define/etiology/patho
Treatment Resistive Depression according FDA
Pt with MDD and doesn't respond to 2 or more antidepressant.
Treatment must begin given with adequate doses for adequate duration and pt must adhere to treatment
Chronic ________ may contribute to TRD
stress
Antipsychotics approved for MDD
Aripiprazole/Abilify
Brexpiprazole/Rexulti
Cariprazine/ Vraylar
Extended release quetiapine/Seroquel
olanzapine-fluoxetine combination/Symbyax
ECT 1st developed in Rome for pts with ___________
ECT is best used for ___________ &_____________
schizophrenia
psychomotor retardation & psychosis (95% rate)
Appropriate use for ECT
TRD
Bipolar with depressed or manic features
Catatonia
Schizophrenia
Psychotic episode that is refractory to antipsychotic agents
Pregnant females
Agitation& aggression in older adults with dementia
CMS is concerned with
response vs remission
TRD changes the fxn of the ______ __________
HPA Axis
additional FDA approval for TRD
Esketamine
Electroconvulsive Therapy (ECT)
Repetitive Transcranial Magnetic Stimulation (rTMS)
Vagus Nerve Stimulation (VNS)
Explain the process of ECT & typical schedule
Pt under general anesthesia, administer muscle relaxer
electrodes placed on the head, seizures are monitored by EEG while stimulus is applied
seizures are generally 30-90 minutes
Scheule: 2-3 days per week for 3-4 weeks
10-12 treatments during initial course
maintenance ECT tx maybe required with occasional tune up
Process for preparing the pt for ECT
Informed consent
medical clearance
cardiac clearance for risk factors
Anesthesia clearance
review and adjust medications accordingly
NPO prior night before and until procedure. COMMUNICATE with staff
______ % dx with MDD will develop TRD
30%
Chronis stress leads to ________ because depressive sx become more challenging to treat
TRD
additional treatment sans (without) FDA approval
dextromethrphan-buprion (don't sepate from placebo in clinical trial
Ketamine infusions
Manetic Resonance therapy (MeRT)
Lithium( reduced suicide risj
MAOIs
Psilocybin and other hallucinogens
The typical range of current for ECT is ____ to ______
Voltage is __________ future treatments depending on ________ and _________ of seizure
70-120 (approximately 100)
adjusted, duration & quality
Medication considerations for ECT remember:
1. MOA for meds-they can suppress or exaggerate sx
2. Lithium should be avoided d/t delirium, prolonged seizure, and higher risk for toxicity
3 MAOIs & TCAs + HTNsive Crisis
4. Buproprion- reduces seizure threshold
5. Benzos-taper or stop they decrease quality of seizure (may need Flumazenil prior but not ideal)
6. antiepileptics-suppress seizures
7. FGA-d/t anticholinergic effects similar to aesthesia
8. Clozapine-reduce dose assoc. with dose dependent reduction in seizure threshold.
_______ & ________ chemistry play a role in the etiology /pathology of TRD
genetics & brain
Strategies used to treat TRD
increase current dose of meds
change agents with in class
adding another antidepressant type
add an antipsychotic or mood stabilizer
explore non-pharm interventions(therapy)
GOAL- stay on label
typically 6-8weeks
Method of therapy in which a current is passed through the brain with the intention of causing a brief controlled seizure
Electroconvulsive Therapy (ECT)
The quality of the seizure is captured by_______
Current is applied using which two approaches?
EEG
Unilateral (front o back) or bilateral (temple to temple ***** may adjust placement depending on results
GOOD QUALITY SEIZURE NEEDED FOR GOOD OUTCOME
Side effects from ECT
1.confusion-few mins-hours rarely last servel days or longer
2. memory loss: antegrade amnesia (right before tx, impaired immediate recall ), Retrograde amnesia (trouble remembering events yrs, months, or weeks before treatment) tend to improve in a few moths
Psychical SE: Nausea, lethargy, h/a, jaw pain, and myalgias
The risk is _________ in medical pts
higher
Other considerations for TRD
reevaluate DX
borderline Personality disorder?
malingering?
psychotherapy-meds sometimes not enough
address underlying physical health issues
The thought of ECT is to.........
reset the brain fxn, impacting most NTs systems
(increasing DA, 5HT, GABA, NE, and Glutamine)
ECT is most effective tx for MDD which is __________ as high as pharmacological intervention
twice
Contraindications for ECT
No absolure contraindications
aneurysm, space occupying leisions, intracanial process/tumor/increased ICP
CVA/brain hemmorraghe
cardiac concerns
retinal detachment
cochlear implants (?)
recent MI
any condition or clinical scenario that would contraindication to anesthia