#13 Depression.txt

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dohertys
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#13 Depression.txt
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2012-07-25 09:59:29
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Depression Family Medicine OSCE
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Depression
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  1. #13 Depression
  2. OSCE appraoch to depression?
    • ID
    • RFA
    • Stressors, Symptoms, Coping, Substances, Safety/Abuse
    • Screen for psychosis, mania, anxiety, abuse, suicidality
    • PPsychHx - diagnoses, meds, hospitalizations
    • FHx of depression, bipolar, suicide, schizo
    • PMHx
    • Phsyical exam
    • Labs - TSH, CBC
  3. OSCE approach to depression - mgmt?
    • Explain what depression is
    • Psychoeducation - explain need to take meds every day, not to stop without telling even if feel better, usually will be at least 6 months
    • Self-management approaches - exercise, supports
    • Antidepressant Skills Workbook - in multiple languages, audio as well
    • (www.comh.ca/antidepressant-skills/adult/)
    • Feeling Good Handbook
    • Mind over Mood
    • Start antidepressant and explain s/e, lag time, need to continue
    • Refer to therapy - CBT, PST, IPT
    • FOLLOW UP!
  4. DDx - Organic Causes for Depression
    • hypothyroidism
    • chronic fatigue syndrome
    • fibromyalgia
    • anemia
  5. Screening for organic causes in Depression
    • History and physical
    • CBC
    • TSH
    • Other tests if suggestive
  6. DDx Mental Illnesses
    • Bereavement
    • Adjustment disorders
    • Bipolar disorder
    • Anxiety disorder
    • Personality disorder (especially Cluster B)
  7. 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?
  8. 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
  9. 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
  10. 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
  11. 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)
  12. First choice treatment for depression?
    • Antidepressants are 1st choice for depression, especially moderate or severe
    • 1st line antidepressants - SSRIs, buproprion, mirtazepine, venlafaxine
  13. Choosing an anti-depressant
    Based on efficacy, tolerability and anxiety indications
  14. Antidepressants with evidence for superior efficacy
    • escitalopram (Cipralex)
    • sertraline (Zoloft)
    • venlafaxine-XR (Effexor)
    • Possibly duloxetine (Cymbalta), buproprion-SR (Wellbutrin), mirtazepine (Remeron)
  15. Antidepressants with evidence for superior tolerability
    • citalopram (Celexa)
    • escitalopram (Cipralex)
    • sertaline (Zoloft)
    • meclobemide (Manerix)
  16. Antidepressants with evidence in anxiety disorders
    • (based on Canadian Guidelines)
    • escitalopram (Cipralex)
    • paroxetine (Paxil)
    • sertraline (Zoloft)
    • venlafaxine-XR (Effexor)
  17. Name the SSRI's
    • Citalopram
    • Escitalopram
    • Fluoxetine
    • Fluvoxamine
    • paroxetine
    • sertraline
  18. SNRIs
    • desvenlafaxine (Pristiq)
    • duloxetine (Cymbalta)
    • venlafaxine-XR (Effexor)
  19. Novel action
    buproprion-SR, mirtazepine, trazodone
  20. What is a RIMA
    • reversible monoamine oxidase inhibitor
    • Moblobemide
  21. 2nd line antidepressants
    TCA's (amitriptyline, clomipramine, desipramine, imipramine, nortriptyline)
  22. 3rd line antidepressants
    • MAOI's
    • Phenezline
    • Tranylcypromine
  23. 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
  24. If no response to initial antidepressant therapy
    • Reassess diagnosis
    • consider psychotherapy
    • Optimizine antidepressant - increase to maximum tolerable dose
  25. 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
  26. 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)
  27. Typical doses of antipsychotics in augmentation
    • Olanzepine 2.5-10mg/d
    • Risperidone 0.5 - 3 mg/d
    • Quetiapine 100-300 mg/d
  28. What is the augmentation dose of olanzepine?
    Olanzepine 2.5 - 10 mg/d
  29. What is the augmentation dose of risperidone?
    Risperidone 0.5 - 3 mg/d
  30. What is the augmentation dose of quetiapine?
    Quetiapine 100-300mg/d
  31. If stopping an antidepressant, what do you tell pt to watch out for?
    • Common discontinuation Sx:
    • FINISH
    • Flu-like symptoms
    • Insomnia
    • Nausea
    • Imbalance (dizziness)
    • Sensory disturbance (electric shocks)
    • Hyperarousal (agitation)
  32. What is length of time on meds for anti-depressant
    • while depressed
    • at least 4-6 months after remission if no RF's
    • If risk factors (chronic, recurrent, severe or difficult to treat) then continue at least 2 years. may need lifetime.
  33. What is reasonable to expect from a primary care clinician?
    • diagnose depression
    • develop treatment plan
    • assess suicide risk
    • assess for past mania
    • monitor response using rating scales (PHQ-9)
    • Coach self-mgmt techniques
    • manage medications
    • refer when necessary
  34. When to refer to a specialist
    • complicating comorbidity - substance abuse, personality d/o, anxiety d/o
    • Severe presentation - very suicidal, psychotic, bipolar with mania
    • diagnostic clarification
    • refractory to standard treatment (CBT, 2+ meds)

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