18.1.0 - Principles of depression treatment Flash Cards

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Title:	18.1.0 - Principles of depression treatment
Description:	Sources: AMH, TG, lecture notes
Number of Cards:	32
Save Count:	1
Author:	crazy_tree_creature11
Created:	2008-08-22
Tags:	amh depression pharmacy
Private	No

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- Question
- Answer
- Side 3

- DSM IV criteria for depression (unipolar)
  
  Duration of symptoms required?
- Pervasive low mood/loss of interest or pleasure (or irritability in children) and 4 or more of:
  1. hopelessnes
  2. feelings of guilt or worthlessness
  3. insomnia / hypersomnia
  4. weight gain / loss
  5. Psychomotor retardation or agitation
  6. Fatigue
  7. decreased concentration or indecisiveness
  8. suicidal ideation
  
  DSM IV: 2 months
  Others: 2 weeks
- In treatment of depression, what is the greatest contributer to positive outcome?
- It is not the choice of drug. It is
  1. Patient compliance
  2. Maintainenance of treatment for as full course
  3. Address risk factors for relapse
- What general advice should all depressed people be given?
- 1. Signs of depression, to enable recognition of relapse
  2. Recognise negative thoughts to be a product of the disease and not true (e.g. self worth, guilt)
  3. Put off important decisions
  4. Moderate exercise helps
  5. Using social supports helps
- For people with mild depression for <2/12, what is the treatment?
- There is no evidence for CBT/IPT/drugs (Up-to-date)
  Use
  1. genreal advice
  2. address comorbities, such as substance abuse, physical disorders, anxiety, personality disorders
- For moderate depression, what is the treatment
- 1. drugs, or
  2. CBT/IPT for 8-12 sessions, if a qualified psychiatrist is available; other techniques may be useful
  3. or both
  Also: ~weekly monitoring
  And if melancholic: give drugs first then psychotherapy
- All AD have equal effectivenss. What proportion will respond?
- 50%, even to different drugs in same class
  30% placebo effect
- What is the brand name of duloxetine
- Cymbalta
- If a patient is severely depressed or has melancholy, what drugs may be better?
- TCA, MAOIs vs SSRIs
- If a patient has atypical depression, what drug may be better?
- Mirtazapine
- Which antidepressants cause O.H.
- TCA
  mianserin (also vertigo)
- When is psychotherapy alone inadequate
- major depression
- When can ECT not be used
- 1. raised intracranial pressure (hmm.. a hypertensive crisis then)
  2. a CI to GA (e.g. AMI, unstable ANGINA, ALCOHOL, sepsis, MI in last 6/12, poor cardiac output, poor lung function, DVT/PE)
  
  ** after use give drug treatment to maintain remission
- St John's Wort - place as an antidepressant
- Discourage use
  - more effective than placebo for mild to mod depression & MAY be as effective as standard ADs.
  - Less AEs than other ADs - AEs are rare
  - lack of standardisation
  - seritonin syndrome
  - Drug interactions
- St john's Wort -
  dosing
- Standardised hydroalcoholic extracts at daily dose of up to 900 mg providing 0.2–2.7 mg total hypericins
  2–4 g of herb as an infusion per day
- St John's wort
  - DIs.
- 1. SS: MAOIs, other antidepressants, etc
  
  2. Induces CYP450 enxymes: 2C9 AND 3A4
  (a)Warfarin: reduced INR - AVOID
  (b) Calcineurin inhibitors: AVOID - 1 case of heart tx rejection
  (c) COCs - avoid; monitor for breakthrough bleeding
  
  3. Induces P-glycoprotein, reducing GI absorption of digoxin - AVOID
  
  Use with caution with alprazolam, midazolam, omeprazole, fexofenadine, statins, verapamil and theophylline
- St John's wort
  - A/Es
- Mild: gastrointestinal symptoms, anxiety, hypomania, dizziness, dry mouth, restlessness and sleep disturbances
- What adjuncts may be used in depression? (3)
- A carefully planned course of benzodiazepines, zolpidem or zopiclone may help insomnia and/or anxiety in the early phase of antidepressant treatment.
  
  If antidepressant therapy (at appropriate maximum doses) produces only a partial response, augmentation, eg with lithium, may improve outcome.
  
  Psychotic depression requires antipsychotic treatment in addition to antidepressants.
- Considerations for use of ADs in the elderly?
- May respond more slowly. Consider a lower starting dose with a more gradual increase. Claims that the newer antidepressants are better tolerated in the elderly are not well supported by evidence.
- What odd discontinuation syndrome may be associated with paroxetine?
- a flu like syndrome
- What percentage of mothers have post-natal depresssion?
- 10-20%
- Besides depression, when can ECT be used?
- psychosis
- Side effects of ECT
- 1. muscle aches and pains
  2. headaches
  3. transient confusion for an hour or so after treatment
  4. some memory loss
- How many times is ECT done per course?
- 3 times per week (2 times if there is severe confusion)
  
  About 6-24 times, usually 9
- What is done pharmacologically before and after an ECT treatment?
- 1. withdraw BZDs (increase seizure threshold)- Can use zopiclone or zolpidem
  2. anaesthesia and short acting muscle relaxant
  
  Follow with an antidepressant, mood stabiliser or both
- What alternative treatments are available for depression?
- Good evidence for
  - SJW
  - Exercise
  - Self help books with CBT
  Some evidence for
  - SAM-E
  - Folate
  - Relaxation therapy
  - Yoga
  - Accupuncture
- What other treatments are available for anxiety?
- Good
  - Relaxation
  - Exercise
  - Bibliotherapy: using written materials, audiotapes or computer materials to gain understanding of and solving problems relevant to personal development
  Some evidence
  - alcohol avoidance
  - music, dance
  - meditation
- Suicide - what % of depressed patients?
- 15%
- Which agents are recommended in the elderly
- the PROSPECT study recommended SSRIs started at half the recommended adult dose and titrated every 6 weeks
- What is the remission rate with ECT for severe depression?
- 80-90%
- Which neurological disorders are most commonly associated with depression?
- PD (50%)
  Alzheimers (15-30%)
  Stroke (25%)
- With PD, what AD?
- TCA - anticholinergic effect may improve PD
  SSRIs - infrequently cause EPSE
  Selegeline - avoid SSRIs and venlafaxine!
- a good website for patients?
- Beyond blue