Antidepressants

Question 1

Drugs with anticholinergic side effects (e.g. constipation, delirium, dry mouth, urinary hesitancy, visual changes)

Answer 1

TCAs

Question 2

Drugs with sexual side effects

Answer 2

TCAs, SSRIs, SNRIs, trazodone, MAOIs

Question 3

Which antidepressant medication does not have an effect on sexual function?

Answer 3

Bupropion

Question 4

Name the SSRIs

Answer 4

fluoxetine (Prozac)

sertraline (Zoloft)

Question 5

Name the SNRIs

Answer 5

duloxetine (Cimbalta)

Question 6

Name the other antidepressant drugs (ADDs)

Answer 6

bupropion
mirtazapine
trazodone

Question 7

Name the TCAs

Answer 7

amitriptyline

despramine

Question 8

Name the MAOIs

Answer 8

tranylcypromine

Question 9

Describe the mechanism of action of SSRIs

Answer 9

They selectively block serotonin receptors (SERTs) thus inhibiting reuptake, which increases serotonin at the synapse. With long-term use, the neuronal pathways adapt and exhibit enhanced serotonergic transmission

Question 10

Describe the mechanism of action of SNRIs

Answer 10

They block serotonin receptors (SERTs) preventing the reuptake of serotonin, thus increasing serotonin in the synapse. They also block norepinephrine reuptake receptors (NETs)

Question 11

Describe the mechanism of action of bupropion

Answer 11

It inhibits dopamine and norepinephrine reuptake receptors (DAT, NET), enhancing levels of both neurotransmitters in the synapse and possibly even increases their release

Question 12

Describe the mechanism of action of mirtazapine

Answer 12

It is an autoreceptor antagonist at a2, enhancing norepinphrine release and thus indirectly enhancing neurotransmission

Question 13

Describe the mechanism of action of trazadone

Answer 13

It is a serotonin receptor antagonist

Question 14

Describe the mechanism of action of tricyclic antidepressants (TCAs)

Answer 14

They block neuronal reuptake pumps for serotonin and norepinephrine (SERT and NET), increasing concentrations and duration of these amines in the synapse

Question 15

Which of the TCAs has fewer side effects and why: amitriptyline vs despramine

Answer 15

Despramine has fewer side effects because it is a secondary amine. Amitriptyline is a tertiary amine which preferentially blocks SERTs and is metabolized to secondary amines, which preferentially block NET

Question 16

Describe the mechanism of action of MAOIs

Answer 16

Monoamine oxidase is an enzyme that degrades serotonin. MAOIs irreversibly inhibit monoamine oxidase, increasing norepinephrine and serotonin in the nerve terminals

Question 17

Explain the role of tyramine in MAOIs

Answer 17

Tyramine is found in foods like wine, cheese, dried meats, etc that interacts with MAOIs and causes hypertensive crisis. It is the reason for strict dietary limitations for patients taking MAOIs

Question 18

What is the source of most side effects associated with TCAs?

Answer 18

The fact that they block many neurotransmitter receptors (muscarinic, cholinergic, a1 adrenergic, H1 histamine)

Question 19

What antidepressant class is safest for pregnant women?

Answer 19

TCAs

Question 20

Name the first-line medications for major depression

Answer 20

SSRIs, SNRIs, bupropion

Question 21

Drugs that have cardiovascular side effects

Answer 21

TCAs- arrhythmias
SNRIs, bupropion- htn
MAOIs- hypertensive crisis

Question 22

Common sx of serotonin syndrome

Answer 22

• neuromuscular sx (hyperreflexia, clonus, tremor)
• autonomic (tachycardia, mydriasis, diaphoresis, diarrhea)
• AMS (agitation, delirium)

Question 23

What distinguishes serotonin syndrome from anticholinergic poisoning?

Answer 23

Hyperactive bowel sounds, normal skin color, diaphoresis, and neuromuscular abnormalities

Question 24

Describe an overview of management for serotonin syndrome

Answer 24

Control agitation w/ benzodiazepines (regardless of severity), autonomic instability, & hyperthermia, and administer 5-HT(2A) antagonists

Question 25

What is the essential feature of a major depressive episode?

Answer 25

A period of at least 2 weeks in which there is either depressed mood or loss of interest/pleasure in nearly all activities

Question 26

What is the only antidepressant approved by the FDA for major depressive disorder in children?

Answer 26

Fluoxetine

Question 27

When is serotonin syndrome most severe?

Answer 27

When SSRIs are used in combination with MAOIs (or SNRIs, just don’t use MAOIs w/ other things…)

Question 28

With which SSRI do you need to wait longer following discontinuation before starting an MAOI?

Answer 28

Fluoxetine. You should wait 5-6 weeks, as opposed to 2 with other SSRIs

Question 29

Which SSRI is least likely to cause discontinuation syndrome?

Answer 29

Fluoxetine

Question 30

Before starting a TCA, who should have an ECG?

Answer 30

Patients with significant cardiac risk factors and those over age 50

Question 31

In suicidal patients, what antidepressants are safest?

Answer 31

SSRIs, bupropion, and mirtazapine are safest because they are less toxic in overdose. TCAs are dangerous as a 10 day supply of 200mg/day ingested at once is often lethal

Question 32

What has the highest rate of response and remission in the treatment of depression?

Answer 32

Electroconvulsive therapy

Question 33

When should ECT be considered?

Answer 33

In patients with severe major depressive disorder not responsive to psychotherapeutic and/or pharmacological intervention

Question 34

When is ECT considered first-line therapy?

Answer 34

For patients with severe major depressive disorder with psychotic features, catatonia, suicide risk, or food refusal

Question 35

Describe the general consensus regarding St. John’s wort

Answer 35

In smaller studies it has been shown to be superior to placebo, however this hasn’t been corroborated with larger studies. It would not meet FDA approval and can cause drug interactions because it induces metabolism via CYP3A4. Contraindicated with MAOIs.

Question 36

What adjunctive therapies are safe to recommend for major depressive disorder?

Answer 36

Folate, omega-3 fatty acids, and light therapy

acupuncture, S-adenosyl methionine, and St. John’s wort lack evidence for recommendation

Question 37

What is considered remission?

Answer 37

3 weeks of the absence of both sad mood and reduce interest, no more than 3 remaining features of major depressive disorder

Question 38

How long does it typically take for antidepressant medications to take effect?

Answer 38

4-6 weeks

Question 39

Following successful acute phase therapy, what is the recommended duration for treatment in the continuation phase?

Answer 39

4-9 months

Question 40

What is maintenance therapy strongly suggested?

Answer 40

For patients with additional risk for recurrence (residual sx, continuing psychosocial stressors, etc)