Antidepressants and Mood Stabilizers (Segars)

Question 1

What can occur with sudden discontinuation of antidepressant medication?

Answer 1

withdrawal syndrome, including symptoms:
F - flu-like symptoms
I - insomnia
N - nausea
I - imbalance
S - sensory disturbances
H - hyperarousal

Question 2

How should you discontinue antidepressant medications?

Answer 2

“deprescribing,” a slow titration downward

Question 3

Indication for bupropion besides depression

Answer 3

nicotine withdrawal

Question 4

indication for imipramine besides depression

Answer 4

enuresis

Question 5

indications for duloxetine besides depression (4)

Answer 5

1) diabetic peripheral neuropathy
2) fibromyalgia
3) chronic musculoskeletal pain
4) stress incontinence

Question 6

SSRI that is also a partial agonist of 5-HT1A

Answer 6

Vilazodone

Question 7

SSRI that is also a partial agonist of 5-HT1B and full agonist of 5-HT1A/5-HT1D,3,7

Answer 7

Vortioxetine

Question 8

Concerns with SSRI and sudden termination of medication

Answer 8

acute withdrawal reactions (concern with all categories)

Question 9

serious side effects SSRI (2)

Answer 9

1) serotonin syndrome

2) suicidality (highest risk in children/adolescents/young adults)

Question 10

When taking an SSRI, when are you at the greatest risk for serotonin syndrome?

Answer 10

when given concurrently with other “serotonin-affecting” agents (MAOIs, TCAs)

Question 11

Describe serotonin syndrome symptoms (4)

Answer 11

1) sweating
2) hyperreflexia
3) akathisia/myoclonus
4) shivering/tremors

Question 12

SSRI with highest risk of CYP450 drug-drug interactions

Answer 12

Fluoxetine

Question 13

SSRIs (2) with lowest risk of CYP450 drug-drug interactions

Answer 13

1) Vortioxetine

2) escitalopram

Question 14

TCA affects which receptors

Answer 14

1) inhibit serotonin and norepinephrine reuptake via SERT/NET
2) block H1 receptors
3) block muscarinic receptors
4) block alpha 1 adrenergic receptors

Question 15

TCA side effects due to alpha 1 adrenergic blockade

Answer 15

cardiovascular:

• tachycardia
• orthostatic hypotension
• dysrhythmias

Question 16

TCA side effects due to muscarinic blockade

Answer 16

anticholinergic

• dry mouth
• urinary retention/constipation
• blurred vision/increased IOP

Question 17

TCA side effects due to histamine (H1) blockade

Answer 17

CNS

• sedation/fatigue
• dizziness/seizures

Question 18

Symptoms of toxic ingestion of TCAs (3)

Answer 18

1) coma
2) cardiotoxicity
3) convulsions
“quinidine-like” effect due to sodium channel blockade

Question 19

important side effect of Bupropion

Answer 19

seizures

Question 20

Major side effect of MAOIs

Answer 20

hypertensive crisis (especially with excessive tyramine consumption)

Question 21

MAOIs drug interactions and how to prevent them

Answer 21

5-HT/NE affecting drugs

- need 2 week wash-out period of other drugs before starting MAOIs (fluoxetine; 5 weeks)

Question 22

signs/symptoms of hypertensive crisis

Answer 22

• severe HA
• n/v
• sweating/severe anxiety
• nosebleeds
• tachycardia
• chest pain/SOB

Question 23

Foods containing tyramine

Answer 23

• aged cheeses
• wine
• fermented meats

Question 24

Lithium drug class

Answer 24

mood stabilizer

Question 25

lithium action of brain structure

Answer 25

neuroprotective/ neuroproliferative

Question 26

lithium action on neurotransmitter modulation

Answer 26

lithium interferes with activity of both stimulatory and inhibitory G-proteins (Gs and Gi) by keeping them in an inactive state & downregulates NMDA receptor & promotes GABAergic neurotransmission

Question 27

Lithium’s action in kidneys

Answer 27

• lithium is monovalent ion
• handeled by kidneys similar to Na/K+
• Li+ competes with Na+ for kidney reabsorption

Question 28

Renal side effect of lithium

Answer 28

polyuria/polydipsia (clinical picture of nephrogenic diabetes insipidus)

Question 29

lithium drug interactions

Answer 29

other drugs impacting Na/K+:

• diuretics
• ACEIs
• NSAIDs

Question 30

therapeutic window of lithium

Answer 30

NARROW 0.6-1.2 mEq/L

Question 31

carbamazepine class

Answer 31

mood stabilizer/anti-seizure agent

Question 32

mood stabilizer that is a major CYP450 inducer

Answer 32

carbamazepine