Antidepressants Flashcards
The RAS (Reticular Activating System) produces which neurotransmitters?
NE
Serotonin
Dopamine
Acetylcholine
What is the stupid pneumonic for depression symptoms?
SIG-E-CAPS
Sleep disturbance Interest (lack of) Guilt Energy (lack of) Concentration difficulties Appetite (too much or too little) Psychomotor agitation or retardation Suicidal ideation
What should be in your DDx for depression?
Psychiatric disorders (MDD, dysthymia, adjustment disorder, bipolar disorder, cyclothymia, PMDD, substance use/induced)
Neurological conditions (Stroke, TIA, Parkinson’s, dementia, MS)
Thyroid disorders
Metabolic conditions (Hyponatremia, CKD, hypoglycemia)
Malignancy
Infectious diseases
Med effects (Transplant anti-rejection drugs, chemo, interferon, steroids, BBs, supplements)
What screening tools can you use for depression?
PHQ-9
MDQ (bipolar screen)
Beck Depression Inventory for PC (BDI-PC)
Hamilton Rating Scale for Depression (HRSD)
Why is it so important to rule out bipolar disorders in cases of depression?
B/c giving them an SSRI can induce mania
DSM-5 for Major Depressive Disorder
≥5 Sx for a two week period and representative of change from previous functioning, with at least one being either depressed mood or lost of interest/pleasure
- Depressed mood
- Loss of interest or pleasure in activities
- Weight loss or gain or increased/decreased appetitive)
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive/inappropriate guilt
- Decreased concentration or indecisiveness
- Thoughts of death or suicidal ideation or attempt
Impairing, not due to GMC or substance abuse, NO HX OF MANIA
What are the treatment goals for depressive disorders?
Response - >50% improvement of Sx
Remission - within ‘normal’ range of tests (ie PHQ <5)
What are the treatment options for depression?
Selective serotonin inhibitors (SSRIs)
Serotonin and NE reuptake inhibitors (SNRIs)
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)
What drug class is first line for depression due to low side effect profile and decreased OD risk?
SSRIs
What can help you decide what antidepressant to prescribe to your depressed patient?
Prior use (personal or family hx)
Provider preference/familiarity
Side effects
Co-morbid medical conditions
COST
Formulary preference
What is the biggest warning when starting a patient on a new antidepressant?
Can precipitate mania if underlying bipolar disorder - always rule out!
Increased risk of suicidal thinking/behavior in children/adolescents with MDD and other psychiatric disorders
Which SSRI has the longest half-life?
Fluoxetine (Prozac)
Why should you take Fluoxetine (Prozac) in the morning?
Could increase energy
SE - insomnia, HA, nervousness, decreased libido, somnolence, N/D, anorexia, dry mouth
What conditions is Fluoxetine (Prozac) approved for?
Depression
OCD
Bulimia***
Panic Disorder
PMDD
How is Sertraline (Zoloft) used?
Depression
OCD
Panic Disorder
PTSD
Social anxiety disorder
Nocturnal eating***
PMDD
How is Parozetine (Paxil) used?
Depression
Panic Disorder
OCD
GAD***
PTSD
Social anxiety disorder
PMDD
Which SSRI is associated with more weight gain than other SSRIs?
Parozetine (Paxil)
Which SSRI is only FDA-approved for MDD (no other indications)?
Citalopram (Celexa)
In addition to depression, Escitalopram (Lexapro) can be used for …
GAD
How should all SSRIs and SNRIs be discontinued?
Should be tapered down gradually
What are the three SNRIs we learned?
Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Uses for Venlafaxine (Effexor)
Depression
GAD
SAD
Panic disorder
How should venlafaxine (Effexor) be taken?
WIth food
What are the FDA-approved indications for Desvenlafaxine (Pristiq)?
Only depression
Antidepressant that can also be sued for GAD, pain associated with diabetic neuropathy, and fibromyalgia?
Duloxetine (Cymbalta)
Duloxetine (Cymbalta) is contraindicated in patients with…
Liver disease
Which antidepressant is a dopamine-reuptake inhibitor with less sexual side effects compared to SSRIs?
Bupropion (Wellbutrin)
Bupropion (Wellbutrin) should be avoided in patients with ….
Seizure disorder (lowers threshold)
Anorexia
In addition to depression, Buproprion can be used for …
SAD
Smoking cessation (Zyban)
When might you use Mirtazapine (Remeron)?
In elderly patients to help with depression, sleep, and/or appetitie/weight
Less sexual side effects compared to SSRIs
What is the MOA for Mirtazapine (Remeron)?
Alpha-2 antagonist
Enhances noradrenergic and serotonergic transmission
What is the recommended length of treatment with antidepressants?
Duration of treatment 4-9 months after determining therapeutic dose
Continuation therapy for patients with risk factors for recurrence (1-3 years of maintenance therapy)
Following continuation treatment, pt w/ hx of multiple episodes or comorbid psych disorders should be encouraged to maintain treatment indefinitely
When should you refer to psych?
Suboptimal effect from initial antidepressant
Severe depression w/ thought disorder, bipolar disorder, or suicidal/homicidal ideation
Co-morbid psych, substance abuse, or medical conditions
Diagnosis in question
When should your depressed patient be hospitalized?
Suicidal or homicidal ideations
Severe psychomotor retardation or agitation
Associated psychosis
