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nmsp exam 3 > Antidepressants and Mood Stabilizers > Flashcards

Antidepressants and Mood Stabilizers Flashcards

1
Q

What are some treatment options for depressive disorders?

A
  • Pharmacotherapy
  • Biopsychosocial therapies
  • Electroconvulsive therapy
  • Deep Brain Stimulation
  • Transcranial Magnetic Stimulation
  • Light therapy
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2
Q

What are some other indications for antidepressants?

A
  • Anxiety
  • PTSD
  • Panic disorder
  • OCD
  • SAD
  • Premenstrual dysphoric disorder
  • Disruptive mood dysregulation disorder
  • Nicotine withdrawal
  • Enuresis
  • Diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain
  • Stress incontinence
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3
Q

What are the 5 R’s of antidepressant efficacy?

A
  • Response
  • Remission
  • Relapse
  • Recovery
  • Recurrence
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4
Q

What is response in antidepressant efficacy?

A
  • > 50% reduction in symptoms form baseline

- Not well, just better

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5
Q

What is remission in antidepressant efficacy?

A
  • Symptom free (very low to no symptoms)

- Not only better, but well; a healthy state of functioning

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6
Q

What is recovery in antidepressant efficacy?

A
  • 6-12 months of ongoing remission

- Not cured

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7
Q

What is relapse in antidepressant efficacy?

A
  • Return of symptoms after Remission but before recovery
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8
Q

What is recurrence in antidepressant efficacy?

A
  • Return of symptoms after recovery
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9
Q

When is the usual time frame for antidepressive agents to demonstrate their clinical benefits?

A
  • 3-8+ weeks
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10
Q

When do most patients see up to 50% of reduction in symptoms?

A
  • Within the first 3-4 weeks
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11
Q

When should you consider switching to another antidepressant in a patient?

A
  • If the patient does not respond after an 8 week trial
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12
Q

What should you do if a partial response is observed?

A
  • Add another drug (like antipsychotics)
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13
Q

What are all antidepressants well know for?

A
  • Cause or be associated with a withdrawal syndrome

- This means that we need to slowly titrate off of medicaton

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14
Q

What is the acronym for the symptoms of the withdrawal syndrome of antidepressants?

A
  • FINISH
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15
Q

What does FINISH stand for?

A
  • Flu-like symptoms
  • Insomnia
  • Nausea
  • Imbalance
  • Sensory disturbances
  • Hyperarousal
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16
Q

What are the general antidepressants MOA?

A
  • Primarily, agents block 5-HT and/or NE reuptake by presynaptic transporters (SERT, NET, or both)
  • Secondary mechanisms of a few agents block or stimulate pre and/or postsynaptic receptors
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17
Q

What are SSRI’s?

A
  • Selectively Inhibit the presynaptic reuptake of serotonin (via SERT)
  • Results in enhanced, prolonged serotonergic neurotransmission to postsynaptic receptors
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18
Q

What is seen in SSRI’s when compared to TCA’s?

A
  • Much less impact on histamin, muscarinic, and adrenergic receptors
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19
Q

What are some primary side effects of SSRI’s?

A
  • CNS (sedation or insomnia/agitation/nervousness)
  • Sexual dysfunction (change in libido/impotence)
  • Weight gain (adults)/Weight loss (mild; adolescents)
  • Acute withdrawal reactions (concern with all categories)
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20
Q

What are some rare side effects of SSRI’s?

A
  • QT prolongation
  • Hyponatremia
  • Serotonin syndrome (sweating, hyperreflexia, akathisia/myoclonus, shivering/tremors)
  • Suicidality
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21
Q

What is the risk of drug interactions with SSRI’s?

A

Variable risk of drug-drug interactions resulting (CYP450):

  • Most is fluoxetine
  • Least is vortioxetine and escitalopram
  • Low/mild include citalopram, sertraline, and vilazodone
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22
Q

What are some drugs that are SSRI’s?

A
  • Citalopram
  • Escitalopram
  • Fluoxetine
  • Paroxetine
  • Sertraline
  • Vilazodone
  • Vortioxetine
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23
Q

What are SNRI’s?

A
  • Selectively inhibit the presynaptic reuptake of serotonin and norepinephrine (via NET)
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24
Q

What is the MOA of tertiary amine TCAs?

A
  • Inhibit both NE/5-HT relatively equally

- Except clomipramine/amitriptyline which impact 5-HT>NE

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25
Q

What is the MOA of secondary amine TCAs?

A
  • Inhibit NE>5-HT
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26
Q

What are some side effects of TCAs?

A
  • Block other receptors like Histamine, Muscarinic, and alpha 1 adrenergic
27
Q

What are the cardiovascular side effects seen in TCA use?

A
  • Tachycardia
  • Orthostatic hypotension
  • Dysrhythmias
28
Q

What are the anticholinergic side effects seen in TCA use?

A
  • Dry mouth
  • Urinary retention/constipation
  • Blurred vision/Inc. IOP
29
Q

What are the CNS side effects seen in TCA use?

A
  • Sedation/Fatigue

- Dizziness/Seizures

30
Q

What are the 3 C’s of toxic ingestion of TCAs?

A
  • Coma
  • Cardiotoxicity (conduction abnormalities)
  • Convulsions
31
Q

How are side effects of SNRI’s similar to SSRI’s?

A
  • Relatively similar to SSRI’s with a less risk of sexual dysfunction
32
Q

What drugs are tertiary amine TCA’s?

A
  • Amitriptyline
  • Clomipramine
  • Doxepin
  • Imipramine
33
Q

What drugs are secondary amine TCA’s?

A
  • Amoxapine
  • Desipramine
  • Nortriptyline
34
Q

What drugs are SNRI’s?

A
  • Desvenlafaxine
  • Venlafaxine
  • Duloxetine
  • Levomilnacipran
35
Q

What are SARA’s?

A
  • Two agents act like SSRI’s and also selectively block postsynaptic alpha1 receptors on noradrenergic neurons and postsynaptic 5-HT receptors (Trazodone and Nefazodone)
  • One agent blocks presynaptic alpha2 receptors on noradrenergic and serotonergic neurons and blocks postsynaptic 5-HT receptors (Mirtazapine)
36
Q

What are some side effects of SARA’s?

A
  • CNS (sedation) –> most with trazodone/mirtazapine
  • Orthostatic hypotension –> most with trazodone
  • Weight gain –> mirtazapine
37
Q

What are NDRI’s?

A
  • Selectively inhibits presynaptic reuptake of norepinephrine (via NET) and dopamine (via DAT)
  • Results in enhanced, prolonged NE and DA neurotransmission to postsynaptic receptors
38
Q

What are some side effects of NDRI’s?

A
  • Agitation/Insomnia (stimulating)
  • Hypertension/Tachycardia/Tremors
  • Weight loss
  • Seizures
39
Q

What drug is a NDRI?

A
  • Bupropion
40
Q

What is MAOI’s MOA?

A
  • Inhibition of MAO increases levels of monoamines in neuronal vesicles and increase amounts of NE, 5-HT, and DA released
41
Q

What are all oral MAOI’s considered?

A
  • Irreversible MAOI’s
42
Q

What are some side effects of MAOI’s?

A
  • Orthostatic hypotension
  • Sexual dysfunction
  • Weight gain
  • Insomnia/Agitation/Nervousness
43
Q

What are the drug interactions of MAOI’s?

A
  • Some anti-hypertensives, amphetamines, SSRIs/TCAs/SNRIs
  • 2 week wash out period (fluoxetine)
  • Risk of serotonin syndrome
  • Risk of hypertensive crisis
44
Q

Why is there a major concern of hypertensive crisis with MAOI’s?

A
  • Non-selective MAOI’s inhibit MAO-A necessary in GI for tyramine metabolism
  • Increased tyramine can induce significant catecholamine release and hypertensive crisis
45
Q

What are the symptoms/signs of hypertensive crisis?

A
  • Severe headache
  • Sweating/severe anxiety
  • Nosebleeds
  • Tachycardia
  • Chest pain
  • Changes in vision
  • Shortness of breath
  • Confusion
  • Nausea/Vomiting
46
Q

What are some examples of tyramine containing foods/beverages?

A
  • Aged cheeses
  • Fava/broad/soy beans, or snow peas
  • Fermented or pickled meats/poultry/fish
  • Processed, pickled, or cured meats/sausages (bologna, pepperoni, salami, summer sausage
  • Tap beers/beers not pasteurized, or red wine, sherry and liqueurs
  • Yeast or protein extracts
  • Overripe or spoiled fruits
  • Soy/fish/shrimp sauces
47
Q

What drugs are MAOI’s?

A
  • Isocarboxazid
  • Phenelzine
  • Selegiline
  • Tranylcypromine
48
Q

What is esketamine?

A
  • An NMDA-receptor antagonist

- Indicated for treatment-resistant depression in conjunction with ongoing antidepressant therapy

49
Q

How is esketamine given?

A
  • Nasal administration by authorized physician
50
Q

Why is a patient observed after getting esketamine?

A
  • Look at BP and dissociation/cognitive impairment/sedation
51
Q

What is brexanolone?

A
  • A GABA-A receptor positive allosteric modulator

- Identical to endogenous allopregnanolone

52
Q

What is brexanolone indicated for?

A
  • Post-partum depression
53
Q

How is brexanolone given?

A
  • 60 hour IV administration by authorized physician in healthcare facility
54
Q

What is observed after giving brexanolone?

A
  • Excessive somnolence

- Loss of consciousness

55
Q

How long does efficacy last for brexanolone?

A
  • Lasts up to 30 days post dose
56
Q

What is lithium?

A
  • Monovalent ion
  • Handled by kidneys similar to Na+/K+
  • Li+ competes with Na+ for kidney reabsorption
57
Q

What does lithium do in the kidney?

A
  • Li+ enter principal cells of collecting duct via Na+ channels in luminal membrane
  • Accumulation of Li+ in these cells interferes with ADH-mediated effects and can lead to resistance to ADH, resulting in polyuring/polydipsia
58
Q

What is a side effect of lithium?

A
  • Polyuria (polydipsia) –> Clinical picture of nephrogenic diabetes insipidus
  • Tremor
  • Mental confusion/dizziness/sedation
  • Thyroid goiter
  • Leukocytosis
  • Seizures and serotonin syndrome
59
Q

What are some drug interactions with lithium?

A
  • Diuretics via preferential Na+ loss and Li+ reabsorption (especially thiazides)
  • ACEIs: especially lisinopril
  • NSAIDs: through alteration of renal perfusion
60
Q

What are some indications for lithium?

A
  • Acute and management treatment of mania/bipolar I disorder

- Augmentation in unipolar depressive patients with inadequate response to antidepressant therapy

61
Q

What is the off label use of lithium?

A
  • Reduced risk of suicide and all cause mortality in patients with mood disorders
62
Q

What are three mood stabilizers that were initially developed to be anti-seizure agents?

A
  • Valproic acid
  • Lamotrigine
  • Carbamazepine
63
Q

What are the uses for mood stabilizers?

A
  • Valproic acid used for acute Bipolar I
  • Lamotrigine use for maintenance of bipolar disorder (I and II)
  • Carbamazepine used for acute and maintenance treatment of acute mania and mixed episodes (bipolar I)

nmsp exam 3 (18 decks)

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