Card Set Information
Depression Family Medicine OSCE
OSCE appraoch to depression?
Stressors, Symptoms, Coping, Substances, Safety/Abuse
Screen for psychosis, mania, anxiety, abuse, suicidality
PPsychHx - diagnoses, meds, hospitalizations
FHx of depression, bipolar, suicide, schizo
Labs - TSH, CBC
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
Feeling Good Handbook
Mind over Mood
Start antidepressant and explain s/e, lag time, need to continue
Refer to therapy - CBT, PST, IPT
DDx - Organic Causes for Depression
chronic fatigue syndrome
Screening for organic causes in Depression
History and physical
Other tests if suggestive
DDx Mental Illnesses
Personality disorder (especially Cluster B)
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?
Diagnostic Criteria for Depression
A) 5+ of depression Sx
B) not a mixed or manic episode
C) significant distress or impairment
D) not 2º to substance abuse or general medical condition
E) not better accounted for by bereavement
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
How to screen for MDE in past?
Any times where felt depressed in past enough that:
missed work or school
tried to kill themselves or was suicidal
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)
First choice treatment for depression?
Antidepressants are 1st choice for depression, especially moderate or severe
1st line antidepressants - SSRIs, buproprion, mirtazepine, venlafaxine
Choosing an anti-depressant
Based on efficacy, tolerability and anxiety indications
Antidepressants with evidence for superior efficacy
Possibly duloxetine (Cymbalta), buproprion-SR (Wellbutrin), mirtazepine (Remeron)
Antidepressants with evidence for superior tolerability
Antidepressants with evidence in anxiety disorders
(based on Canadian Guidelines)
Name the SSRI's
buproprion-SR, mirtazepine, trazodone
What is a RIMA
reversible monoamine oxidase inhibitor
2nd line antidepressants
TCA's (amitriptyline, clomipramine, desipramine, imipramine, nortriptyline)
3rd line antidepressants
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
If no response to initial antidepressant therapy
Optimizine antidepressant - increase to maximum tolerable dose
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
What are the augmenting agents?
Triiodothyronine 25-50 micrograms per day
Lithium 600-900mg/d or to serum level of 0.6-1 mM
atypical antipsychotic (olanzepine, risperidone, quetiapine)
Typical doses of antipsychotics in augmentation
Risperidone 0.5 - 3 mg/d
Quetiapine 100-300 mg/d
What is the augmentation dose of olanzepine?
Olanzepine 2.5 - 10 mg/d
What is the augmentation dose of risperidone?
Risperidone 0.5 - 3 mg/d
What is the augmentation dose of quetiapine?
If stopping an antidepressant, what do you tell pt to watch out for?
Common discontinuation Sx:
Sensory disturbance (electric shocks)
What is length of time on meds for anti-depressant
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.
What is reasonable to expect from a primary care clinician?
develop treatment plan
assess suicide risk
assess for past mania
monitor response using rating scales (PHQ-9)
Coach self-mgmt techniques
refer when necessary
When to refer to a specialist
complicating comorbidity - substance abuse, personality d/o, anxiety d/o
Severe presentation - very suicidal, psychotic, bipolar with mania
refractory to standard treatment (CBT, 2+ meds)