: amitriptyline = sedating, imipramine = non-sedating
What are the uses of SNRIs?
Venlafaxine + duloxetine:
- Depression
- Anxiety
- Panic disorder
- Pain syndrome: fibromyalgia
Desvenlafaxine:
- Major depressive disorder
What are the adverse effects of SNRIs?
- Inc BP
- Weight loss
- Hepatitis
- GI discomfort
- Dizziness + headache
What is venlafaxine?
- Weak NA/5-HT uptake inhibitor
- Non-selective
- S/e similar to SSRI
- W/drawal effect if dose missed
- For treatment resistant patients
What is duloxetine?
- Potent + non-selective NA/5-HT uptake inhibitor
- Use: urinary incontinence + diabetic neuropathy
- S/e: sexual dysfunction, sedation + nausea
What is reboxetine?
- NRI
- Use: depression
- S/e similar to TCA
- Safe in OD
- Low risk of cardiac dysrhythmias
What is St John’s wort?
- Weak NA/5-HT uptake inhibitor
- Non-selective
- Use: depression
- Potent enzyme inducer
- Interactions: warfarin, theophylline, cyclosporine + oral contraceptives
What is mirtazapine?
- Enhance NA + act more rapidly than other antidepressants
- Cause less nausea + sexual dysfunction than SSRI
- S/e: sedation, hypotension + cardiac dysrhythmias
What is mianserin?
- Risk of bone marrow depression
- Regular blood count advisable
- S/e: Dry mouth, sedation + weight gain
Give examples of MAOIs
- Moclobemide: depression
- Selegiline + rasagiline: PD
What are the uses of MAOIs?
- Depressive illness, alone or combined w/ TCAs
- Atypical oral depression
- Phobia anxiety + depression w/ anxiety
What are the adverse effects of MAOIs?
- Orthostatic hypotension
- Weight gain
- Sexual dysfunction
- Dizziness
- Aggravation of migraine
- Antimuscarinic effect
What are the drug interactions of MAOIs?
- Accumulation of amine NT = hypertensive crisis + hyperpyrexia
- Sympathomimetics (cough + decongestants)
- SSRI + TCA
- Levodopa
- Opioid
- Tyramine containing food (cheese, beans)
What are the contraindications of MAOIs?
- Hepatic dysfunction
- Epilepsy
- Pheochromocytoma
- Cerebrovascular disease
What are the important points to remember when taking MAOIs?
- Avoided due to severe s/e
- W/drawn slowly due physiological dependence + w/drawal syndrome
- Due to irreversible MAO inhibition, other antidepressants shouldn’t be started for at least 2 wks after stopping
What is the choice of antidepressant when on NSAIDs + aspirin?
Mirtazapine, trazodone, moclobemide for reboxetine
What is the choice of antidepressant when on warfarin or heparin?
Mirtazapine
