Antidepressants/Anxiolytics Flashcards
1
Q
main 2 sx’s for dx of major depressive episode?
A
depressed mood, lack of enjoyment in pleasurable activities (anhedonia)
2
Q
what is persistent depressive disorder (dysthymia)?
A
depressed mood for more days than not for at least 2 years
these pts are depressed but still do things vs major depressive they don’t do anything
3
Q
what is NOT recommended as first line tx for bipolar depression?
A
SSRIs/SNRIs
4
Q
what can antidepressants cause in bipolar patients?
A
increase mania
5
Q
what MUST you screen for before initiating an antidepressant as mono therapy?
A
Bipolar disorder
-need to screen for mania in their hx b/c they won’t present when manic, only present when depressed
6
Q
what has a dramatic impact of moving a person on continuum to high risk of suicide?
A
substance use - makes them act more on their suicidal thoughts
7
Q
what is the mortality of depression?
A
suicide
8
Q
what can happen with suicide and tx of depression with antidepressants?
A
antidepressants can worsen someone’s suicidality when it’s supposed to reduce their suicidal thoughts (paradoxical rxn)
9
Q
what is bereavement?
A
Depressive symptoms which occur after the loss of a loved one
10
Q
what is adjustment d/o?
A
Development of emotional and/or behavioral symptoms w/in 3 months after an identifiable stressor
-Patient not coming out of their depression after a trigger occurs (ex: spouse dies)
11
Q
do bereavement and adjustment d/o require tx?
A
not really, they do need counseling tho
may start antidepressants with adjustment d/o
12
Q
what meds MUST BE R/O as they can induce depressive sx’s ?
A
Steroids
Monotherapy with Benzo’s
13
Q
what tx is effective for mild depressions monotherapy? when is it good for moderate to severe depression?
A
psychotherapy (CBT and interpersonal therapy)
good for mod-severe depression when added to meds
14
Q
what are the most commonly used meds for depression? recommended as FIRST LINE tx in what population?
A
SSRIs
-recommended as FIRST LINE tx in older depressed pt
15
Q
what are the generic SSRIs?
A
Fluoxetine, Paroxetine, Sertraline, Fluvoxamine, Citalopram, Escitalopram
16
Q
what are the 2 SSRI and Serotonin Receptor Modulators?
A
Vilazodone and Vortioxetine
-these are NOT generic
17
Q
what serotonin receptors are involved with anxiety and depression?
A
5-HT1 and 5-HT2
18
Q
what are 2 important differences b/w the SSRIs?
A
Relative rates of adrs (same adrs, but some more than others)
Elimination half-lives
19
Q
what are adrs of SSRIs?
A
diarrhea, nausea/vomiting, headache, somnolence, sexual dysfunction, weight gain, QTc risk
20
Q
what are the adrs of SSRIs that the patient will gain a tolerance to?
A
all adrs EXCEPT sexual dysfunction
21
Q
what is the only adr of SSRIs that doesn’t go away?
A
sexual dysfunction
22
Q
what SSRI causes the MOST sexual dysfunction?
A
Paroxetine
23
Q
what SSRI causes the most weight gain?
A
Paroxetine
24
Q
what do you want to find out about patients when starting SSRIs?
A
their baseline weight - if go past their baseline while on SSRI then can blame the drug
25
what SSRI has the great risk of QTc increase?
Citalopram - 10msec increase
26
what other meds that are used to treat depression have twice the impact on QTc than SSRIs?
TCAs
27
what should you get for patient in terms of watching out for QTc risk for SSRIs?
baseline EKG (can be months before prescribing the SSRI)
28
which two SSRIs last the shortest amount of time in the body?
Paroxetine and Fluvoxamine
29
what SSRI lasts the longest amount of time in the body?
Fluoxetine
30
what are the withdrawal symptoms of SSRIs?
flu-like symptoms, insomnia, dizziness, irritability, ataxia
31
when do withdrawal symptoms from SSRIs occur after abrupt cessation and how many days can they last up to?
Occurs within 1-10 days after abrupt cessation and can last up to 14 days
32
what 2 SSRIs inhibit CYP2D6?
Fluoxetine and Paroxetine
| also Sertraline, but not as much
33
what CYP enzyme do Fluoxetine and Paroxetine inhibit?
CYP2D6
34
what 2 SSRIs are the safest and have the least potent DDIs?
escitalopram and sertraline
35
what 2 SSRIs have the most potent DDIs?
Paroxetine and Fluoxetine
36
when would you use Vilazodone or Vortioxetine for depression? what's their side effect profile like compared to SSRIs
if SSRIs didn't work
have greater side effects than SSRIs
37
Trazodone adrs?
sedation
38
other effects of Trazodone? what's it good to use for?
promoter of good sleep (b/c block 5-HT2)
used as a hypnotic more than as an SSRI (Better to give than Xanax for sleep)
good for insomnia patients that also require SSRI
39
when do you use the SNRIs?
for severe depression (replace SSRI with SNRI)
40
what must be monitored for when using SNRIs that's not monitor for when using SSRIs?
BP, HR, and urinary hesitation
41
what are the 4 SNRIs used for severe depression?
Venlafaxine, Desvenlafaxine
Duloxetine
Levomilnacipran
42
what are the adrs of Venlafaxine?
Nausea, Headache, Insomnia
BP increases (3-15 mmHg systolic) -> d/t adding NE reuptake inhibition
43
what is desvenlafaxine a metabolite of?
venlafaxine
44
dexvenlafaxine has more effect on what?
HR and BP
45
effects of Duloxetine on HR and BP? neuropathy?
mild HR and BP increases
effective for neuropathy
46
Duloxetine may possibly be toxic to what? seen in who?
hepatotoxic - seen in pts with concurrent chronic alcohol dependence
47
what is the easiest SNRI to use?
Duloxetine
48
Levomilnacipran has more of an effect on what compared to the other SNRIs?
more effect on NE, a little 5-HT -> NOT A GOOD CHOICE
49
what SNRI is NOT a good choice to use d/t it's greater effects on NE vs 5-HT?
Levomilnacipran
50
what are the TCA medications?
- Imipramine
- Clomipramine
- Desipramine
- Amitriptyline
- Nortriptyline
51
adrs of TCAs?
constipation, blurred vision, dry mouth, sedation, headache, sexual dysfunction
cognitive impairment, photosensitivity, arrhythmias, hyperglycemia, lowers seizure threshold
MUCH MORE ADRS THAN SSRIs OR SNRIs
52
TCAs are deadly at what dose?
one weeks worth of med can make you OD and die
53
when is the ONLY time to use TCAs for depression?
when fail other meds
54
what are 2 other meds for depression?
Mirtazapine and Bupropion
55
ADRs of Mirtazapine
Somnolence (inverse dose relationship) - ceiling effect vs Trazadone doesn't
Increased appetite (weight gain)
***Hyperglycemia, Hypertriglyceridemia, hypercholesterolemia
Antiemetic (b/c blocks 5-HT3)
56
good and bad about Mirtazapine?
Mirtazapine sedates you and gives you good sleep cycles, but has bad metabolic effects
57
MOA of Bupropion? DA chemical is what in the brain?
DA and NE reuptake pump inhibitors
-DA is the "getting high" chemical in the brain -> Bupropion has potential for abuse
58
Bupropion has potential for...
abuse b/c works on DA
59
what drugs does Bupropion interact with?
alpha-1 blocks (terazosin, prazosin, doxazosin, tamsulosin), DA blockers
60
ADRs of Bupropion
Agitation (d/t effect on DA)
Insomnia, irritability, dry mouth
Promotes smoking cessation
Useful for drug induced sexual dysfunction
61
does Bupropion treat anxiety? why does it make you MORE irritable and agitated?
NO!!! it's doesn't treat anxiety b/c it works on DA, not 5-HT
increases DA so make you more agitated and irritable
62
how does Bupropion help with sexual dysfunction?
b/c increases DA, so increases libido
63
what meds for depression have a risk for serotonin syndrome?
all antidepressants EXCEPT bupropion
64
which med for depression does NOT have a risk for serotonin syndrome?
Bupropion
65
what meds can interact with antidepressants to cause serotonin syndrome?
St. John’s wort, tramadol, meperidine, tryptophan, dexfenfluramine, isoniazid
66
what effect do Triptans have?
cause coronary vasoconstriction, so can cause chest pain -> MUST MONITOR!!!
stimulate 5-Ht to vasoconstrict (used for migraines)
67
Serotonin Syndrome is caused by overstimulation of what 2 receptors?
5-HT1a and 5-HT2a
68
what are symptoms of Serotonin Syndrome? what can it cause? when do symptoms occur? when do symptoms resolve?
Restlessness, akathisia, tremor, hypomania, confusion, hyperreflexia, myoclonus, diaphoresis, hyperthermia
can cause death
symptoms occur within hours and symptoms resolve after 24hrs once the pro-serotonergic agents are stopped
69
what is the treatment for Serotonin Syndrome?
5-HT antagonist cyproheptadine
70
can you use SSRIs in pregnancy?
Yes, but it is preferred not to
71
what SSRI is the BEST studied for use in pregnancy, but not necessarily the first choice?
Fluoxetine
72
what SSRI should you NOT use in pregnancy?
Paroxetine
73
when is it best to start mom on SSRI if she needs it or was already on it while pregnancy?
after giving birth
74
what 2 SSRIs are the safest to use while breast feeding?
Sertraline and Paroxetine
75
when can you increase dose of SSRI upon initial antidepressant therapy?
after 4-8 weeks of tx if only partial response (25% reduction in symptoms)
76
when can you switch patient to another antidepressant upon initial antidepressant therapy?
if no response after 4-8 weeks of treatment
77
when can you consider depressed patient to be treatment resistant?
after 2 trials of medication
| -meds SHOULD be from 2 different classes (but can be from same)
78
wha are the treatment options for depressed patient refractory/resistant to meds?
(1) Switching to a 3rd antidepressant monotherapy (one from diff pharm class -> most likely SNRI)
(2) Adding a second antidepressant (from diff pharm class)
(3) Augmenting with a non-antidepressant (e.g. Lithium, T3, atypical antipsychotic) - last option b/c more adrs/monitoring with antipsychotics
(4) Non-pharmacologic options (e.g. ECT)
79
what antidepressant meds can you combined?
SSRI with Bupropion (more stimulating effect)
SSRI or SNRI with Mirtazapine (more hypnotic effect)
80
after how many days of initiating treatment for depression do you meet with the patient to assess tolerability and safety/suicidal thoughts?
after 10-14 days
81
at how many weeks to do you meet with patient to assess efficacy?
4 weeks
82
after how many weeks after the 4 week meet for assess efficacy do you meet to measure maximal response?
2-4 weeks after (maximal response is 6-8 weeks of therapeutic dose)
83
for how long do you meet every month with patient?
for next 4-9 months after assess maximal response at 6-9 week mark
84
if this is patients first episode of depression, can you taper their antidepressant med down after 1 year of use?
yes you can taper their meds down -> off when 1st episode of depression
85
if this is patients second or more episode of depression, can you taper their antidepressant med down after 1 year of use?
no, you should not
86
what score on children's depression rating scale indicates depression?
>40
87
what score on children's depression rating scale indicates remission?
< 28
88
for what ages is Fluoxetine approved for in peds?
ages 8-17 y/o
89
for what ages is Escitalopram approved for in peds?
ages 12-17 y/o
90
what antidepressant is FIRST CHOICE in peds?
12-17 y/o
91
what are the only 2 SSRIs are that approved for adolescent depression?
Fluoxetine and Escitalopram
92
what SSRI is NOT recommended in adolescents?
Paroxetine - d/t lack of efficacy and worse tolerability
93
BBW for what with SSRIs?
suicide
94
what is an adr of SSRIs in kids that you MUST monitor? what is the monitoring criteria?
Must monitor SUICIDE RISK
-monitor every week x4 weeks -> every other week x4 weeks, by phone if necessary -> after 12 weeks it's up to the doc
95
for depression in kids, what antidepressant do you start them on for monotherapy?
Fluoxetine
96
what is another main tx for depression especially in kids <18 y/o?
psychotherapy
97
what comorbid condition is common to have with depression?
anxiety
98
how long does anxiety adjustment d/o last?
<6 months after the end of the stressor
99
what is the FIRST LINE medication for anxiety?
benzo's
100
MOA of benzo's
Bind to GABA, thus increasing GABA effect
101
use of benzo's?
tx of acute anxiety symptoms
102
what are the main ADRs of benzo's?
Sedation (tolerance develops in 2 weeks of daily use)
Cognitive impairment (long-term use of benzo's causes permanent memory changes/cognitive impairment)
Respiratory depression (in high doses or when combined w/other CNS depressants like ETOH, opiates, barbiturates)
103
what are risks of using benzo's?
Withdrawal (pretty intense with bad rebound anxiety)
Disinhibition
ED visits (related to combining with ETOH or opiate)
Motor Vehicle Accidents
104
is there a tolerance of benzo's to anxiolytic or muscle relaxant effects? what does this mean?
no!!! - means that patient shouldn't be coming to ask for dose increase
105
if patient on benzo's requires frequent dose increase, what is it a possible sign of?
misuse of the benzo (abuse or diversion)
106
significant risk of death/OD when combine benzo's with what other med?
opiates
107
are benzo's commonly abused by themselves or in combo with other drugs?
benzo's are NOT commonly abused by themselves, they are more commonly added to other drugs to enhance or prolong the 'high' (ex: opiates)
108
what are the 2 main factor for benzo selection?
Potency (high vs low)
Duration of action
109
the smaller the dose (mg) for benzo's, the higher the ___
potency
110
what 2 benzo's have the highest potency?
triazolam > clonazepam
111
what is generalized anxiety disorder (GAD)?
Excessive anxiety and worry more days than not for at least 6 months
112
what meds can be used for GAD?
antidepressants, buspirone (Buspar), benzo's, pregabalin
113
what antidepressants can be used for GAD?
SSRIs, Duloxetine, Venlafaxine
114
what are the MAIN antidepressants (that the professor likes) to treat GAD?
escitalopram, sertraline, duloxetine
115
dosing for antidepressants in anxiety is similar to dosing in ___
depression
116
what anxiety disorder is Buspirone ONLY used to treat?
GAD (not panic d/o b/c not strong enough)
117
what are the 4 advantages of treating GAD with Buspirone?
Almost as effective as benzos for GAD
No sedation, cognitive impairment, respiratory depression, dependence or withdrawal
Lacks abuse potential (takes awhile to kick in)
No sexual dysfunction (vs SSRIs do)
118
what is the disadvantage of treating GAD with Buspirone?
onset of effect is about 2 weeks, but can take 6 weeks for full effect (similar to antidepressants)
119
what is the goal dose of Buspirone?
40mg/day -> lower than that is NOT effective
120
what SSRIs have the WORST outcomes when treating GAD? SSRIs with best outcomes for treating GAD?
Venlafaxine and Paroxetine = worst
Sertaline and Fluvoxamine = best
121
how do you dose the SSRIs when treating GAD?
dose low to start as they may initially worsen anxiety if dose is too high b/c serotonin will go up abruptly and acutely
122
what are the Guideline Recommendations for tx of GAD in the Acute Phase?
Start SSRIs and add BZD if necessary
123
why do you add BZD to SSRI in acute phase tx of GAD or Panic d/o?
as a bridge b/c of the delayed effect of SSRIs (once SSRIs kick in, don't need BZDs)
124
what are the Guideline Recommendations for tx of GAD in the Prophylaxis Phase?
***SSRIs, SNRIs
or
Buspirone, Pregabalin
125
what SSRI is preferred in the ppx phase of GAD?
sertraline
126
if sertraline is ineffective in ppx phase of GAD, what can you do for the patient?
offer a different SSRI or an SNRI
127
when would you consider putting patient on pregabalin for GAD ppx? what's bad about pregabalin?
if patient can't tolerate SSRI/SNRI
| but want to stay away from Pregabalin b/c it has street value
128
what are the Guideline Recommendations for tx of Panic Disorder in the Acute Phase?
SSRIs or SNRIs and BZD if necessary (again, to bridge for first 4-6 weeks of tx only)
129
what are the Guideline Recommendations for tx of Panic disorder in the Prophylaxis Phase? when do you use TCAs?
***SSRIs
-use TCAs if multiple SSRIs fail
130
why is it appropriate to treat anxiety with SSRIs/SNRIs?
b/c most people with anxiety d/o will develop depression
131
when can you give a patient with anxiety d/o hydroxyzine pamoate, propranolol, clonidine?
for both acute response and chronic tx of anxiety d/o
may be better to use these 3 as a bridge to SSRI/SNRI for anxiety d/o vs BZDs b/c these 3 are safer
132
what 2 comorbidities should you screen for in patient with GAD or Panic Disorder?
depression and substance abuse
133
what are some non-pharmacologic tx's for anxiety d/o's?
Cut down on caffeine and other stimulating chemicals
Reduce depressant agents that can result in rebound excitation (e.g. ETOH)
Relaxation techniques rather helpful
Psychotherapy with medication therapy increases efficacy
134
GAD response well to ___?
supportive psychotherapy (should be done before prescribe meds - same for mild depression)
135
Panic d/o needs ___ for tx
meds
136
if serotonin goes up abruptly and acutely, what can it induce? why is this important?
anxiety sx's
-important b/c want to start low on SSRIs/SNRIs to prevent this
