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100 Cards in this Set

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  • Back
What constitutes major depression?
Period of at least 2 weeks of a depressed mood at least everyday ---

An episode may be characterized by sadness, indifference, apathy, or irritability and is usually associated with: changes in sleep patterns, appetite, and weight; motor agitation or retardation; fatigue; impaired concentration and decision-making; feelings of shame or guilt; and thoughts of death or dying.
What % of the population will experience a major depressive period?
15% at some stage in their life

6-8% of Pt in outpatient care meet the criteria for depression
Risk factors for depression?
Female Gender (apart from very young and very old;
men express distress through substance abuse and
antisocial behavior)
Low Socioeconomic Status
Single parent
Unemployed or economically inactive
Lower level of education
Homemaker rather than having outside employment
Childhood - abuse or bad/absent parenting
Differentials for depression?
Other psychiatric disorders
Alcohol misuse
Amphetamine (and derivatives) misuse and withdrawal
Borderline personality disorder
Normal and pathological grief

Organic (secondary) affective illness :
Cushing's syndrome
Thyroid disease
Corticosteroid treatment
Brain tumour (rarely without other neurological signs)
Investigations for depression - following Hx and PE?
measurement of free T4 and TSH (particularly in women), calcium,
sodium, potassium, mean corpuscular volume, γ-glutamyl
transpeptidase, haemoglobin, white cell count, ESR or plasma viscosity.

Less commonly a chest X-ray, antinuclear antibody, morning and
evening cortisols, electroencephalogram or a brain scan are indicated.
Main pathological theory associated with depression
Monoamine theory
What is the basis of monoamine theory?
Reduced levels of monoamines - NA and 5-HT in certain areas of the brain result in the depression
What evidence backs up the monoamine theory?
Drugs affecting increasing the effects of NA and 5-HT alleviate depression

Reduced NA metabolites and by products of it's synthesis (MOPEG & VMA) in Urine and CSF
What evidence is there against the monoamine theory of depression?
Other drugs not affecting these neurotransmitters are also effective in treating depression (iprindole)

There is no alteration in 5-HT by products in urine or CSF (5-HIAA)

No alteration of 5- HT levels in brain of depressive patients

Other drugs such as amphetamines and cocaine which alter monoamine levels in the brain have no effect on depression - yet lead to euphoria in normals
T/F.... the action of antidepressants has an immediate effect on the patient?
False -

the drugs can take 2-4 weeks to have an effect despite the biochemical changes occur immediately.
This is thought to be due to long term changes rather than specific excitation of excitatory neurons.
Serotonin Pathways project from where to where?
Fom raphe nuclei
To the amygdala, hippocampus, striatum (caudate & lentiform -
putamen & globus pallidus- nuclei)

Cortex – Behaviour regulations (keeps us in touch with reality - ↓ 5-HT - disruption of connection to reality) – LSD
Pre-frontal Cortex – Mood (↓ 5-HT  depression)
 Amygdala or Hypothalamus – Aggression (5-HT released in stressful situations will dampen down the mood)
 Descending Inhibitory fibers – Pain – for overactive pain signals
BV’s are wrapped by serotonergic fibres – affect the diameter of BVs (↑5-HT – vasoconstrictions, ↓ 5-HT – Vasodilation)
What does the noardrenaline system effect?
From locus coreleus to wide projections in the cortex

Reduced activity – depression
Activation – euphoria, manic episodes?
Where does the serotonin pathway start and end?
Fom raphe nuclei

To diffuse cortical projections

Cortex - behavior regulations - in touch with reality - LSD
Pre-frontal Cortex – Mood (↓ 5-HT - depression)
Amygdala or Hypothalamus – Aggression
Descending Inhibitory fibers – Pain – for overactive pain signals
BV’s are wrapped by serotonergic fibres – Blood Flow Control (↑5-HT – vasoconstrictions, ↓ 5-HT – Vasodilation)
Is Lithium is first line treatment for depression?
False - it is first line treatment for bipolar disorder
1st line treatment for depression include the use of SSRIs?
True - these act by selectively inhibiting 5-HT into the nerve terminal by serotonin transporter

TCAs are also used as first line treatment
Treatment of depression involves a variety of therapies - list some of these.
Stop depressing drugs (alcohol, steroids)
Regular exercise (good for mild to moderate depression)
Antidepressants (choice determined by side-effects, co-morbid
illnesses and interactions)
Adjunctive drugs (e.g. lithium; if no response to two different
Electroconvulsive therapy (ECT) (if life-threatening or non-
Antidepressants should be used with caution in bipolar disorder - T/F?
True - although they can be used as a treatment - but are not standard therapy.
What is one of the most important factors when treating bipolar disease?
Medication compliance -

patients often will not want to take MedS - especially when hypomanic or manic - education for patients and family are VERY IMPORATANT
Exercise is recommended therapy for depression - T/F?
True - for mild to moderate depression
Whats is the effectiveness of antidepressants?
50-70% (30-50% failure)
Tricyclic antidepressants are commonly used antidepressants?
What is the MOA of TCAs?
The non-selectively inhibiting reuptake of monoamines - such as NA and 5-HT.
What are the side effects or ADRS of TCAs?
Cardiac toxicity – dysrhythmias, VF, and anticholinergic Effects
Name commonly used TCAs?
Amitriptyline, Imipramine, Dosulepin, Clomipramine
Amytriptyline is a common SSRI?
False - it is a TCA
Examples of SSRIs?
Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Sertraline,
What is the MOA of Monoamine oxidase inhibitors ?
act by irreversibly inhibiting the intracellular enzymes monoamine oxidase
A and B, leading to an increase of norepinephrine (noradrenaline),
dopamine and 5-hydroxytryptamine in the brain.
MOAIs are first line treatment in depression - T/ F?
False - they are 2nd line - and used for atypical cases
Fluoxetine is an example of an SSRI -t/F?
Problems associated with MAOIs?
Cannot be taken at the same time as SSRIs - MUST BE CAREFUL!!

Severe and dangerous hypertensive reaction with foods containing
tyramine or dopamine, not normally be given within 2 weeks of a SSRI
Phenelzine, Tranylcypromine, Moclobemide, are examples of?
What is Reboxetine?
selective inhibitor of NA reuptake

Depression Rx
Selegiline - what is the MOA of this drug?
Is it MAOI specific of B subtype -
Not used for depression
Electroconclusive therapy is commonly used for mild depression - T/F?
False - this is reserved for severe depression - often psychotic depression - although is very effective.
Dopamine - origins of cells?
Substantia nigra - pars compacta --> basal ganglia

Ventral tegmental area --> mesocortical and mesolimbic pathways.
Beck's theory is an influential theory in cognitive behavioural therapy - what are the main ideas behind becks theory?
Cognitive triad:
Negative view the the depressed individual holds of:
Themselves (worthless & inadequate)
The world (hostile environment)

Thinking errors:
Black-and-white thinking
Is insomnia a diagnosis ? And what are the associated complaints?
NO - complaint

fatigue, irritability, mood disturbance, poor concentration,
reduced work performance, and daytime sleepiness.
Is Insomnia often linked to chronic disease - such as chronic pain, cardiac or lung disease?
Is insomnia associated with depression?
Yes - often a precursor
Genetic factors; Circadian characteristics; Personality; Age; Stress;
Shift work

Are all RF for insomnia - T/F?
MOA of benzodiazepines?
Potentiate the effect of GABA at GABA-A receptors. They increase the probablility of the linked chloride channel of opening -increased inhibition
What kind of drug is diazepam?
Anxiolytic Benzodiazepine - Valium
Dopamine pathways include?
What is the mesolimbic pathway?
Dopaminergic pathways from the VTA to the limbic structures (medial temporal cortex, cingulate gyrus and nucleus accumbens)

Plays a role in the positive symptoms of schizophrenia -- hallucinations
Which dopaminergic pathway is involved in parkinson's disease?
What is the mesocortical pathway involved in?
It projects from the VTA to the prefrontal cortex.

Involved in working memory and attentional aspects of motor initiation.
Which of the following is the most likely mechanism of the anti-
anxiety effect of diazepam?
A) Enhancement of the action of 5-hydroxytryptamine (5HT)
in the brain
B) Direct activation of inhibitory gamma-aminobutyric acid
(GABA) receptors in the brain
C) Enhancement of the inhibitory action of GABA in the brain
D) Inhibition of the action of 5HT in the brain
C - enhancement of the inhibitory action of GABA in the brain

*** Benzos do not directly activate the GABA-A receptors - they increase the probability of opening
Which one of the following explains the preference of SSRIs over TCAs in the treatment of depression?
A) SSRIs are of superior efficacy to TCAs in randomised controlled trials
B) SSRIs are also useful in the treatment of anxiety whereas TCAs are not
C) There is no difference in the risk of conversion to mania in patients with bipolar disorder
D) They are safer in overdose
Answer D
SSRIs are safer in overdose than TCAs. There is no difference
between the two classes of drug in randomised controlled trials, in fact
the later may be more efficacious. SSRIs and TCAs are both effective
in the treatment of anxiety disorders, but the former but are less likely to cause conversion to a manic episode.
Which of the following combination of factors would result in the
highest risk for suicide?
A) Female, history of suicide attempt and living alone
B) Male, history of suicide attempt and living alone
C) Female, alcohol abuse and high IQ
D) Male, cannabis use and unemployment
Answer B
B is the combination most at risk.
What percentage of patients with anxiety will have an underlying medical condition?
1/3 Have a medical condition causing their psyc symptoms
What is the most common psychiatric problem?
Who should be referred to a psychiatrist ?
Those who have psychotic symptoms, mania, severe depression, or anxiety; symptoms of posttraumatic stress disorder (PTSD); suicidal or homicidal preoccupation; or a failure to respond to first-order treatment
What percentage of the population have anxiety disorders?
15-20% of medical clinic patients
What are the symptoms associated with panic attacks?
palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, and a fear of impending doom or death
Somatic symptoms are often associated with panic attacks T/F?
T/F - panic attacks start abruptly with 10 min onset and resolve over 4hours?
False the first part is true although they should resolve within 1 hour
What is a panic attack?
A distinct episode with intense fear and associated somatic symptoms
What is panic disorder?
Life time risk?
Pt having worried about or having had the panic attacks disrupt her life for at least a month

Life time risk - 1-3%
Can panic disorder lead to a patient not wanting to leave their house alone?
Yes - panic disorder can lead into antipatory anxiety - such as agoraphobia -
What percentage of peole with panic disorder will at some stage meet the criteria for major depression?
Self medication for panic condition is relatively common - what can may be used?
What medical conditions should be investigated as a cause of anxiety?
pheochromocytoma, thyrotoxicosis, or hypoglycemia
What is the treatment of panic disorder?
Antidepressants - SSRI, TCA, MAOI
What are the side effects of TCA?
Anticholinergic (dry mouth, tachycardia, constipation, urinary retention, blurred vision); sweating; tremor; postural hypotension; cardiac conduction delay; sedation; weight gain
What are some SSRIs?
Fluoxitine (Prozac)
Sertraline (Zoloft)
What kind of drug is amytriptyline?
What kind of drug is citalopram?
What kind of drug is Imipramine ?
What is phenelzine?
What is clonazepam ?
Benzo with longer half life - 2/day sowing - reduced dependence
Benzodiazepines differ in their milligram per kilogram potency, half-life, lipid solubility, metabolic pathways, and presence of active metabolites- T/F?

And what does this mean when prescribing?

Mean that they must be taken into consideration - ie is liver disease - drugs metabolized via oxidation will accumulate where as those via combination will not.
Also halfLife is important in treating symptoms and also preventing dependency
Diazepam is a short acting benzo - T/F?
This means that is good for treating events such as panic attacks although patients are at higher risk for developing dependence.
Depression has a major illness and is ranked fourth on the DALYs world wide - T/F
This ranking is projected to rise to 2nd by 2020
What are the 3 main types of mood disorders?
Major depression
Depression associated with a medical condition or alcohol/drug abuse
Bipolar disorder/manic depressive
True/false- virtually all medications have some component that may induce depression.

Common drugs include:
Antihypertensive drugs, anticholesterolemic agents, and antiarrhythmic agents, also -- glucocorticoids, antimicrobials, systemic analgesics, antiparkinsonian medications, and anticonvulsants
Depression can increase your risk for coronary heart disease - T/F?
True - perhaps via serotonin induced platelet aggregation
TCA- not used in people with heart problems - why?
Because they can induce tachycardia - problems in patients with BBB (bundle branch block) and congestive heart failure
What Conditions do patients have higher risks for depression?
Cancer - ESP pancreatic and oropharyngeal
neurologic disorders, particularly cerebrovascular disorders, Parkinson's disease, dementia, multiple sclerosis, and traumatic brain injury
diabetes mellitus varies from 8–27%- associated with level of hyperglycemia and complications
Hypothyroidism + hyperthyroidism (generally geriatrics)
HIV-positive individuals has been estimated at 22–45%
hepatitis C
Chronic fatigue syndrome and fibromyalgia
What is needed to Dx major depression?
At least 2 weeks with depressed mood.

An episode may be characterized by sadness, indifference, apathy, or irritability and is usually associated with: changes in sleep patterns, appetite, and weight; motor agitation or retardation; fatigue; impaired concentration and decision-making; feelings of shame or guilt; and thoughts of death or dying.
What are the features of depression?
Depressed mood - most of the day - nearly every day
Loss of interest or pleasure
Weight gain or loss
Sleep disturbances - insomnia or hypersomnia
Psychomotor agitation or retardation (restlessness or being slowed down)
Fatigue or loss of energy
Feelings of worthlessness or guilt
Reduced ability to think of concentrate - descisions
Thoughts of death or suicide ideation
Symptoms cause signification impairment in social and occupational functioning
The symptoms are not due to medical illness, drug taking or recent family death (>2months, or functional impairment etc --are considered depression)
What if the life time risk for major depression?
What % of depressive patients have an underlying medical condition or substance abuse?
What % of depressed patients will commit suicide?
4-5% (most will gave consulted a doctors within 1 month of doing so)
Who is more likely to develop depression - women or men?
Women are 2x as likely to develop depression
Is it is believed that the direct effect of antidepressants - inhibiting monoamine uptake - is the MOA for their effect in treating depression.
False - it is believed that the neuroadaptive changed associated with this chemical changes are the reason for depression resolution in these patients -
What 3 factors improve outcome of treatment for depression ?
(1) increased intensity and frequency of visits during the first 4–6 weeks of treatment,
(2) supplemental educational materials, and
(3) psychiatric consultation as indicated
What % of patients will respond to treatment if treatment is maintained for at least 6-8 weeks?
SSRIs are better at treating depression than TCAs - T/F?
False - there is no Convincing evidence of this but they are SAFER!
Is a patient has suicidal ideation - what should be considered when choosing therapy for depression?
Toxicity in overdose
Which antidepressants can be lethal in overdose?
What is serotonin syndrome?
thought to result from hyperstimulation of brainstem 5HT1A receptors and characterized by myoclonus, agitation, abdominal cramping, hyperpyrexia, hypertension, and potentially death.

Can occur when SSRIs are combined with MOAIs
SSRIs - impair sexual function or loss of libido - T/F?
True and must be asked about specifically because it can lead to non-compliance.
ECT is not as effective as medication - that is why is it not commonly used - T/F?
False - it is at least as effective at medication but is reserved for treatment resistant patients or delusional depression.
MOAIs are used as first line treatment in depression. - T/F?
They are usually used for atypical cases.
What is mania? Signs and symptoms.
mania, which in its pure form is associated with increased psychomotor activity; excessive social extroversion; decreased need for sleep; impulsivity and impairment in judgment; and expansive, grandiose, and sometimes irritable mood
Delusions and paranoid thinking indistinguishable from schizophrenia are common in bipolar disorder. T/F?
These are only found in patients with severe bipolar disorder.
What is type II bipolar characterized by?
It is characterized by depression with recurrent episodes of a mild activation or rise in energy (hypomania) without an episode of full mania.
What is the prevalence of bipolar disorder?

Age of onset?

Genetics plays a role in most mood disorders - T/f?
Bipolar disorder - has a concordance rate in monozygotic twins of 80%

major depression - 46%
What are the main treatment for bipolar disorder?
Lithium - mainstay - response rate of 70-80% in manic phase
- also sodium valproate and olanzapine

Depressed state - lamotrigine