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Psychopharm > Antidepressants > Flashcards

Antidepressants Flashcards

1
Q

Pharmacological Treatment of Depression: General

A

50% of all patients are tx-resistant to AD’s

All classes of AD’s work on the same/ similar neural pathways, but wide range of symptoms (syndrome) suggests large variance in individual neurochemistry

Limited neural area of effect of AD’s may explain the high rates of failure

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2
Q

Disorders treated with Antidepressants

A

Anxiety disorders

Depressive disorders

Personality Disorders

Schizoaffective Disorder

Eating Disorders

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3
Q

Antidepressant Selection

A

Most AD efficacy is similar

Selection is based on:

  • past response hx
  • side effect profile
  • coexisting medical conditions
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4
Q

Depression, General

A

Requires 2 weeks of symptoms (considered a syndrome)

No objective test for depression

Limited understanding of pathophysiology –several brain systems involved

Wide range of symptomatology:

  • depressed irritable mood
  • anhedonia
  • weight changes,*
  • sleep changes
  • psychomotor agitation
  • fatigue
  • worthlessness
  • guilt*
  • diminished concentration
  • suicidal ideation / bx
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5
Q

Biological theories of depression

A

Permissive hypothesis
● Depleted 5-HT increases NE

Catecholamine thoery: decreased NE

Indolamine theory: decreased 5-HT

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6
Q

Tricyclics (TCA)

A

5-HT and NE reuptake inhibition

Very effective but can have serious side effects

Lethal in overdose
*even 1-week supply can be lethal

Also indicated for neuropathic pain and migraines

E.g.
Imipramine (Tofranil, developed 1951)
Clomiprimine (Anafranil, effective for OCD)

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7
Q

Selective Serotonin Reuptake Inhibitors (SSRIs)

A

Block presynaptic serotonin reuptake

Similar therapeutic benefits as MAOIs and TCAs, but fewer side effects

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8
Q

SSRI: Paroxetine (Paxil): Pro’s

A

Short half-life, with no active metabolite
*no long-term build-up

Sedation helps with sleep disturbances

Well absorbed in GI tract, good for patients with absorption problems

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9
Q

Monoamine Oxidase Inhibitors (MAOIs)

A

Inhibit MAO-A enzyme from being created
*Preventing breakdown of NE, DA, 5-HT

*Very effective for depression

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10
Q

MAOI Side Effects

A

Weight gain

Dry mouth

Sedation

Sexual dysfunction

Sleep disturbances

Orthostatic hypotension

Serotonin syndrome

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11
Q

MAOI food restrictions

A

Tyramine leads to hypertensive crisis by increasing the release of norepinephrine (NE)

MAO-A is inhibited and NE levels get too high, leading to dangerous increases in blood pressure (hypertension)

Foods to avoid:
Aged meats and cheeses
soy sauce
draft beer
wine 
avocados
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12
Q

MAOI Indications

A

Currently used with treatment-resistant patients
[* = non-responsive to at least 3 separate treatments]

e.g. Nardil, Parnate

More effective at treating atypical depression

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13
Q

SSRI: Sertraline (Zoloft) Pro’s

A

Less sedating

Lower risk of P450 interactions

Short half life with lower build-up of metabolites

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14
Q

SSRI: Fluoxetine (Prozac) Pros:

A

Long half-life
*decreased risk of overdose and withdrawal

Initially activating, may provide increased energy

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15
Q

SSRI: Citalopram (Celexa) Pro’s:

A

Fewest drug interactions of all SSRIs

Intermediate half-life lowers risk of discontinuation syndrome

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16
Q

SNRI’s: Serotonin-Norepinephrine Reuptake Inhibitors

e.g. Effexor, Cymbalta

A

SNRI’s commonly used to treat:

  • major depression
  • anxiety
  • neuropathic pain

Function similarly to TCAs but without antihistamine, antiadrenergic, and anticholinergic side effects

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17
Q

SNRI: Venlafaxine (Effexor) Pro’s

A

Effexor:

Short half life and fast renal clearance avoids build-up *good for geriatric populations

High therapeutic success rate
*effective for treatment-resistant depression

Quick onset of antidepressant and anxiolytic activity

Minimum interactions

18
Q

SNRI: Duloxetine (Cymbalta) Pro’s:

A

Cymbalta:

Effective in elderly patients with recurrent MDD

AD effects may be noticed after one week

**Less BP increase than Effexor

Reduces painful physical symptoms of depression

Low risk of weight gain

Lower rate of sexual side effects vs SSRIs

Low risk hypomania, mania, or hypomanic-like symptoms

19
Q

Novel/Atypical Antidepressants: Remeron: Indications

A

Remeron:

MDD, but not a first-line drug

*Good choice for people with depression, anxiety, and insomnia (off label tx of insomnia)

20
Q

Novel/Atypical Antidepressants: Bupropion (Wellbutrin/Zyban): General

A

Wellbutrin (NDRI):

Popular as augmenting agent for first-line SSRI

Also used as a second or third-line ADHD tx

21
Q

Selective Serotonin Reuptake Enhancers (SSREs)

e.g. Coaxil

A

Opposite mechanism of SSRI

SSRE reduces 5-HT levels

5-HT and DA inversely related

MDD tx: decrease 5-HT to increase DA

22
Q

Norepinephrine Reuptake Inhibitors (NRI or NERI)

A

Lower abuse potential than stimulants

Strattera: ADHD

Edronax: MDD

23
Q

SSRI’s: Common Side effects

A

GI complaints

Anxiety, Restlessness, Insomnia

Sedation, Fatigue, Dizziness

Sexual dysfunction (30% chance)

Less Common:
Low risk of cardiotoxicity in overdose

24
Q

SSRI’s: Discontinuation Syndrome

A

Agitation

Nausea

Disequilibrium

Dysphoria

25
Q

Serotonin syndrome

A

Group of mild to severe symptoms that may occur following use of certain serotonergic medications or drugs:

High body temperature

Agitation

Increased reflexes

Tremor

Sweating

Dilated pupils

Diarrhea

26
Q

TCA’s: Side Effects

A

Lethal in overdose

Anticholinergic effects

Q-T interval prolongation
*Slows down blood flow through the heart

27
Q

Common Anticholinergic Side Effects

A

Blurred vision

Constipation

Decreased sweating

Dizziness

Dry mouth

Difficulty urinating and/or kidney failure

28
Q

Future of Antidepressants

A

Since 1950s, all antidepressants/anti-anxiety medications attempt to alter DA, 5-HT, NE

Anxiety and Depression are both linked with increased activation in the HPA axis
*excessive release of the corticotrophin-releasing hormone or factor (CRF)

Current push to discover medications that act as CRF-antagonists

29
Q

Antidepressants: Delayed Onset

A

Often a 3-6 week delay before sx improvement after tx dose is achieved

*Likely due to 2nd messenger process

30
Q

SSRI: Paroxetine (Paxil): Cons

A

Contraindicated in Pregnancy

Weight gain

Increased risk of drug interaction

More prone to discontinuation symptoms

31
Q

Atypical Depression

A

Increased sensitivity to loss

Dysthymia

Limbs feeling heavy

Melancholic depression (weight / sleep disturbances)

*Treated with MAOI’s (e.g. Nardil, Parnate)

32
Q

SSRI: Sertraline (Zoloft): Cons:

A

Zoloft Cons:

Requires full stomach

Strong GI disruptions

33
Q

SSRI: Fluoxetine (Prozac) Cons:

A

Prozac Cons:

Long half-life may cause buildup

Significant drug-drug interactions

May increase anxiety and insomnia

More likely to induce mania

34
Q

SSRI: Citalopram (Celexa) Cons:

A

Celexa Cons:

GI issues

May cause initial anxiety

May be overly sedating

Affects cardiovascular health

35
Q

SNRI: Venlafaxine (Effexor) Cons:

A

Effexor Cons:

  • Hypertension
  • High rate of tx-emergent mania and hypomania

Nausea and Increased GI effects

Short half-life: Withdrawal sx possible after missing a single dose

More toxic than SSRIs in overdose

36
Q

SNRI: Duloxetine (Cymbalta) Cons:

A

Cymbalta Cons:

Nausea, sedation, Insomnia

May cause severe withdrawal symptoms

Patients with preexisting liver disease or excessive alcohol use are at a greater risk of liver injury

Unstable absorption rate a fraction of a dose is taken

37
Q

Novel/Atypical Antidepressants:

Mirtazapine (Remeron) Pros:

A

Remeron Pro’s:

Good for severe depression and insomnia

*Indicated for depressed geriatric population who show failure to thrive and marked weight loss

Selective effects on serotonin receptors
*good augmentation strategy for SSRI’s

38
Q

Novel/Atypical Antidepressants:

Mirtazapine (Remeron) Cons:

A

Remeron Cons:

Significant weight gain and sedation

Increases cholesterol

Beneficial effects decrease as dosage increases

May cause agranulocytosis

39
Q

Novel/Atypical Antidepressants:

Bupropion (Wellbutrin/Zyban) Pro’s:

A

Wellbutrin (NDRI) Pro’s:

Less weight gain

Less sexual dysfunction

Less sedation or cardiac risks

Little risk of inducing mania

40
Q

Novel/Atypical Antidepressants: Bupropion (Wellbutrin/Zyban) Cons:

A

Wellbutrin Cons:

Cost: $75-$100 per day

Increased risk of seizure
*can’t be used with TBI, bulimia, or anorexia

Interactions with TCAs

Can increase anxiety, agitation, and insomnia

Abuse potential, can induce psychosis in high dosages

41
Q

Non-response to AD, considerations

A

If no improvement after at least 2months at adequate dose:

  • switch to another antidepressant
  • or augment with another agent

Psychopharm (13 decks)

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