Psych > Depression > Flashcards

Depression Flashcards

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1
Q

lifetime prevalence of depression?

A
  • major depression - US 17%

- persistent depressive disorder 3% (no remission of depression)

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2
Q

Epidemiology of depression?

A 
- gender:
10-25% in women
5-12% in men
puberty to 50: women 2x rate of men
after 50 - men = women
- age:
prevalence decreases with age
becomes more common in odler adults with greater burden of medical illness
assist. living, skilled nursing, acute/chronic medical conditions esp high risk
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3
Q

Pathogenesis of depression?

A
  • group of heterogenous disorders that are phenotypically similar
  • final common pathway of diff disease processes that occur across biopsychosocial continuum
  • genetics
  • early life adversity
  • social factors
  • psychological factors
  • secondary depression (gen medical disorders/meds/substance abuse)
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4
Q

pathogenesis - genetics?

A
  • genes+enviro+enviro altered gene expression
  • no specific genes linked to risk - mult small genetic effects
  • epigenetics: changes in expression of genes caused by early life experiences or chronic stress
  • concordance rate for major depression in monozygotic twins: 37%
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5
Q

pathogenesis - early life adveristy?

A
  • predisposes to major depression by alt sensitivity to stress and response to negative stimuli
  • early life stress: hyperactive corticotropin releasing factor cells in hypothalamus - increased stress response (HPA axis)
  • stress responses can be set for life and modify the activation of certain genes (epigenetic) and transmitted to offspring
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6
Q

pathogenesis - social factors?

A
  • may lead to depression onset or lead to depressive episodes
  • isolation
  • poor social relationships
  • criticism from family members (expressed emotion)
  • depression in social networks
  • influence sxs expressed and willingness/ability to access care
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7
Q

pathogenesis - psychological factors?

A
  • cognitive/behavioral: negative/distorted patterns of thinking predispose to depression
    these patterns worsen in depressed person
  • personality:
    neuroticism - anxiety, moodiness, envy, frustration, loneliness - respond poorly to stressors, interpret ordinary situations as threatening, and minor frustrations as hopelessly difficult
  • psychodynamic: early losses, interpersonal relationships
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8
Q

Pathogenesis - secondary depression?

A
  • general medical conditions
  • meds
  • drugs of abuse
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9
Q

Medical conditions that can lead to depression?

A
  • sleep apnea
  • hypothyroidism/vit D def/diabetes
  • chronic pain and opioid use
  • stroke
  • heart disease - ischemic, HF, cardiomyopathy
  • parkinsons
  • MS
  • epilepsy
  • head injury
  • cancer
  • COPD
  • dementia
  • HIV/neurosyphilis
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10
Q

Meds that can cause depression?

A
  • interferon
  • corticosteroids - more likely to cause bipolar
  • benzos/opioids
  • varenicline (chantix)/BBlockers
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11
Q

Drugs of abuse that can cause depression?

A 
as you are withdrawing:
- PCP
- amphetamines
- cocaine
- marijuana
during intoxication:
- sedative-hypnotics 
- alcohol
- opiates
- steroids
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12
Q

Neurobio of depression? - structure and fxn?

A
  • altered brain structure and fxn: unknown if alterations represent cause or consequence of depression (mult episodes of depression causes structural changes in your hippocampus)
    structure:
    -increased ventricular - brain ratio
  • smaller frontal lobe volumes
  • smaller hippocampal volumes
  • number/density/size of neurons and glial cells are abnormal

fxn:
-NTs - abnorm fxning
monoamines (serotonin, NE, dopamine), GABA, glutamate
- HPA axis: excess excretion of glucocorticoids may lead to suppression of neurogenesis and hippocampal atrophy
- abnormal neuronal networks
- sleep/circadian rhythms: decreased REM latency and slow wave sleep inflammation - higher levels of inflammatory markers

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13
Q

3 diff manifestations of sxs of major depression?

A
  • psychological
  • neurovegetative
  • psychomotor/physical
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14
Q

Psychological sxs of major depression?

A
  • depressed mood (dyphoria)
  • numbness
  • anhedonia - inability to experience joy
  • decreased interest
  • irritability/anxiety
  • guilt/worthlessness
  • suicidal ideation
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15
Q

neurovegetative sxs of major depression?

A
  • appetite - wt loss
  • sleep - can’t sleep, wake up 3 am
  • energy
  • concentration
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16
Q

Pyschomotor/physical sxs of major depression?

A 
- psychomotor: 
retardation 
agitation
- physical:
aches/pain
weakness/malaise
GI distress
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17
Q

Qualifers that rule in depression?

A
  • sxs occur in same 2 weeks
  • most of day nearly every day
  • distress or impairment
  • R/o substances/general med condition
  • R/o bereavement
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18
Q

subtypes of depression?

A
  • anxious
  • atypical
  • catatonic
  • melancholic
  • mixed features
  • peripartum
  • psychotic
  • seasonal
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19
Q

Subcategories of depression?

A
  • bipolar
  • secondary:
    medical illness
    meds
    drugs of abuse
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20
Q

comorbid psych conditions?

A 
1. anxiety disorders:
generalized anxiety
panic disorder
OCD
PTSD
2. substance abuse
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21
Q

SIGECAPS?

A 
S: sleep
I: interest 
G: guilt/worthlessness
E: energy
C: concentration
A: appetite
P: psychomotor disturbance
S: suicidal ideation
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22
Q

Depression eval?

A
  • chronology of current sxs
  • sxs occur in same 2 weeks
  • most of day nearly q day
  • distress or impairment
  • prior hx of depressive episodes
  • impact of episode on occupational and interpersonal fxning
  • alleviating and aggravating factors (stressful life events)
  • address comorbidity (substance, illness, meds, psych)
  • eval for mania/hypomania
  • distinguish major depression from persistent depressive disorder (dysthymia) - 2 yrs w/o s free interval of 2 months
  • suicide risk
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23
Q

depression eval cont. - History component?

A
  • general medical illness
  • family hx: depression, suicide, psychosis, bipolar
  • social hx: interpersonal, occupational, financial stressors - sources of support, assessment of family/relationship dynamics
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24
Q

depression eval cont. - exam and labs?

A
  • complete physical and neuro exam
  • MMSE
  • toxicological screen
  • lab screen: CBC, TSH, LFTs, Chem7, Ca, B12, folate, HIV
  • brain imaging (psychosis or neuro findings)
  • +/- EEG, LP (psychosis or neuro findings)
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25
Psychotic features of depression? | What ?s should you ask pt?
- delusions - hallucinations - disordered thought - up to 20% of pts - markedly higher suicide risk ?s: does your mind ever play tricks on you? do you ever hear things/see things? do you ever feel like people are out to get you?
26
Suicide RFs?
- S: sex (male) - A: age- elderly or adolescent - D: depression - P: prev. suicide attempts - E: ethanol abuse - R: rational thinking loss - S: social supports lacking - O: organized plan - suicide - N: no spouse-div, wid, single - S: sickness (physical illness)
27
How to ask about suicide attempts?
- organized plan? - access to lethal means? - previous attempts? - family hx? - non-suicidal self injury ``` - previous attempts: who, what, when, where, why, how? - what exactly did you do? - was it planned? - did you tell anyone? - risk/rescue ```
28
suicidal ideation - assessment?
- do you feel hopeless? - do you feel like life isn't worth living? - do you think about suicide? - Have you ever.....?
29
How to ask about suicide intent, plan and means?
- what specific thoughts have you had? - do you have access to guns? - have you been stock piling meds? Can you bring them in?
30
When should you hospitalize a potential suicidal pt?
- plan, intent, means = hospitalization - less acute - safety plan - crisis center, stay with family, more freq visits (even daily)
31
What is a part of the safety tx plan?
- crisis numbers - written and programemd in phone (family, friends, suicide hotline, ER, clinic) - ROI for family in chart - commitment to adhere to emds, appts, contact office with concerns - agree to remove lethal means - have someone take guns, bring in extra meds
32
Alcohol questionnaire?
C: have you ever felt you should Cut down on your drinking? A: have people Annoyed you by criticizing your drinking? G: have you ever felt Guilty about your drinking? E: have you ever had an Eye opener? 2 or more= clinically significant
33
Scales to use for depression screening?
1. Beck depression inventory: self admin, for screening and tx response 2. quick inventory of depressive symptomatology 3. mood disorder questionnaire 4. hamilton anxiety rating scale: over 20 indicates sig anxiety, pts with depression tend to score higher
34
MSE: observation?
presence of depressive signs: - affect - cognition (attention/concentration, memory) - psychomotor activity - ruminative thought process - speech - psychosis - suicidal thoughts
35
SSRI MOA?
- block reuptake of serotonin | - downregulates receptors because there is so much serotonin in synaptic cleft
36
SSRIs indications? | Common SSRIs?
- 1st line tx of depressive disorders - no real diff in efficacy - diff in SEs and half lives - paxil - zoloft - celexa - prozac - lexapro
37
Common side effects of SSRIs?
- GI disturbance: nausea, diarrhea, appetite - sexual dysfxn: SSRI/SNRI - 50-70% - anxiety - insomnia or sedation - sweating - dizziness
38
SNRIs? Use?
- effexor - cymbalta - 2nd line of depressive disorders, more SEs - acts on both serotonin and NE - not clearly more efficacious - when effexor is less than 225 mg = SSRI SEs: HTN, tachycardia - cymbalta: good for diabetic neuropathy
39
Why aren't TCAs widely used? Examples?
- amitriptyline - clomipramine - doxepin - imipramine - More side effects: anticholinergic (constipation), antihistamine orthostatic hypotension cardiac arrythmia - lethal in overdose - more drug-drug interactions
40
Use of MAOi's? Why aren't these widely used?
- Nardil - pamate - more efficacious but.. - poorly tolerated - wt gain and sedation - drug-drug interactions: serotonin syndrome, hypertensive crisis - dietary restrictions - can't eat tyramine containing foods
41
Indications for trazodone? What to watch for?
- good for sleep at low doses - if tolerated - fxns as AD at higher doses - watch for sedation, orthostasis, priapism - use lowest dose possible
42
When should you avoid buproprion? What happens with excess dopamine?
- avoid in seizure disorders - avoid in bulimia - enhances dopamine = caution: anxiety psychosis dopaminergic agents
43
Pros of bupropion?
- no sexual side effects - smoking cessation - comorbid ADHD - often used with SSRIs: augment antidepressant, reverse sexual side effects - consider with sleepy, slowed down pts - safe in pregnancy (B)
44
Pros and cons of mirtazapine?
- good for pts with nausea - less sexual side effects - causes sedation - wt gain: use in elderly
45
Is it better to augment or switch classes of antidepressants?
- switching classes doesn't improve remission - tolerability similar b/t classes - augmentation may be better than switching - remission rate decreases with each failed med trial
46
Positive predictors of remission?
- caucasian - female - employed - educated
47
Negative predictors of remission?
- longer index episodes - drug abuse - anxiety disorders - medical disorders - lower fxning
48
Why is Remission such a great thing in depression?
- return of normal fxning - lower rates of relapse - lower risk of suicide - less alcohol and drug abuse
49
acute tx of depression (1st 12 weeks)?
- mild: consider psychotherapy alone - mod-severe: med +/- therapy - bipolar: mood stabilizer +/- antidepressant - psychotic: antipsychotic + antidepressant
50
continuation phase of depression tx?
- 4-6 months following remission - high risk of relapse - use full therapeutic dosage
51
lifetime recurrence rate (off meds)?
- one episode: 50% - 2 episodes: 70% - 3 episodes: 90% (lifelong depression)
52
Med adherence factors, tolerability of meds?
``` - 40% are non-adherent first month socioeconomic factors tolerability - SSRI, SNRI more tolerable than TCA pyschiatric = nonpsychiatric psychotherapy education ```
53
Med education for pt?
- min of 2-4 weeks needed for meds to be effective - take q day even if feeling better - will need to take 4-6 months - SEs often time dependent
54
General principles of pharmacotherapy in depression tx?
- titrate to target dose w/in 1st couple of weeks - monitor for side effects: agitation suicidal ideation insomnia sexual - monitor adherence - no improvenment in 4-6 wks - consider switch - limited response: consider increase or augmentation - side effects: switch or augment
55
factors to be considered when choosing an antidepressant?
- personal hx - pharmacogenics - family hx - cost - overdose/safety - side effects/unique benefits - drug-drug interactions - comorbid conditions - depression subtypes
56
What is pharmacogenetics?
- study of the role of genetic variation on drug response - the ID of genetic factors that influence drug absorption, metabolism, and action at receptor level - allow for individualized therapy - this could optimize drug effficacy and minimize toxicity. The potential for cost savings and for decreased morbidity and mortality and fewer adverse drug rxns
57
Overdose of drug classes?
- TCAs: highly lethal - SSRIs: much safer - lithium - lethal, shown to decrease suicidal ideation and impulsivity though
58
BBW for antidepressants? Importance of antidepressants?
- increased risk of SI with antidepressants up to 24 yrs - tx depression beneficial - there is also risk of suicide with untx depression - suicide attempt rates highest month b/f tx - decline after AD or psychotherapy begins - monitor pt at regular intervals - SI, substance abuse, hopelessness, impulsivity - refer for psychotherapy - avoid giving refills to encourage f/u - start low and go slow in 18-24 year olds
59
What should you do if a pt encounters SEs?
1. wait!!! 2. lower dose, slow titration 3. change dosing schedule 4. augment
60
Wht should you recommend if pt encounters sexual side effects?
1. drug holiday - watch for withdrawal 2. augment: bupropion trazodone - rare risk of priapism ED meds buspirone 3. lower dose 4. wait or switch meds
61
What are good drugs for anxiety?
- benzos - gabapentin - lyrica - buspirone - therapy/medication/exercise * if prominent agitation consider BIPOLAR!!
62
What are good drugs for insomnia?
- benzos - sleepers: zolpidem - trazodone - therapy/meds/exercise
63
benzos - use?
- goal of short term use - scheduled over prn - longer acting with lower abuse potential: clonazepam, lorazepam over alprazolam, diazepam - caution in comorbid substance abuse
64
D/c of drugs - withdrawal adverse effects?
- nausea, HA, irritability, vivid dreams, vertigo - slow taper +/- short term bentos - worst - paroxetine, venlafaxine - fluoxetine - self tapering
65
SSRIs - drug interactions?
- 2D6 inhibition - fluoxetine (prozac), paroxetine (paxil), fluvoxamine - have most drug interactions - escitalopram (lexapro) - has least amt
66
Pt is on risperidone, trazodone and hydrocodone, and he is now started on paroxetine for depression, he calls a week later complaining of stiffness, anxiety and pain. Why is this and why is he having these sxs?
- 2d6 inhibition from paroxetine - so there is increased risperdone - EPS - increased metabolite of trazodone - leading to anxiety - decreased conversion of codeine to morphine - leading to pain
67
Depression subtypes?
- psychotic depression: higher remission with combo of AD and antipsychotic - bipolar depression: 30-50% risk of cycling into mania on AD w/o mood stabilizer
68
Psychotherapy options?
- cognitive behavior psychotherapy: understand distortions in thinking learn new ways of coping - interpersonal thinking: grief, role transition/role dispute, interpersonal deficits - both are evidenced based with well documented efficacy
69
Augmentation strategies?
- bibliotherapy - self help books - relaxation techniques - visualization/muscle relaxation - meditation - exercise - aerobic 3-5x/wk for 45-60 min - apps/support groups/telepsychology for rural areas
Psych
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