Depression & ADHD

Question 1

Diagnostics for Major Depressive Episode:

Answer 1

• prolonged & cause SIGNIFICANT distress/dysfunction
• incl. depressed mood or anhedonia

Question 2

What are the common Fx’s of a Major Depressive Episode (MDE)?

Answer 2

Depressed most of the day, Anhedonia, Weight Change, Sleep Disturbance etc.

• diagnosed when a change from baseline & sustained for 2 weeks or longer

Question 3

What is the prevalence of major depression?

Answer 3

Yearly prevalence ~ 6-7%

Lifetime prevalence of about 16%, almost 1 in 6

leading cause of disability worldwide

Question 4

What is the Neuropathology & Neuroimaging of Depression?

Answer 4

• small reduction in hippocampal size
• increased activation of the amygdala by (-) stimuli
• reduced activation of the nucleus accumbens by rewarding stimuli (+ events)

Question 5

How is the presentation of depression often misleading?

Answer 5

• often complain of stomach upset, pain sensitivity, fatigue, fibromyalgia
• anxiety/insomnia often co-exist (req BZDs/Z drugs)

Question 6

What is the global Pt assessment for depression?

Answer 6

• Medical - low thyroid, anemia, chronic pain, infections, electrolytes, liver, CV, epilepsy, PD’s, AD’s, Malignancy
• Substance-related - EtOH, THC, Nicotine, Opiate, Stimulant
• Drugs/Hormones
• Stresses/Losses

MUST include Thyroid Function!! - hard to get depression to improve if this is low

Question 7

Use of BZD’s?

Answer 7

may be useful to reduce distress, anxiety, insomnia - esp. early in Tx

do NOT really treat the illness

consider potential for dependence & non-adherence

Question 8

Antidepressants

What do they target?

Why don’t they work fast?

Why take them when things are going better?

Can you become addicted?

Answer 8

take several weeks to work (3-6 ish)

can get relapse?

cannot get addicted to them

Question 9

Can you use St. John’s Wort for Depression?

Answer 9

• multiple active components which impact many NT’s/targets
• effective for MILD to MODERATE depression

Question 10

____ is a key cause of depression

Answer 10

NT dysfunction

• altered communication b/t brain neurons & neuron tracts/systems

Question 11

What are the 2 key potential sites for drug action?

Answer 11

1. REUPTAKE into the nerve ending or UPTAKE into a glial cell
2. Degradation

Question 12

Antidepressants

Immediate effects vs Long-term effects

Answer 12

Immediate effects:
- enhance “impact” or signalling of NT across synapse (esp. 5HT, NE, & DA)

• IMMEDIATE BENEFITS UNLIKELY, SE’s ARE LIKELY

Over 2-4 weeks & beyond:
- sustained enhanced signalling
- DO NOT CAUSE ADDICTION, DEPENDENCY

Long-term admin is NEEDED for FULL & OPTIMAL BENEFITS

Question 13

Ketamine for Depression?

Answer 13

lower dose of IV may produce Antidepressant effects within 4hrs

how? NO SPECIFIC EFFECTS ON NTs

RAPID effects on G proteins (like a flood of NT)

Question 14

Try use something that targets more than 1 NT b/c…

Answer 14

if any of these are under-preforming, it can affect there effects

Question 15

What is consistent with better outcomes?

Answer 15

• access to supports
• adherence to tx
• a history of “more rapid” response
• lower life stressors are consistent with better outcomes

Question 16

If we don’t treat depression, ppl tend to…

Answer 16

get better

Question 17

What is the Pharmacist’s role?

Answer 17

• Adherence
• Education
• Support & adverse effect reduction/management

Question 18

Who is susceptible/vulnerable to depression?

Answer 18

• genetics
• pyscho-social elements like feeling connected, feeling valued & supported
• life events & stressors, socio-economic factors
• overall physical/medical health
• out “psych immune system”

Question 19

ADHD main Sx

Answer 19

• inattention
• distractibility
• impulsivity
• hyperactivity

Question 20

How many months are req’d for diagnose?

Answer 20

6 months (req’s thorough assessment)

Question 21

What is seen with ppl with ADHD?

Answer 21

• more injuries
• lower grades
• worse driving record
• higher risk of drug abuse
• more antisocial
• lower job status & performance

COMORBITIES are common

Question 22

What are the ADHD symptoms that are usually mixed?

Answer 22

Inattentive cluster
- distractibility
- forgetfulness
- poor organization
- lack persitence
- mistake-prone
- work avoidant

Hyperactive cluster
- fidgetiness
- intrusiveness
- restlessness
- noisiness
- talkativeness
- inappropriate activity

Question 23

What is the ADHD course look like?

Answer 23

variable

• onset by 12 yoa, but usually earlier
• hyperkinesis improves 1st, inattention spectrum is last & least to remit
• (+) family Hx & comorbid disorders

Question 24

What predominates in adults?

Answer 24

Sx often move away from the Hyperactive domains
- DISTRACTIBILITY & INATTENTION may predominate in adults

Question 25

What is the etiology of ADHD?

Answer 25

multifactoral - genetics!!!! (~80%) - right-sided hypofrontality - Locus Ceruleus "underperforms" (OPPOSITE FROM ANXIETY) - more evident once they start school

Question 26

What is the neuropathology & neuroimaging of ADHD?

Answer 26

- small increase in cerebrum growth at age 1-3 yoa - reduced #'s of cerebellar Purkinje neurons - reduced cell size & increased cell density in the limbic areas of the brain

Question 27

What are the risk factors of ADHD?

Answer 27

- high risk in 1st degree relatives - risk increases with diff situations during pregnancy - D4 allele abnormalities = response inhibition &/or arousal regulation deficits!

Question 28

What is the multimodal approach for ADHD?

Answer 28

- behavioural - structure, checklists, attainable goals - avoiding triggers, if known - chiropractic approach - use combo Tx DRUGS WITHOUT SUPPORT = LOW SUCCESS RATE

Question 29

What are the Tx goals for ADHD?

Answer 29

- Collaborative: Support System & School

Question 30

What are the ADHD deficits?

Answer 30

- inhibition of the ability to: control behaviour, resist distractions, maintain an awareness of space & time - arousal dysregulation - leads to insufficient alertness, often alternating with overarousal

Question 31

What are the neurochemical targets for ADHD?

Answer 31

- underperformance of DOPAMINERGIC & NORADRENERGIC tracts is consistent with the deficits seen in ADHD - STIMULANTS, which increase BOTH of these systems, are considered 1st line Tx - the improvement in "gating" ability can improve behaviour control, executive function & regulate arousal

Question 32

What are ADHD's stimulant targets?

Answer 32

- to SELECT restraint & to mentally FOCUS - regulated arousal = IMPROVED PERFORMANCE - increased control = reduced hyperactivity & distractibility, &/or aggression

Question 33

What psychostimulants could be used?

Answer 33

Methylphenidate, Amphetamines ALL block NE & DA reuptake - INCREAED NE/DA ACTIVITY in Locus Ceruleus improves attention, ability to FOCUS or SELECT - Amphetamines also promote DA & NE release from presynaptic neurons

Question 34

What are the adverse effects of stimulants?

Answer 34

- may decrease appetite - may increase BP, anxiety, irritability, difficulty falling asleep, stomach complaints, headache etc.

Question 35

What is recommended in terms of ADHD medication?

Answer 35

drug holidays - to reassess tx/minimize growth effects