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44 Cards in this Set

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Depression facts
1. leading cause of disability in the US
2. onset usually b/t mid-20s and mid-30s
3. high prevalence in women
4. second leading cause of disease burden worldwide
5. independent risk factor for cardiac disease
6. 15% of pts with complete a suicide
Major Depressive episode- 5+ of the following sx for at least 2 weeks
1. Depressed mood
2. diminished interest or pleasure in activities
3. a significant decrease or increase in appetite
4. insomnia or hypersomnia
5. psychomotor agitation or retardation
6. fatigue or loss of energy nearly every day
7. feelings of worthlessnes or guilt
8. dec attention, concentration; indecisiveness
9. recurrent thoughts of death, suicidal ideation, suicide attempt
how does depression present
DIG SPACES
1. depressed mood
2. Interests
3. Guilt/helpessness/hopelessness
4. Sleep disturbances, somatic complaints, sex
5. psychomotor disturbance
6. appetitie distrubance
7. concentration/memory/ decision-making
8. Energy/fatigue/sense of "heaviness"
9. suicidal ideation/gestures/attempts
What causes depression
1. Genetics: + FH increases one's risk 2-5x
2. Enviornmental factors: stressors, poor family functioning, poor support system, early loss of parent etc.
3. Biology" "catecholamine hypothesis"- dec levels of serotonin, NE, DA in the brian
Hypothalamic-pituitary-adrenal hypothesis
-chronic, prolonged stress disinhibits the negative feedback loop between cortisol and Corticotropin Releasing Factor (CRF). Therefore, increased CRF does not lead to decreased cortisol.
-elevated CRF and cortisol can lead to poor sleep, decreased appetite, and low sex drive
The Neurotrophic hypothesis
-Stress elevates glucocorticoid steroids, which reduce growth factors, such as BDNF, leading to atrophy in the limbic system, especially the hippocampus
How to diagnose depression
1. complete H&P and bloodwork
2. Complete med review
3. structured psychiatric interview
4. beck depression inventory
5. ASK!!
complete history
1. Sleep disorders: sleep apnea, narcolepsy, circadian, rhythm disorder
2. Neurologic: seizure, alzheimers, parkinsons, CNS tumor, MS
3. Endocrinologic: thyroid, DM, cushings, addisons
4. Nutritional: iron/folate/ thiamine/B-12 def, malnutrition
5. infectious disease: syphilis, lyme disease, HIV
6. AI disease: lupus, CFIDS
meds and drugs
-anti-hypertensives
-OCs
-steroids
-chemo
-antacids
-benzo
-alcohol, pot, heroin, cocaine, ecstacy
Blood work
-CBC: infeciton
-SMA-7: renal failure, hypoglycemia
-TSH
-U/A: UTI
-U-Tox
-RPR: syphilis
-B-12 folate
-EG
-CXR
-consider endocrine testing!
Depression facts
1. leading cause of disability in the US
2. onset usually b/t mid-20s and mid-30s
3. high prevalence in women
4. second leading cause of disease burden worldwide
5. independent risk factor for cardiac disease
6. 15% of pts with complete a suicide
Major Depressive episode- 5+ of the following sx for at least 2 weeks
1. Depressed mood
2. diminished interest or pleasure in activities
3. a significant decrease or increase in appetite
4. insomnia or hypersomnia
5. psychomotor agitation or retardation
6. fatigue or loss of energy nearly every day
7. feelings of worthlessnes or guilt
8. dec attention, concentration; indecisiveness
9. recurrent thoughts of death, suicidal ideation, suicide attempt
how does depression present
DIG SPACES
1. depressed mood
2. Interests
3. Guilt/helpessness/hopelessness
4. Sleep disturbances, somatic complaints, sex
5. psychomotor disturbance
6. appetitie distrubance
7. concentration/memory/ decision-making
8. Energy/fatigue/sense of "heaviness"
9. suicidal ideation/gestures/attempts
What causes depression
1. Genetics: + FH increases one's risk 2-5x
2. Enviornmental factors: stressors, poor family functioning, poor support system, early loss of parent etc.
3. Biology" "catecholamine hypothesis"- dec levels of serotonin, NE, DA in the brian
Hypothalamic-pituitary-adrenal hypothesis
-chronic, prolonged stress disinhibits the negative feedback loop between cortisol and Corticotropin Releasing Factor (CRF). Therefore, increased CRF does not lead to decreased cortisol.
-elevated CRF and cortisol can lead to poor sleep, decreased appetite, and low sex drive
The Neurotrophic hypothesis
-Stress elevates glucocorticoid steroids, which reduce growth factors, such as BDNF, leading to atrophy in the limbic system, especially the hippocampus
How to diagnose depression
1. complete H&P and bloodwork
2. Complete med review
3. structured psychiatric interview
4. beck depression inventory
5. ASK!!
complete history
1. Sleep disorders: sleep apnea, narcolepsy, circadian, rhythm disorder
2. Neurologic: seizure, alzheimers, parkinsons, CNS tumor, MS
3. Endocrinologic: thyroid, DM, cushings, addisons
4. Nutritional: iron/folate/ thiamine/B-12 def, malnutrition
5. infectious disease: syphilis, lyme disease, HIV
6. AI disease: lupus, CFIDS
meds and drugs
-anti-hypertensives
-OCs
-steroids
-chemo
-antacids
-benzo
-alcohol, pot, heroin, cocaine, ecstacy
Blood work
-CBC: infeciton
-SMA-7: renal failure, hypoglycemia
-TSH
-U/A: UTI
-U-Tox
-RPR: syphilis
-B-12 folate
-EG
-CXR
-consider endocrine testing!
Psychotherapy
1. cognitive behavioral therapy: identify, challenge, and change dysfunctional thought processes such as:
-al or nothing thinking
-over-generalization
-rumination
-jumping to conclusions
Pharmacotherapy
1. SSRIs (Prozac)- sexual SE-dec libido, erectile dysfuntion, anorgasmia
2. SNRIs (Effexor)
3. NDRIS (wellbutrun)
4. Alpha-2 antagonists (remeron)
5. Tricyclics- heavy anticholinergic SE
6. MAOIs
7. off-label: antipsychotics, antiepileptics, lithium, thyroid hormone, psychostimulants
pharmacotherapy cont
-antidepressants should be continued for at least 6 months after symptom resolution
-maintenance therapy should be consider in pt who are:
1. 40 yo with 2 depressive episodes
2. 50 yo with 1 depressive episodes
3. any age with 3 depressive episodes
4. depressed for at least 2 yrs before initiating meds
Electroconvulsive therapy
-used when a rapid antidepressant response is needed or when drug therapies have failed
-electric shocks delivered to the brain cause brief seizures
-no absolute C/I
-can be used in preg pts
-SE: post-ictal confusion and anterograde amnesia, arrhythmia
Don;t forget....
1. diet
2. exercise
3. supplements
4. light therapy
5. social support/interpersonal contact
6. pets
7. spiritual/religious affiliation
8. SLEEP
prognosis of depression
-without treatment, up to 60-80% will recover spontaneously
-with tx, 80-90%
-The risk of relapse after one episode is 50%. The risk of relapse after two episode is 90%. The risk of relapse after three episodes is ~ 100%
good predictors of prognosis
1. FH
2. Acute onset
3. late onset
4. early intervention
5. good support system
6. no psychotic symptoms
7. no substance abuse
poor predictors of prognosis
1. no FH
2. gradual onset
3. early onset
4. late intervention
5. poor support system
6. psychotic sx
7. substance abuse
when do we refer to a psychoatrist/specialist
Evaluation for pharmacotherapy
Failure of adequate antidepressant trial
Psychiatric comorbidities
Complicated medical comorbidities
Suicidal ideations, gestures
Patient in need of hospitalization
Dysthymia
-depressed mood for most of the day, for more days than not, for at least 2 yrs
-presence of 2+
1. poor appetie or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or inability to make decisions
6. feelings of hopelessness
what is dysthymia
C) During the two year period, the patient has not been without symptoms for more than two months
D) During the two year period, the patient has not suffered a Major Depressive Episode
E)There has never been a Manic, Hypomanic, or Mixed episode
F) The disturbance does not occur exclusively during the course of a psychotic disorder
G) The symptoms are not due to substance use or general medical condition
how does dysthymia present
-presents as a depressed mood not as severe as that of Depression, but lasts much longer.
-Onset is earlier (adolescence to early twenties) and more insidious than Depression
tx for dysthymia
-same as that for depression
-percentage of pts who respond to antidepressants is less than with depression
-Magnitude of response is generally less than with Depression
-Recovery rate at 5 years is 30-40%
10% will develop Major Depressive Disorder
risk factors for suicide
SAD PERSONS
-sex (males)
-age
-depression
-previous attempt
-ethanol
-rational thinking
-support
-organized plan
-no spouse
-sickness
Mania
-abnormally elevated, expansive, or irritable mood, lasting at least 1 week
1) Inflated self-esteem or grandiosity
2) Decreased need for sleep
3) More talkative than usual; pressure to keep talking
4) Flight of ideas or racing thoughts
5) Distractibility
6) Increase in goal-directed activity or psychomotor agitation
7) Excessive involvement in pleasurable activities that have negative consequences
how does mania present
DIG FAST
-distractibility
-insomnia
-grandiosity
-flight of ideas
-activities
-speech
-thoughtlessness
mania symptom domains
1. Elation
2. Dysphoria
3. Cognition
4. Psychotic
What causes mania
1. Genetics (~30% have a FH)
2. psychosocial- trauma or interpersonal loss may trigger or exacerbate sx
3. biology
hypomania
-period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 4 days
-3+ sx
1) Inflated self-esteem or grandiosity
2) Decreased need for sleep
3) More talkative than usual or pressure to keep talking
4) Flight of ideas or racing thoughts
5) Distractibility
6) Increase in goal-directed activity or psychomotor agitation
7) Excessive involvement in pleasurable activities that have negative consequences
hypomania cont
1) The episode is associated with an unequivocal change in function that is uncharacteristic of the person when not symptomatic
2) The disturbance in mood and change in functioning are observable by others
3) The episode is not severe enough to cause marked impairment of occupational, social, or other activities or relationships
4) The symptoms are not the cause of a substance or general medical condition
Bipolar disorder type I and II
I: Alternating periods of Depression and Mania

II: Alternating periods of Depression and Hypomania
Cyclothymia
-Alternating periods of dysthymia and hypomania for at least two years. There can be no absence of symptoms for more than two months
-1/3 of cyclothymics convert to a major mood disorder, usually bipolar disorder type II
how to tx bipolar disorder
-Lithium- drug of choice
SE: Hypothyroidism, tremor, thirst, polyuria, GI distress, arrhythmia, leukocytosis. Teratogenic in first trimester. Narrow therapeutic index.
-labs: CBC, U/A, BUN/creatinine, HCG, electrolytes, thyroid functions, EKG
-Antiepileptics (depakote, tegretol, lamictal)
-Antipsychotics
-Electroconvulsive therapy
when to use electroconvulsive therapy for bipolar disorder
-For acute mania or severe depression that are not responsive to medication.
-For psychotic symptoms
-For strong suicide risk