Depression
Major depression can be diagnosed after 2 weeks of what symptoms? (remember “two blue weeks”)
- Depressed mood
- Diminished interest or pleasure in usual activities
- increase/decrease in weight/appetite
- increase/decrease in sleep
- increase/decrease in psychomotor activity
- fatigue/loss of energy
- Feelings of worthlessness/guilt
- Diminished ability to think/concentrate/make decisions
- Recurrent thoughts of death, suicidal ideation, suicide attempts
Depression
In what decade is major depression most common? Is it more common in women or men?
3rd
women (m 12% : f 20%)
(this gap decreases as age increases)
Depression
What is the patho behind depression?
- Both functional and structural changes have been shown in people’s brains when they suffer from depression
- Possible link between neurotransmitter availability, and receptor regulation and sensitivity.
- Possible disruption inserotoninactivity (why SSRI’s work well)
- Other neurotransmitters which may be involved include:Nor-epinephrine, dopamine, BDNF
- Hypothesis that vascular lesions of hippocampus and amygdala may affect emotional regulation pathways predisposing a person to depression
- Neuroimaging studies suggestdecreased metabolic activityin the depressed brain
- Vascular depression hypothesis-cerebrovascular disease can contribute to depression
Depression
What are the classifications of depression?
- melancholic(worse in the morning, usually involving weight loss)
- Atypical(worse at night, usually involving over eating and weight gain)
- psychotic(concurrent delusions and hallucinations)
- chronic(lasting over 2 years)
- postpartum(onset within 6 weeks of childbirth) *now peripartum
Depression
Key/focused history for depression
-Patients will often present with asomatic complaint such as headache, stomach ache, difficulty sleepingetc.
- Major life stress recently
- Previous depressive episode
-Family hx depression
- History abuse or adversity
Depression
Common S & S depression (in addition to depressed/low mood)
- Anhedonia (reduced motivation)
- Feelings of guilt, worthlessness, helplessness or hopelessness
- Sleep disturbances
- Decreased energy
- Suicidal ideation
- Difficulty concentrating
- Social withdrawal
- Ruminations
- If over 65, consider dementia
- Weight changes
- Psychomotor retardation
- Agitation
- Flat affect
Depression
SWIGECAPS
- sleep
- worthlessness
- interest
- guilt
- energy
- concentration
- appetite
- psychomotor changes
- suicidality
Depression
What are some potential investigations to rule out other causes of depression (based on H&P)?
- CBC with differential
- Lytes, calcium and phosphorus
- thyroid profile
- liver profile
- Vitamin D25 hydroxy
- Vitamin B12/folate
- Lead level
- FSH/LH
- Viral cultures
- Blood alcohol level
- Urine drug screen
- Monospot
- CT/MRI to r/o organic cause
- dexamethasone suppression test
Depression
Non-pharm management?
- Cognitive behavioral therapy
- Psychotherapy - counseling (narrative, EMDR, and other therapeutic interventions by counsellor)
- Online therapy (kelty’s key, VCH- narrative therapy)
- Social engagement/connection
- SAFER group - outpatient referral (for individuals who have had 2+ suicide attempts)
- CBT/DBT groups
- Light therapy (discussed further in a separate ILO)
- Electroconvulsive therapy (ECT) (80-90% response rate; 6-12 treatments over 10-14 days)
- diet
- sleep
- stress
- exercise
- transcranial magnetic stimulation
Depression
What are two KEY questions (high sensitivity) for depression?
1) mood - over the past month have you often been bothered by feeling down, depressed or hopeless?
2) anhedonia - over the past month have you often been bothered by having little interest or pleasure in doing your usual activities?
The sensitivity of these two questions is high (97%)
Depression
Before starting first-line antidepressants such as SSRIs what other psychiatric condition must be ruled out?
bipolar disorder
serotenergic drugs may trigger manic episode
Depression
What investigation needs to be done prior to starting citalopram?
ECG! Qtc prolongation
Depression
What is the most common side effect of sertraline?
diarrhea (squirtraline)
Depression
What SSRI is safest for people who are breastfeeding?
sertraline (squirtraline)
Depression
Concerning side effect of paroxetine?
withdrawal symptoms
if given in pregnancy, neonate withdrawal =seizures
Depression
Your patient is on one million medications, what SSRI might be a good option?
Escitalopram, “cleanest” in terms of enzyme interactions
Depression
What psycho-emotional responses are associated with serotonin? Norepi?
- serotonin - satisfaction and anxiety
- norepi - increased energy and focus
Depression
What meds boost BOTH serotonin and norepi?
venlafaxine
duloxetine
mirtazapine
Depression
What is a major s/e of venlafaxine?
Transient hypertension
Depression
What is a common s/e of mirtazapine?
weight gain
Depression
What neurotransmitters does bupropion work with?
dopamine
norepi
Depression
What is a major adverse reaction for bupropion?
Seizures!
Lowers seizure threshold
can cause seizures in patient with bulimia
Depression
What is a medical emergency caused be trazodone (*hint trazo-bone)
priapism
Depression
What neurotransmitters do tricyclic antidepressants effect?
Increased
- serotonin
- norepi
Decreased
- ACh
- Histamine
- Na
- Ca
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Pharmacologic Management T2DM24
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T2DM & Diabetes Canada13
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GAD12
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Depression35
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Substance use (including AUD, Smoking & Opioid)50
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Eyes (chalazion, hordeolum, conjunctivitis, subconjunctival hemorrhage, corneal abrasion)36
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Rhinitis, Hearing Loss, Epistaxis, Pharyngitis21
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Chronic Cough9
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Asthma18
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URI8
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OSA8
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obesity11
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dyslipidemia15
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varicose veins4
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hypertension27
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anemia30
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hypothyroidism18
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hyperthyroidism11
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metabolic syndrome3
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Headaches14
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BPPV8
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borderline personality disorder and other PD's23
