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DDx - Organic Causes for Depression
- hypothyroidism
- chronic fatigue syndrome
- fibromyalgia
- anemia
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Screening for organic causes in Depression
- History and physical
- CBC
- TSH
- Other tests if suggestive
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DDx Mental Illnesses
- Bereavement
- Adjustment disorders
- Bipolar disorder
- Anxiety disorder
- Personality disorder (especially Cluster B)
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Quick screening questions for Depression:
- In the past month, have you lost interest or pleasure in things you usually like to do?
- Have you felt sad, low, down, depressed or hopeless?
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Diagnostic Criteria for Depression
- A) 5+ of depression Sx
- B) not a mixed or manic episode
- C) significant distress or impairment
- D) not 2ยบ to substance abuse or general medical condition
- E) not better accounted for by bereavement
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A criteria for depression
- 5+ of following during same 2 week period with change from prior fxn.
- At least 1 of 5 is depressed mood or loss of interest/pleasure.
- 1) depressed mood (most of day, nearly every day)
- 2) loss of interest or pleasure in all, or almost all actives
- 3) significant weight loss (> 5% in month) or change in appetite nearly every day
- 4) insomnia or hypersomnia
- 5) psychomotor agitation or retardation (observed by others)
- 6) fatigue or loss of energy
- 7) worthlessness or excessive guilt
- 8) diminished ability to think or concentrate
- 9) recurrent thoughts of death, recurrent suicidal ideation
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How to screen for MDE in past?
- Any times where felt depressed in past enough that:
- missed work or school
- lost weight
- tried to kill themselves or was suicidal
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How to differ between bereavement and MDE?
- MDE can be differentiated from bereavement by:
- severity of Sx (psychosis or suicidal)
- anhedonia (total loss of pleasure)
- duration of impairment (longer than 2 months)
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First choice treatment for depression?
- Antidepressants are 1st choice for depression, especially moderate or severe
- 1st line antidepressants - SSRIs, buproprion, mirtazepine, venlafaxine
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Choosing an anti-depressant
Based on efficacy, tolerability and anxiety indications
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Antidepressants with evidence for superior efficacy
- escitalopram (Cipralex)
- sertraline (Zoloft)
- venlafaxine-XR (Effexor)
- Possibly duloxetine (Cymbalta), buproprion-SR (Wellbutrin), mirtazepine (Remeron)
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Antidepressants with evidence for superior tolerability
- citalopram (Celexa)
- escitalopram (Cipralex)
- sertaline (Zoloft)
- meclobemide (Manerix)
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Antidepressants with evidence in anxiety disorders
- (based on Canadian Guidelines)
- escitalopram (Cipralex)
- paroxetine (Paxil)
- sertraline (Zoloft)
- venlafaxine-XR (Effexor)
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Name the SSRI's
- Citalopram
- Escitalopram
- Fluoxetine
- Fluvoxamine
- paroxetine
- sertraline
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SNRI
- desvenlafaxine
- duloxetine
- venlafaxine-XR
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Novel action
buproprion-SR, mirtazepine, trazodone
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What is a RIMA
- reversible monoamine oxidase inhibitor
- Moblobemide
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2nd line antidepressants
TCA's (amitriptyline, clomipramine, desipramine, imipramine, nortriptyline)
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3rd line antidepressants
- MAOI's
- Phenezline
- Tranylcypromine
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How long should patients be on an antidepressant?
- MDE - at least 4-6 months
- MDE with risk factors (chronic, recurrent, severe or difficult to treat depression) at least 2 years
- Recurrent 2+ MDE - lifelong
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If no response to initial antidepressant therapy
- Reassess diagnosis, consider psychotherapy
- Optimizine antidepressant - increase to maximum tolerable dose
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If you have optimized antidepressant and no response:
- Switch antidepressants - no difference between within or between classes
- Augment with an augmenting agent
- Add augmenting agent to current
- Add 2nd anti-depressant in different class to current
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What are the augmenting agents?
- Triiodothyronine 25-50 micrograms per day
- OR
- Lithium 600-900mg/d or to serum level of 0.6-1 mM
- or
- atypical antipsychotic (olanzepine, risperidone, quetiapine)
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Typical doses of antipsychotics in augmentation
- Olanzepine 2.5-10mg/d
- Risperidone 0.5 - 3 mg/d
- Quetiapine 100-300 mg/d
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What is the augmentation dose of olanzepine?
Olanzepine 2.5 - 10 mg/d
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What is the augmentation dose of risperidone?
Risperidone 0.5 - 3 mg/d
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What is the augmentation dose of quetiapine?
Quetiapine 100-300mg/d
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OSCE appraoch to depression?
- ID
- RFA
- Stressors, Symptoms, Coping, Substances, Safety
- Screen for psychosis, mania, anxiety, abuse, suicidality
- PPsychHx - diagnoses, meeds, hospitalizations
- FHx of depression, suicide, schizo
- PMHx
- Phsyical exam
- Labs - TSH, CBC
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