5.1 Pharmacotherapy of depression Flashcards
What is the risk of recurrence after a subsequent episode(s)?
- After 1 episode: 50-60%
- After 2 episodes: 70%
- After 3 episodes: 90%
What is the definition of remission for depression?
A period of 2 or more months w no sxs or only 1-2 minimal sxs
When does the risk of recurrence get lower?
Risk becomes lower over time as duration of remission increases
What is a predictor of recurrence?
Persistent mild sxs during remission
When does function get worse and better?
Function deteriorates during the episode and goes back to baseline upon remission
According to the DSM5, what is the diagnostic criteria for depression?
At least one of the sxs must be depressed mood or loss of interest or pleasure in doing things
What is the mnemonic for the DSM5’s diagnostic criteria sxs for depression?
SIGE CAPS:
- Sleep (insomnia/hypersomnia)
- Interest decreased (anhedonia)
- Guilt/worthlessness
- Energy loss/fatigue
- Concentration difficulties
- Appetite change (increase or decrease)
- Psychomotor agitation/retardation
- Suicidal ideation
What setting was the PHQ9 developed for?
Developed for the primary care setting
What is PHQ9 used for?
Used repeatedly to determine efficacy and treatment
What does the PHQ9 scores of 5, 10, 15, and 20 correspond to?
- 5: minimal
- 10: mild
- 15: moderately severe
- 20: severe
What setting was the quick inventory of depressive symptomatology self-report (QIDS-SR-16) developed for?
Developed for psychiatric practice
What does the QIDS-SR-16 focus on?
Focuses on 16 diagnostic sxs
What does the QIDS-SR-16 scores of <=5, 6-10, 11-15, 16-20, and >= 21 correspond to?
- <=5: normal
- 6-10: mild
- 11-15: moderate
- 16-20: moderately severe
- > =21: severe
What can the MDQ be used for?
Can be used to rule out bipolar disorder
What does the MDQ consist of?
5 question assessment
What is a positive score for bipolar disorder on the MDQ?
> = 7 yes responses
What are the goals of tx for depression?
- 1: reduce or eliminate s/sxs of depression
- 2: restore occupational and psychosocial functioning to baseline
- 3: reduce the risk of relapse and recurrence
- 4: reduce the risk of harmful consequences (suicidal ideation)
How do you choose the pharmacotherapy?
- Pt preference
- Prior medication response
- Safety, tolerability, SEs
- Co-occurring psychiatric and medical conditions
- Pharmacologic properties
- Cost
What are the phases of depression tx?
- Acute
- Continuation
- Maintenance
What does the acute phase of tx consist of?
- 6-12 weeks or remission of sxs
- Goal: induce remission
What does the continuation phase of tx consist of?
- 4-9 additional months, recommended for all pts
- Goal: prevent relapse
What does the maintenance phase of tx consist of?
- Pt-specific duration
- Often indefinite tx if >= 3 major depressive episodes
- Goal: prevent recurrence
What is the boxed warning for all antidepressant medications?
Boxed warning for suicidality in ALL antidepressant meds (for pts aged <= 24 yo)
What is required w MAOis?
Tyramine diet
Why is a tyramine restricted diet required w MAOis?
Tyramine is degraded by monoamine oxidase –> MAOis inhibit monoamine oxidase –> increase in tyramine increases BP
What is included in the tyramine diet?
- Smoked, aged, pickled meats or fish
- Sauerkraut
- Aged cheeses
- Yeast extracts
- Flava beans
- Beer and wine
What can happen if MAOi is not taken w a tyramine restricted diet?
Hypertensive crisis
What is the mechanism of Bupropion (Wellbutrin)?
- Dopamine and norepinephrine reuptake inhibitor (DNRI)
- Stimulating: insomnia and appetite suppression
What is the dosing of bupropion (wellbutrin)?
SR/XL dosing: 150-450 mg/day
What are clinical pearls of bupropion (wellbutrin)?
- 2D6 inhibitor
- CI in active seizure disorder and eating disorders
- Can be used in combination w SSRI/SNRIs
What is the dosing of Mirtazapine (Remeron)?
Sedation and increased appetite occur w doses <= 15 mg/day
What are AEs of mirtazapine (remeron)?
- Warnings: agranulocytosis, increased cholesterol
- Can be used in combination w SSRI/SNRIs
What is the mechanism of trazodone (desyrel)?
Selectively inhibits neuronal reuptake of serotonin and acts as an antagonist at 5HT1, 5HT2, H1, and alpha1
What is a dosing pearl of trazodone (desyrel)?
Higher doses needed for depression
What are the SEs of trazodone (desyrel)?
- Orthostatic hypotension
- risk of priapism: medical emergency
What is the mechanism of vilazodone (viibryd)?
- Primarily SSRI, may have some 5HT1A agonism which may provide anxiolytic effects
- DO NOT USE in combination w SSRI/SNRIs
What are clinical pearls of vilazodone (viibryd)?
- 3A4 substrate
- Nausea
Take w food: - Significant nausea
- Bioavailability increases w food
What is the tx for serotonin syndrome?
- Stop the offending agent + supportive care
- Potentially could use serotonin blockers (cyproheptadine –> variable efficacy)
- 70% of pts recover within 24h
What can cause antidepressant withdrawal syndrome?
- Common w ALL antidepressants EXCEPT fluoxetine
- Abrupt discontinuation can lead to it
What should be tapered no matter what?
Antidepressants w anticholinergic activity
What are the FDA approved augmentation agents?
Atypical antipsychotics:
- Aripiprazole (Abilify): 2-15 mg/day
- Brexipiprazole (Rexulti): 0.5-3 mg/day
- Cariprazine (Vraylar): 1.5-3 mg/day
- Quetiapine (Seroquel): 50-300 mg/day
What are the non-pharmacologic tx options for depression?
- Psychotherapy
- Electroconvulsive therapy (ECT)
- Vagus nerve stimulation (VNS)
- Transcranial magnetic stimulation (TMS)
