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Pharmacology > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

Principles of Psychopharmacotherapy

A
  • Diagnosis/assessment is fundamental
  • Pharmacotherapy alone is not sufficient
  • Phase of illness is important (Normal mood to depression to recovery/remission)
  • Risk benefit ratio must be considered
  • Prior personal or family hx of effective agent can dictate first choice
  • Target specific sx to serve as markers and monitor over course of treatment
  • observe for development of adverse effects during course of treatment
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2
Q

5HT (Seratonin) vs NE (Norepinephrine) Deficiency

A

5HT: depressed mood, anxiety, panic, phobia, obsessions/compulsions, food craving/bulimia

NE: impaired attention, problems concentrating, deficiencies in working memory, depressed mood, psychomotor retardation, fatigue

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3
Q

DSM-IV Criteria for Major Depression: Symptoms

A 
Greater than or equal to five of the following must be present for two weeks most of the day nearly every day:
*Depressed mood
*Loss of interest or pleasure
appetite or weight change
sleep disturbance
psychomotor agitation/retardation
fatigue/loss of energy
feelings of worthlessness/guilt
decreased concentration/indecisiveness
suicidal ideation

*at least one of the five must be one of these two

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4
Q

DSM-IV Criteria for Major Depression

A
  1. Must have symptoms present (see other slide)
  2. Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning
  3. Symptoms not due to a medical condition or drug use
  4. Symptoms are not due to bereavement
  5. Symptoms not due to another mental illness
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5
Q

Types of Depression

A 
Major depression
Dysthimia (general mood level is lower, not full-on depression)
Organic causes (trauma/brain problems)
Substance induced
Medication induced
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6
Q

Risk factors for Major Depression

A 
family history
female
previous depressive episode
chronic medical illness
substance abuse
stressful life effects
post partum period
lack of social support
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7
Q

Pathophysiology of depression

A
  • Chemical imbalance
  • Decreased levels of neurotransmitters: 5HT (seratonin), NE (norepinephrine), DA (dopamine)
  • dysregulation of receptors
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8
Q

Target symptoms: DSIGECAPS

A 
Depressed mood
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor retardation
Suicide
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9
Q

Lab assessment for depression

A

CBC (anemic? infection?)
Thyroid (hypothyroid can cause depression)
Urine drug screen (use and withdrawal can cause s/sx)

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10
Q

Medication treatment options for depression

A
  • noradrenergic and specific seratonin antidepressants
  • cyclic antidepressants
  • monoamine oxidase inhibitors
  • selective seratonin reuptake inhibitors
  • selective seratonin norepinephrine reuptake inhibitors
  • benzodiazepines
  • S2 agonists
  • other: lithium, thyroid, stimulants, combo
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11
Q

TCAs

A
  • amitriptyline (Elavil), imipramine (Tofranil), clomipramine (Anafranil), nortriptyline (Pamelor), desipramine (Norpramin)
  • MOA: 5HT and NE reuptake inhibitor (amount of 5HT and NE depends on the compound
  • SE: CV (fatal in OD), anticholinergic, sedation, weight gain, sexual dysfunction
  • Misc: not often used for depression due to SE; new agents are better tolerated
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12
Q

MAOIs

A
  • phenelzine (Nardil), Tranylcypromine (Parnate)
  • MOA: irreversible inhibition of MAO A&B, resulting in increased levels of 5HT, NE, and DA
  • Risks: hypertensive crisis, food-drug interaxns (tyramine), DDI (stimulants, CNS antihypertensives, antidepressants - must start antidepressant 14 days after stopping MAOI, or 5 half life wash out of previous antidepressant before starting MAOI)
  • Tyramine containing foods: Absolute contraind- aged cheese, aged or cured meats, banana peel, saurkraut, soy sauce, tap beer, marmite; Moderate contraind- red or white wine, bottled or canned beer; Unnecessary- avocado, banana, chocolate, fresh and mild cheeses, fresh meat, MSG, peanuts, raspberries, soy milk
  • Misc: usually not first-line treatment
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13
Q

MAOI: Selegeline Patch (Emsam)

A

once daily MAOI patch
6, 9, 12mg patches
dietary restrictions only apply to 9mg or higher dosage
need to apply wash out rule

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14
Q

SSRIs

A
  • citalopram (celexa), escitalopram (lexapro), fluoxetine (prozac), fluvoxamine (luvox), paroxetine (paxil), sertraline (zoloft)
  • SE: initial- nausea, diarrhea, sedation, insomnia, anxiety, HA (only for first few weeks); chronic- HA, sexual dysfunction, sweating, decreased deep sleep
    SSRI Toxicity: Seratonin syndrome
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15
Q

Sexual dysfunction

A
  • antidepressant sexual SE: 10-75%
  • reduction in desire mediated by dopamine
  • delayed ejac or absent/delayed orgasm mediated by 5HT 2A and 2C receptor subtypes
  • no sexual SE: buproprion, mirtazapine
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16
Q

Seratonin Syndrome

A 
hyperthermia
excitement
rigidity
hypotension
diaphoresis
tachycardia

tx: monitor and treat with supportive care
* careful for additive effects of meds that increase seratonin levels

17
Q

SSRI: Fluoxetine (Prozac)

A

Ind: major depressive disorder, OCD, PMDD, bulimia, panic, bipolar depression (in combo with olanzapine)
Misc: long half-life (active metabolite)- no need to taper, caution in elderly, good for noncompliance, no withdrawal; 5HT2C antagonist properties could increase NE/DA; causes activation- may be helpful in sedated/fatigued patients; multiple drug interactions

18
Q

SSRI: Paroxetine (Paxil)

A

Ind: MDD, OCD, panic, social anxiety, PTSD, PMDD
Misc: short half life (=flu-like withdrawal, even with missing one dose), least activation (=better for insomnia), anticholinergic effects (dry mouth, sedation, constipation), most likely SSRI to cause weight gain; Paxil CR better than Paxil when first starting- don’t get as much nausea in first two weeks, otherwise no difference

19
Q

SSRI: Sertraline (Zoloft)

A

Ind: MDD, PTSD, PMDD, panic, OCD, social anxiety disorder
Misc: activation, helpful in atypical depression, more likely to cause diarrhea/sweating, has withdrawal symptoms (must taper)

20
Q

SSRI: Citalopram (Celexa)

A

Ind: MDD
Misc: mild antihistamine- sedation 50/50 (may take at bedtime), potential advantage in elderly, minimal DDI, R enantiomer is inactive

21
Q

SSRI: Escitalopram (Lexapro)

A

Ind: MDD, GAD
Misc: mild antihistamine, sedation 50/50 (may take at bedtime); potential advantage in elderly; minimal DDI; 100x more potent than citalopram; some insurances do not cover bc there is no clear advantage over citalopram

22
Q

SNRI: Venlafaxine (Effexor)

A

Ind: MDD, GAD, social anxiety dx
SE: nausea, diarrhea, HA, sexual dysfunction, nervousness, insomnia, increased BP (isolated systolic)
Misc: XR formulation may decrease SE; slow titration needed bc of SE, dual action occurs at high doses (>150mg), *withdrawal (difficult to get patients on and off this medication)

23
Q

SNRI: Duloxetine (Cymbalta)

A

Ind: MDD, naturopathic pain
SE: most common are nausea, insomnia, HA; weight gain and urinary retention also reported
Misc: multiple DDI, has dual action on 5HT and NE at all doses; this is the newest available antidepressant

24
Q

NDRI: Buproprion (Wellbutrin, Zyban)

A

Ind: MDD, smoking cessation
Misc: activating- do not dose past dinner time; restlessness, insomnia, HA common; no sexual dysfunction- may help increase sex drive (may add in for combo tx)
ContraInd: seizure dx, eating dx

25
Q

Alpha 2 Antagonist: Mirtazapine (Remeron)

A

MOA: stimulates manufacturing of neurotransmitters
Ind: MDD
SE: weight gain, sedation (dose at bedtime), dry mouth, constipation, NO sexual dysfunction
Misc: effective augmenting agent due to unique mechanism

26
Q

S2 Antagonists: Nefazodone

A

MOA: SRI and S2 antagonist, NRI at higher doses
DDI: Potent CYP 34A inhibitor
*Brand name pulled by manufacturer; black box warning
SE: nausea, dizziness, sedation, LIVER FAILURE, no sexual dysfunction

27
Q

Heterocyclic Antidepressant: Trazodone

A

MOA: increase 5HT
Misc: potent H1 blocker- primarily used for insomnia rather than depression

28
Q

St. John’s Wort

A 
herbal OTC
Active ingredient: hypericum
MOA: thought to be similar to SSRI
*can reduce effectiveness of BCPs
*watch DDIs
*shown to be effective for mild to moderate depression
29
Q

Current Treatment Guidelines for Depression

A
  1. monotherapy
  2. switch (after therapeutic trial of 6-8 weeks at therapeutic dose)
  3. augmentation
  4. antidepressant combos (different classes)
  5. ECT
  • 3 and 4 may be interchanged
  • must take meds until at least a year after feeling better (then can consider it remission/recovery)
30
Q

When to give Psych referral

A
  • psychotic symptoms
  • worsening symptoms despite treatment
  • failure after 2 trials of different medications
  • augmentation of monotherapy or high dose
  • toxicity
  • co-morbid psychiatric condition
  • pregnancy

Pharmacology (11 decks)

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