Antidepressants

Question 1

Which emerging drug has been found to result in rapid relief of SI?

Answer 1

Ketamine

Question 2

What do we think major depressive disorders result from?

Answer 2

Deficiency of NE or 5-HT

Changes in trophic factors & hormones play a role

Question 3

When NTs bind to a specific receptor, what occurs?

Answer 3

Coupling –> cascade of events

Question 4

NTs are ______ back into nerve cells by reuptake pumps (transporter molecules)

Answer 4

reabsorbed

Question 5

What is the primary MOA of antidepressants?

Answer 5

Inhibit transporter molecules & allow more NT to remain in the synapse

Question 6

Depression is a/w changes in ______ or _______

Answer 6

serotonin

norepinephrine

Question 7

Most antidepressants cause changes in ______

Answer 7

amine signaling

Question 8

What is a/w more severe forms of major depression?

Answer 8

Abnormal HPA axis

Elevated cortisol

Question 9

What are other neuroendocrine factors seen in depression?

Answer 9

Thyroid dysregulation

Estrogen deficiency

Testosterone deficiency

Question 10

Describe the acute phase in the tx of MDD

What is the goal?

Answer 10

Lasts 6-12 wks

Goal = remission

Question 11

Describe the continuation phase in the tx of MDD

What is the goal?

Answer 11

Lasts 4-9 months after remission is achieved

Goal = eliminate residual sx or prevent relapse

Question 12

Describe the maintenance phase in the tx of MDD

What is the goal?

Answer 12

12-36 months

Goal = prevent recurrence

Question 13

Which types of medications are a/w drug-induced depressive sx?

Answer 13

Acne tx
Anticonvulsants
Antimigraines 
CV meds
Hormone therapy 
Immunologic agents 
Smoking cessation

Question 14

What are the different classes of antidepressants?

Answer 14

TCAs 
MAO inhibitors
SSRIs, SNRIs 
5-HT2
Heterocyclic

Question 15

What are 4 characteristics of antidepressants?

Answer 15

Rapid oral absorption

Tightly bound to plasma proteins

Undergoes hepatic metabolism

Renally cleared

Question 16

Which group of antidepressants can also be used for chronic pain & enuresis?

Answer 16

TCAs

Question 17

What are examples of TCAs?

Answer 17

Amitriptylline (prototype) 
Imipramine 
Desipramine 
Doxepine 
Nortriptyline

Question 18

Which drug class is also used to treat Selegiline-Parkinson’s disease?

Answer 18

MAOIs

Question 19

What are examples of MAOIs? (3)

Answer 19

Phenelzine
Tranylcypromine
Selegiline

Question 20

What are ADEs/drug interactions of MAOIs?

Answer 20

Combined w/ tyramine & sympathomimetics –> HTN

Combined w/ SSRIs –> serotonin syndrome

Toxicity: hypotension, insomnia

Question 21

What are sx of serotonin syndrome?

Answer 21

Range from mild to lethal & include cognitive, autonomic & somatic effects

Question 22

What foods should be avoided w/ MAOIs?

Answer 22

Cheese 
Beer 
Soy 
Sausage 
*All contain high tyramine

Question 23

What drug class does warfarin interact w/?

Answer 23

SSRIs

Question 24

What is an ADE of SSRIs?

Answer 24

Sexual dysfunction

Question 25

Which SSRI is not used in pregnancy? Why?

Answer 25

Paroxetine Has NE & anticholinergic activity

Question 26

Which SSRI can cause QT prolongation?

Answer 26

Citalopram Therefore doses > 40mg/day are not recommended

Question 27

When can you increase escitalopram (SSRI) to max daily dose?

Answer 27

After 1 week if needed

Question 28

What is important to know in regards to fluoxetine (SSRI) dosing?

Answer 28

Doses > 20mg/day may be given in a single daily dose or divided BID

Question 29

How much do you titrate paroxetine (SSRI) weekly?

Answer 29

10 mg/day OR 12. 5 mg/day * Depends on max daily dose

Question 30

How much do you titrate sertraline (SSRI) weekly?

Answer 30

25 mg/day

Question 31

What is an ADE common to all antidepressants?

Answer 31

Suicidality *Monitor behavior changes & mental status

Question 32

What is an ADE of venlafaxine (SNRI)?

Answer 32

HTN *Dose reductions may be required if sustained HTN occurs

Question 33

Is there a benefit of exceeding 50 mg/day of desvenlafaxine (SNRI)?

Answer 33

No - ADE's are increased & no additional benefit has been shown

Question 34

Are doses exceeding 60 mg/day of duloxetine (SNRI) more efficacious?

Answer 34

No - not shown to provide increased efficacy

Question 35

Besides major depression, what else are 5-HT2 antagonists & 5-HT reuptake inhibitors used for?

Answer 35

Depressed pts w/ anxiety Depression w/ cognitive difficulties

Question 36

How should daily doses of nefazodone (Mixed 5-HT) be taken?

Answer 36

Divided BID

Question 37

How should daily doses of trazodone (Mixed 5-HT) be taken?

Answer 37

Divided TID

Question 38

What is the highest dose of vilazodone (Mixed 5-HT) that has been assessed?

Answer 38

40 mg/day

Question 39

What are 2 examples of other heterocyclics?

Answer 39

Bupropion (NE & dopamine reuptake inhibitor - NDRI) Mirtazepine (serotonin & alpha2-receptor antagonist)

Question 40

What is the MOA of other heterocyclics?

Answer 40

Mirtazepine blocks presynaptic alpha2 Buproprion - NET> SERT

Question 41

Besides major depression, what else are other hertocyclics used for?

Answer 41

Smoking cessation (bupropion) Sedation (mirtazepine)

Question 42

What are ADEs of bupropion?

Answer 42

Lowers seizure threshold *Seizures are dose-related, & may be increased by predisposing factors (hx of seizures, alcohol withdrawal, head trauma, CNS tumor)

Question 43

What are ADEs of mirtazepine?

Answer 43

Sedation & wt gain

Question 44

How often can you increase the dose of mirtazapine?

Answer 44

No more than every 1-2 wks

Question 45

What is the MOA of folate?

Answer 45

Synthesis of NTs, s/a 5-HT

Question 46

In regards to folate, the task force states that...

Answer 46

augmentation w/ folate is reasonable, but more work is needed to clarify which subgroup of pts may achieve the greatest response

Question 47

What is the MOA of TCAs?

Answer 47

Block reuptake transporters of NE & serotonin

Question 48

What ADEs are common to all SNRIs?

Answer 48

``` CV changes Insomnia Nausea Serotonin syndrome Sexual dysfunction ```

Question 49

What ADE is unique to desvenlafaxine (SNRI)?

Answer 49

Dose-related HLD

Question 50

What ADE is unique to duloxetine (SNRI)?

Answer 50

Orthostatic hypotension