11 Mood disorders and related drugs Flashcards
Depression dagnosis and treatment ratios
50% undagnosed
25% untreated
25% Treated
60- 80% improve if treated
Mood disorder epidemiology etc
- 4th in disability adjusted life years
- same cost as heart disease
- Low recognition rate
- Highly treatable
- 5% prevalence for dysthymic disorder and MDD
- functional impairment exceeds: DM, HTN, Arthritis, Back problems, GI
Depression presentation
Multiple Somatic complaints Anxiety "nerves, headaches" mex "Weakness, imbalance"chinese "heartbroken" hopi
Symptom and psychiatric rates
Greater number of symptoms associated with prevalance of psychiatric disorders.
Major depressive episode
5 symptoms at least two weeks with depressed moos or ahedonia
Depression criteria
- 2 weeks or more
- SIGECAPS 5 of 9
- clinically significant distress
- Not substance or medical condition
- not bereavement
PH9 scoring
several days-1pt
More than 1/2 - 2pt
Every day - 3pt
5-9 stable
10-14dysthymia or mild depression TX?
15-19 MDD TX
>20 SEVERE MDD- TX meds and psychotherapy
Suicide red flags
ISPATHWARM
ideation substance abuse purposeless anxiety trapped hopelessness Withdrawl anger recklessness mood swings
Bereavement stages
Stage 1: shock
*numbness, unreality - crying abdominal pang/empptiness, sighing, tightness in throat- thoughts of denial or disbelief
Stage 2: Preocupation
*guilt, anger, sadness- weakness, anorexia, insomnia, fatigue- dreams and thoughts of deceased- ahedonia and introversion
Stage 3:Resolution
*Thinks of past with pleasure- regains interest, new relationships formed
TCAs
Imipramine, Amitryptyline, Desipramine, Nortryptyline, Doxepin, Clomipramine, Maprotilene, Amoxapine, protriptyline, trimipramine
SSRIs
Fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine, escitalopram
SSRI SE
HA/dizziness N,D,Constipation Somnolence/insomnia Sweating/tremor/dry mouth Anxiety/restlessness Sexual drive
Atypical antidepressants
Buproprion, trazodone, nefazodone, venlaflaxine, mirtazapine, duloxetine, alprazolam
MAOi
Phenelzine Isocarboxazid Tranylcypramine selegiline RIMA
Additional treatments
Lithium Psychotherapy ECT Vagal nerve stimulation Transcranial Magnetic stim Deep brain stim *St john's wort, Sam-E, Reboxetine
Depression outcomes
Response Remission Relapse Recovery Recurrence
Bipolar general info
2.6% 1 year prevalence
1% lifetime prevalence
4.4% lifetime rate in us
15% suicide rateq
Manic episode
*Distinct period >1 week
*Elevated or expansive mood (abnormal and persistent)
*Irritable mood
*Severe
Traits:
*Grandiosity
*Decreased need for sleep
*Hyperverbal/pressured speech
*Flight of ideas
*distractability
*Psychomotor agitation and goal seeking actvity
*Pleasurable activity with painful consequences
Mania Stage 1
- increased Psychomotor activity and increased rate of speech
- Labile mood/euphoria
- Grandiosity
- Tagential but coherant thoughts
- Sexual preocupation, religion, spending, letter writing,
- High but not out of control
Mania Stage 2
- Pressured speech, ^ psychomotor activity
- Dysphoric mood/depression
- Hostility/anger
- Explosive/assultive behavior
- Flight of ideas
- Delusional preoccupations
Stage3 mania
- Desperate/panic stricken
- Loose associations
- bizzare idiosyncratic delusions
- hallucinations
- disorientation
- ideas of reference
NE pathways
Loccus ceruleans to cerebellum and around limbic system
Serotonin pathways
Raphe nucleus to limbic, cingulate gyrus, basal ganglia, and neocortex
Mirtazapine MOA
alpha 2, 5ht2, 5ht3 antagonist- antagonizes presynapic receptors
SSRIs
- Fluoxetine, paroxetine, sertraline, citalopram, escitalopram,
- Less acute tox than TCA MAOI
- Similar in effectiveness to TCAs
- nausea, insomnia, sexual dysfunction
- Serotonin rxn if mixed with MAOIs - hyperthemia, muscle rigidity, CV collapse
SSRI withdrawl
Dz/Lightheaded, Vertigo/faint, shock like, paresthesia, anxiety, diarrhea, fatigue, gait instability, HA, insomnia, irritability, NV, tremor, visual disturbances
SSRI usage
MDD, OCD (high dose SAD PTSD GAD PMS Hot flashes
Fluoxetine*
- Affects meetabolism
- 7 day halflife on active metabolite
- Sustained release formulation available
Sertraline*
Shorter half life than fluoxetine
Less metabolism interaction
*OCD, PTSD, Panic attacks
Paroxetine*
Same but hot flashes as well
Fluvoxamine
OCD
SNRIs
*Venlafaxine- Anxiety and depression
*Duloxetine- MDD/anxiety, Fibromyalgia (care with liver DZ)
Minacipran-fibromyalgia and MDD
Buproprion***
Atypical
- DNRI
- Tobacco cessation, SAD
- No weight gain or sexual dysfunction
Mirtazapine***
Atypical
Blocks presynaptic alpha2, 5ht2, 5HT3, H2 antagonist
*increases appetite
Trazodone
Atypical
Weak SSRI
*Sedating and used for insomnia
*CV SE, TrazaBONE
Vortioxetine
Atypical
MDD
SSRI-like + 5ht1 and 5HT3
TCA effects
- Decreased REM and Stage 3/4 sleep
- Prominant anticholinergic
- dry mouth, blurred vision, urinary retention
- sedation
- orthostatic
- cardiac abnormalities (increased NE—> palp, lengthened QRS, T wave abnormalities)
TCA OD
Hyperpyrexia- exceptionally high fever BP changes Cardiac conduction abnormalities Seizures coma
Tx- Supportive with 3 days of observation (long t1/2)
TCA Drug interactions
Guanethidine- blocks uptake
Sympathomimetics
Absorption and metabolism of other drugs
TCA indications
MDD
Enuresis in kids- imipramine
Chronic pain-amitryptyline
OCD-Clomipramine and SSRIs
MAOi
Phenelzine***, Tranylcypromine - MDD, Narcolepsy
- Improves depressed mood
- Corrects depression sleep disorders
- Stimulation in normals
- Lowers BP- orthostasis
- Tox–> Agitation, hallucinations, hyperpyrexia convusions, BP changes
Tyramine
MAO inhibs stop breakdown
Causes NE release and hypertensive crisis
Refractory depression
- Antipsychotic augmentation
- Olanzapine
- Aripriprazole
- Quietapine
- Ketamine-experimental
- Physiological
- ECT
- TMS (transcranial magnetic)
- DBS (deep brain stimulation)
St. John’s wort
MAOi
Might help with mild depression
3A4 induction - inhibits Birth control, Aids drugs, cyclosporine
TCA drugs and mechanisms.
Imipramine, Amitryptyline
Block serotonin and NE reuptake
