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NAPLEX 2024 > 63. Depression > Flashcards

63. Depression Flashcards

1
Q

Neurotransmitters believed to be involved in depression include ____

A

serotonin, NE, Epi, dopamine, glutamate, and ACh

Note: Serotonin (5-HT) may be the most important NT involved with feelings of well-being

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2
Q

Which tool is the most widely used depression assessment scale?

A

The Hamilton Depression Rating Scale (HDRS or Ham-D)

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3
Q

DSM-5 Criteria

A

A least 5 of the following symptoms present during the same 2 week period must include depressed mood or diminished interest/pleasure:
Mood - depressed
Sleep - increased/decreased
Interest/pleasure - diminished
Guilt or feelings of worthlessness
Energy - decreased
Concentration - decreased
Appetite - increased/decreased
Psychomotor agitation or retardation
Suicidal ideation

Mnemonic: M SIG E CAPS

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4
Q

Drugs that worsen depression

A

ADHD medication = Atomoxetine (Strattera)
Analgesics - Indomethacin
Antiretrovirals (NNRTIs) - efavirenz (in Atripla), Filpivirine (in Complera, Odefsey)
CV meds - beta-blockers (esp propranolol)
Hormones - hormonal contraceptives, anabolic steroids
Other - antidepressants, BZD, systemic steroids, interferons, varenciline, ethanol

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5
Q

Medical conditions that may contribute to depression

A

Stroke
Parkinson disease
dementia
MS
hypothyroidism
Low vit D levels
Metabolic conditions (e.g. hypercalcemia)
Malignancy
Overactive bladder
Infectious disease

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6
Q

It is necessary to rule out _____ prior to initiating antidepressant therapy for depression to avoid inducing ____ or causing ___

A

bipolar disorder
inducing mania
causing rapid-cycling (Cycling rapidly between bipolar depression and mania)

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7
Q

When depression and anxiety occur together, __ should not be used alone; they can worsen and/or mask depression and can be problematic in pts with concurrent substance abuse disorders (called Dual Diagnosis)

A

BZDs

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8
Q

Natural products used in depression

A

St. John’s wort
SAMe (S-adenosyl-L-methionine)
Valerian
5-HTP (5-hydroxytryptophan)

Note: St.John’s work, SAMe, and 5-HTP can incrased risk of serotonin syndrome
Valerian can cause sedation
St. John’s wort is CYP inducer - lots of DDIs

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9
Q

The initial choice of meds for depression should be based on side effect, safety, pt-specific symptoms. For most pts, _____ is preferred or (with specific concurrent conditions) mirtazapine or bupropion

A

SSRI or SNRI

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10
Q

First line therapy for mild depression in pregnant pts

A

Psycho therapy, followed by drug treatment if needed

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11
Q

In pregnant pts with depression, SSRIs are often used initially with the exception of ____, d/t potential ____. Although preferred, there is a warning regarding SSRI use during pregnancy and potential risk of ____

A

Paroxetine - d/t cardiac effects
Persistent pulmonary HTN of the newborn (PPHN)

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12
Q

___ helps for physical and emotional symptoms of postpartum depression (also considered beneficial for the baby)

A

Breastfeeding

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13
Q

For nursing moms that require antidepressants, _____ are generally preferred (with the exception of ___ per ACOG recommendations)

A

SSRIs or TCAs
exception of doxepin

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13
Q

___ a C-IV drug, is FDA-approved for postpartum depression (continuous IV infusion over 60 hrs, can cause excessive sedation)

A

Brexanolone (Zulresso)

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14
Q

D/t safety concerns (DDIs, drug-food interactions), MOA inhibitors such as _____ are restricted to patients unresponsive to other treatments

A

Phenelzine, tranylcypromine, isocarboxazid

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15
Q

The risk of serotonin syndrome is most severe when a ____ is administered with another serotonergic med. Higher doses increase risk.

A

MAOi

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16
Q

S/sx of serotonin syndrome

A

severe nausea, dizziness, HA, diarrhea, agitation, tachycardia, hallucinations, or muscle rigidity

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17
Q

T/F: D/c antidepressants require taper

A

True, should be tapered over several weeks to avoid withdrawal (s/sx: anxiety, agitation, insomnia, dizziness, flu-like symptoms)
Exception: fluoxetine (self tapers d/t long half life)

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18
Q

Which antidepressants have higher risk of withdrawal symptoms if not tapered to d/c?

A

Paroxetine
Venlafaxine

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19
Q

Most antidepressants require taper to avoid withdrawal. An exception is ____ d/t self taper from long half-life

A

Fluoxetine

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20
Q

All antidepressants carry a boxed warning of possible increase in ____ in some children, teenagers, or young adults within the first few months of treatment or when dose is changed.

A

suicidal thoughts or actions

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21
Q

T/F: antidepressant meds must be used daily and takes time to work

A

True

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22
Q

Physical symptoms of depression such as low energy will improve within ____ of medication use but psychological symptoms such as low mood may take ____

A

1-2 weeks
a month or longer

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23
Q

SSRI MOA

A

increase 5-HT by inhibiting its reuptake int he neuronal synapse. They weakly affect NE and DA

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24
Q

Examples of SSRIs

A

Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac) (+ olanzapine (Smybyax))
Paroxetine (Paxil)
Sertraline (Zoloft)
Fluvoxamine IR/ER

Note: Paroxetine (Brisdelle) is used for mod-severe vasomotor symptoms a/w menopause

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25
Q

Max dose of citalopram (Celexa)

A

Max dose 40mg/day
Max dose in elderly (>60yo): 20 mg/day

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26
Q

Max dose of escitalopram (Lexapro)

A

Max dose 20mg/day
Max dose in elderly 10mg/day

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27
Q

When is fluoxetine/olanzapine (Symbyax) used?

A

Nightly

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28
Q

Contraindications with SSRIs

A

Do not use with MAOi, linezolid, IV methylene blue or pimozide
Fluoxetine, paroxetine: do not use with thioridazine
Fluvoxamine: do not use with alosteron, thioridazine, or tizanidine
Sertraline solution: do not use with disulfiram
Brisdelle: pregnancy

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29
Q

Warnings for SSRIs

A

QT prolongation: do not exceed citalopram 20mg/day in elderly (>60yo) or escitalopram 10mg/day in elderly
SIADH/hyponatremia, fall risk (Beers criteria)
Bleeding (additive risk)

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30
Q

Side effects of SSRIs

A

Sexual side effects
Somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, HA
Most activating: fluoxetine - take in AM
Most sedating: paroxetine, fluvoxamine - take in PM

Others: osteopenia/osteoporosis, restless leg syndrome

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31
Q

Which SSRI is most activating?

A

fluoxetine - take in AM

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32
Q

Which SSRI is most sedating?

A

paroxetine, fluvoxamine - take in PM

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33
Q

Which SSRIs are approved for premenstrual dysphoric disorder (PMDD)

A

Fluoxetine, paroxetine (Paxil CR) and sertraline

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34
Q

All SSRis are available in solution except ___

A

fluvoxamine

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35
Q

Which SSRI is preferred in pts with cardiac risk?

A

Sertraline

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36
Q

Allow a ___ washout between MAOi and SSRIs d/t risk of serotonin syndrome or hypertensive crisis
Exception is fluoxetine d/t long half-life (4-6 days). Requires ____ washout period if switching from fluoxetine

A

2 week wash out period
5 week wash out period

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37
Q

Do not initiate SSRI in pts receiving ____ d/t serotonin syndrome

A

linezolid or IV methylene blue

38
Q

Which SSRIs most commonly cause QT prolongation?

A

Citalopram and escitalopram
Additive risk with other SSRIs

39
Q

SSRIs and SNRIs can increase bleeding risk when used with ___

A

anticoag, antiplatelets, NSAIDs, ginkgo, garlic, ginger, ginseng, glucosamine, fish oils, thombolytics

40
Q

Which SSRIs are CYP2D6 inhibitors?

A

Fluoxetine, paroxetine, and fluvoxamine

41
Q

Concern with use of fluoxetine or paroxetine with tamoxifen

A

Tamoxifen requires conversion to active form by CYP2D6
Fluoxetine, paroxetine = CYP2D6 inhibitors
Decreased tamoxifen effectiveness if fluoxetine, paroxetine + tamoxifen
Venlafaxine (SNRI) is preferred in combination with tamoxifen

42
Q

Medication with SSRI and 5-HT1A partial agonist

A

Vilazodone (Viibryd)

43
Q

Medication with SSRI, 5-HT3 receptor antagonist, and 5-HT1A agonist

A

Vortioxetine (Trintellix)

44
Q

Compare Vilazodone (Viibryd) and vortioxetine (Trintellix) sexual side effects compared to SSRIs and SNRIs

A

Less sexual side effects

45
Q

If using SSRI combined mechanism meds like Vilazodone (Viibryd) and vortioxetine (Trintellix), do not use within ___ of MAOi

A

14 days

46
Q

SNRI MOA

A

similar mechanism as SSRIs
Increase serotonin by inhibiting reuptake in neuronal synapse
Also inhibit NE reuptake

47
Q

Examples of SNRIs

A

Venlafaxine (Effexor XR) - depression, GAD, panic disorder, social anxiety disorder
Duloxetine (Cymbalta) - depression, peripheral neuropathy (pain), fibromyalgia, GAD, chronic musculoskeletal pain
Desvenlafaxine (Pristiq) - depression
Levomilnacipran (Fetzima) - depression

48
Q

SNRIs and MAOi can potentially cause ___ is used together

A

hypertensive crisis or serotonin syndrome
Washout period needed (14 days recommended) if changing between SNRIs and MAOi
Do not initiate in pts receiving linezolid or IV methylene blue d/t serotonin symdrome risk

49
Q

Additive QT prolongation risk with which SNRI?

A

Venlafaxine

50
Q

Concern with duloxetine and tamoxifen

A

Duloxetine moderate CYP2D6 inhibitor
Tamoxifen requires conversion to active metabolite by CYP2D6&raquo_space; decreased tamoxifen effectiveness

51
Q

Warnings with SNRIs

A

SIADH/hyponatremia, fall risk (Beers)
Bleeding (additive risk)

52
Q

SNRIs have similar side effects to SSRI (d/t decrease 5-HT reuptake). What additional side effects may occur with SNRIs (d/t increased NE)?

A

Increased HR, dilated pupils (can lead to episode of narrow angle glaucoma), dry mouth, excessive sweating, constipation

53
Q

When using SNRI, there is a risk of increased ___ (greatest risk with venlafaxine when dose > 150mg/day but all have risk, esp at higher doses)

A

Increased BP

54
Q

TCA MOA

A

inhibit NE and 5-HT reuptake
Blocm ACh and histamine receptors

55
Q

What are the 2 main categories of TCAs? What are their differences?

A

Secondary amines = relatively selective for NE
Tertiary amines = slightly more effective but worse side effect profile

56
Q

Examples of TCA (secondary and tertiary amines)

A

Tertiary amines:
amitriptyline
doxepine - for depressiona, all are generic; Silenor = insomnia; Zonalon = cream for pruritus
Others: clomipramine (Anafranil), Imipramine (Tofranil), Trimipramine

Secondaty amines:
Nortryptyline (Pmaelor)
Others: amoxapine, desipramine (Norpramin), maprotiline, protrptyline

57
Q

When is Amitriptyline taken?

A

Nightly

58
Q

Contraindications for TCAs

A

Do not use with MAOi, linezolid, IV methylene blue
MI
Glaucoma and urinary retention (doxepine)

59
Q

Side effects of TCAs

A

QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias) - obtain baseline ECG if cardiac risk factors or age > 50 yo
Orthostasis, tachycardia
Anticholinergic - dry mouth, blurred vision, urinary retention, constipation (taper off to avoid cholinergic rebound)
Vivid dreams, weight gain
Fall risk (Beers)

Others: sedation, sweating, myoclonus (muscle twitching - symptom of drug tox)

60
Q

What type of TCAs have increased anticholinergic properties and are more likely to cause sedation and weight gain?

A

Tertiary amines (Amitriptyline, doxepine)

61
Q

Bupropion (Wellbutrin, SR, XL) MOA in depression

A

Dopamine and NE reuptake inhibitor

62
Q

Bupropion do not exceed ___ mg/day d/t seizure risk (up to 522mg/day with Aplenzin)

A

450mg/day

63
Q

What is bupropion SR (Zyban) indicated for?

A

Smoking cessation

64
Q

What is bupropion/naltrexone (Contrave) indicated for?

A

Weight loss

65
Q

Contraindications for bupropion

A

Seizure disorder
Hx of anorexia/bulimia, abruption discontinuation of ethanol or sedatives
Do not use with MAOi, linezolid, Iv methylene blue, or other forms of bupropion

66
Q

Side effects with bupropion for depresion

A

Dry mouth, CNS stimulation (insomnia, restlessness), tremors/seizures (dose-related), weight loss
Sexual dysfunction is rare (no effect on 5-HT)

Others: HA/migraine, N/V, constipation, and possible BP changes (more HTN than hypotension

67
Q

Bupropion has increased risk of ___ with MAOi. Washout period ____ when concerting to a MAOi

A

hypertensive crisis
14 day

68
Q

MAOi MOA

A

Inhibit MAO enzyme, which breaks down catecholamines, including 5-HT, NE, Epi, and DA (if these NTs increase dramatically, hypertensive criss and death can result

69
Q

MAOi exampels

A

Isocarboxazid (Marplan)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Selegine transdermal patch (Emsam) - MAO-B selective inhibitor

70
Q

MAOi warnings

A

Not commonly used, watch for DDIs and drug-food interactions - if missed, can be fatal
Hypertensive crisis or serotonin syndrome can occur when taken with TCAs, SSRIs, SNRIs, many other drugs and tyramine-rich foods

71
Q

If using MAOi, contraindicated drugs that increase serotonin syndrome risk include ____

A

linezolid, lithium, tramadol, opioids, St. John’s wort
SSRIs, SNRIs, mirtazapine, trazodone, triptans, buspirone, and dextromethorphan

72
Q

MAOi is contraindicated with tyramine-rich foods that increase NE. What are some examples?

A

Aged cheese, pickled herring, yeast extract, air-dried meats, sauerkraut, soy sauce

Basically anything aged, fermented, pickled, smoked

73
Q

Which antidepressant meds require 2 week washout period between MAOi

A

SSRIs, SNRIs, TCAs, bupropion

Exception: fluoxetine - 5 week wash out if switching from fluoxetine to MAOi

74
Q

Mirtazapine MOA and place in therapy

A

Tetracyclic antidepressant - central presynaptic alpha-2 adrenergic antagonist effects&raquo_space; increase release of NE and 5-HT

Used commonly in onc or skilled nursing facilities to help with sleep (dose QHD) and to increase appetite (can increase weight gain in frail elderly)

75
Q

Trazodone MOA and place in therapy

A

Inhibits 5-HT reuptake, blocks H1 and alpha-1 adrenergic receptors

Rarely used as antidepressant d/t sedation; used primarily off-label for sleep (dosed QHS)
Can cause priapism (painful erection longer than 4hrs = med emergency)

76
Q

Antidepressant Nefazodone (inhibits 5-HT and NE uptake, blocks 5-HT2 and alpha-1 adrenergic receptor) is rarely used d/t ___

A

hepatotoxicity

77
Q

Selecting best antidepressant: Cardiac/QT Risk

A

Sertraline preferred
Do not choose QT-prolonging drug/dose (e.g. high dose of citalopram or escitalopram)
Watch for additive QT effects when SSRIs, SNRIs, TCAs, mirtazapine, or trazodone are used with other QT-prolonging drugs

78
Q

Selecting best antidepressant: Smoker

A

Bupropion SR is FDA-approved for smoking cessation

79
Q

Selecting best antidepressant: Peripheral neuropathy or pain

A

Consider duloxetine

80
Q

Selecting best antidepressant: Taking serotonergic antidepressants

A

Avoid multiple serotonergic meds d/t risk of serotonin syndrome
Increases bleeding risk with anticoag, antiplatelets, NSAIDs, and some natural products (e.g. ginkgo, garlic, ginger, ginseng, glucosamine, fish oils)

81
Q

Selecting best antidepressant: Seizure disorder or risk for seizures (bulimia/anorexia, recent alcohol or sedative withdrawal)

A

Do not use bupropion

82
Q

Selecting best antidepressant: pregnant

A

Do not use paroxetine
Mild-moderate depression: psychotherapy first line
Severe depression: SSRIs are first-line (e.g. citalopram, escitalopram, fluoxetine, sertraline

83
Q

Selecting best antidepressant: daytime sedation

A

do not take sedating drug early in the day (e.g. paroxetine, mirtazapine, trazodone)
Activating meds taken in the morning are preferred (e.g. fluoxetine, bupropion)

84
Q

Selecting best antidepressant: Insomnia

A

Do not take activating drug later in the day (e.g. bupropion, fluoxetine)
Sedating meds taken at night are preferred (e.g. paroxetine, mirtazapine, trazodone)

85
Q

Selecting best antidepressant: sexual dysfunction

A

high risk with SSRIs and SNRIs
low er risk with bupropion and mirtazapine

86
Q

American Psychiatric Association (APA) guidelines state pts should receive ___ trial of med at a therapeutic dose concluding that a drug is not working

A

4-8 week

87
Q

If pt is not improving or has incomplete response to antidepressants, what can you do?

A

Change to new antidepressant
Increase dose
Use combo with different MOA
Augment with buspirone or a low dose of an atypical antipsychotic (aripiprazole (Abilify), quetiapine ER (Seroquel XR) // other options: olanzapine + fluoxetine (ymbyax), , brexpiprazole (Rexulti), and cariprazine (Vraylar), esketamine (Spravato))

Augementation with lithium, thyroid hormone (i.e. T3), or inc some cases electroconvulsive therapy (ECT)

88
Q

Boxed warning for antipsychotics (aripiprazole (Abilify), Quetiapine (Seroquel))

A

Elderly pts with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death

89
Q

Contraindications for antipsychotics (aripiprazole (Abilify), Quetiapine (Seroquel))

A

Olanzapine/fluoxetine (Symbyax): do not use with MOAi, linezolid, IV methylene blue, pimozide, thioridazine and caution with other drugs/conditions that cause QT prolongation

90
Q

Side effects of aripiprazole

A

Anxiety, insomnia, akathisia, constipation, agitation

91
Q

Side effect of olanzapine

A

Sedation, weight gain, increased lipids, increased glucose, EPs, QT prolongation (lower risk)

92
Q

Side effects of quetiapine

A

sedation, orthostasis, weight gain, increased lipids, increased glucose, EPS (lower risk)

93
Q

Esketamine (Spravato) formulation and administering notes

A

nasal spray, must be administered under supervision of health care provider
REMS program only

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