Antidepressants & Mood Stabilizers Flashcards by Sarah Gillen

MOA of SSRIs

Inhibit the presynaptic reuptake of 5-HT (via SERT)

How well did you know this?

Not at all

Perfectly

Indications for SSRIs

1st line for major depression and GAD

Other indications: panic disorder, PTSD, OCD, bulimia, social anxiety disorder

How well did you know this?

Not at all

Perfectly

Adverse effects of SSRIs

Hyponatremia (SIADH)
QT prolongation
Sexual dysfunction
Weight gain
Drowsiness
Suicidality

How well did you know this?

Not at all

Perfectly

Clinical features of serotonin syndrome

Hyperthermia

Hypertension

Neuromuscular hyperactivity (e.g., hyperreflexia, clonus)

How well did you know this?

Not at all

Perfectly

T/F: Opioids can interact with serotonergic medications and cause serotonin syndrome

True

[risk of serotonin syndrome is increased with any drug that increases serotonin levels]

How well did you know this?

Not at all

Perfectly

Treatment for serotonin syndrome and its MOA

Cyproheptadine

Acts as a 5-HT2 blocker

How well did you know this?

Not at all

Perfectly

SSRIs may increase suicidality; what age group is at highest risk of this adverse effect?

Children, adolescents, young adults

How well did you know this?

Not at all

Perfectly

SSRIs are at high risk of drug-drug interactions due to CYP450 metabolism. What 2 SSRIs are only considered mild inhibitors, and are thus at least risk of causing these drug-interactions?

Citalopram

Sertraline

How well did you know this?

Not at all

Perfectly

List antidepressants and mood stabilizers associated with risk for serotonin syndrome

SSRIs
SNRIs
TCAs
MAOIs
Trazodone
Lithium

How well did you know this?

Not at all

Perfectly

List 8 drugs included in SSRI category

Citalopram
Fluoxetine
Sertraline
Escitalopram
Paroxetine
Fluvoxamine
Vilazodone
Vortioxetine

How well did you know this?

Not at all

Perfectly

Which SSRI is at highest risk for drug-interactions due to its broad and strong inhibition of CYP450?

Fluoxetine

How well did you know this?

Not at all

Perfectly

Of the SSRIs, which one is only used for OCD and SAD?

Fluvoxamine

How well did you know this?

Not at all

Perfectly

SSRI that is also a partial agonist on 5-HT1A

Vilazodone

How well did you know this?

Not at all

Perfectly

SSRI that is also a partial agonist on 5-HT1B, an agonist on 5-HT1A, and an antagonist on 5-HT1D, 5-HT3, and 5-HT7

Vortioxetine

How well did you know this?

Not at all

Perfectly

MOA of SNRIs

Inhibit the presynaptic reuptake of NE and 5-HT via actions on NET and SERT

How well did you know this?

Not at all

Perfectly

Indications for SNRIs

First line option for major depression and GAD

Panic disorder, PTSD, diabetic neuropathy, chronic pain (e.g., neuropathic pain), fibromyalgia, stress urinary incontinence, vasomotor symptoms of menopause

How well did you know this?

Not at all

Perfectly

Adverse effects of SNRIs

Serotonin syndrome

Hypertension

How well did you know this?

Not at all

Perfectly

List drugs included in the category of SNRIs

Duloxetine
Venlafaxine
Desvenlafaxine (metabolite of venlafaxine)
Levomilnacipran
Milnacipran
Amoxapine
All TCAs

How well did you know this?

Not at all

Perfectly

SNRI commonly utilized for diabetic peripheral neuropathy, fibromyalgia, chronic MSK pain, and stress incontinence

Duloxetine

How well did you know this?

Not at all

Perfectly

Levomilnacipran may be used to treat ______

Fibromyalgia

How well did you know this?

Not at all

Perfectly

Tetracyclic atypical antidepressant that acts as an SNRI and a dopamine agonist

Amoxapine

How well did you know this?

Not at all

Perfectly

TCAs act as SNRIs but also affect what other receptors?

H1 histamine receptors

Alpha-1 adrenergic receptors

Muscarinic (cholinergic) receptors

[also block cardiac fast Na+ channels]

How well did you know this?

Not at all

Perfectly

Indications for TCAs

Resistant depression

Diabetic neuropathy

Chronic pain (e.g., neuropathic pain)

Migraine prophylaxis

Enuresis

How well did you know this?

Not at all

Perfectly

What is the difference between TCAs that are secondary vs. tertiary amines?

Secondary amines inhibit NE > 5-HT

Tertiary amines inhibit both NE/5-HT relatively equally, except clomipramine and amitriptyline which inhibit 5-HT>NE

Tertiary amine TCAs inhibit both NE/5-HT equally, except clomipramine and amitriptyline which inhibit 5-HT>NE. Which other TCAs are considered tertiary amines?

Doxepin | Imipramine

Tertiary amine TCA used for OCD

Clomipramine [remember that SSRIs are first line for this!]

Tertiary amine TCA utilized for enuresis

Imipramine

Secondary amine TCAs inhibit NE > 5-HT. What are the 3 secondary amine TCAs?

Amoxapine Desipramine Nortriptyline

Adverse effects of TCAs

Sexual dysfunction Inhibition of mAChRs —> dry mouth, constipation, blurred vision, urinary retention Increased appetite and weight gain Sedation Orthostatic hypotension Cardiotoxicity (‘quinidine-like’ effect) Seizures Serotonin syndrome

Treatment for cardiotoxicity associated with TCA overdose

Sodium bicarb

TCAs are relatively contraindicated in what pt population due to severe anticholinergic and antihistamine effects?

Elderly

What unicyclic atypical antidepressant is considered an NDRI (noradrenergic-dopamine reuptake inhibitor)?

Buproprion

MOA of Buproprion

Inhibits NET and DAT Also shown to increase NE/DA presynaptic release

T/F: Buproprion exerts CNS activating effects and is highly likely to induce sexual dysfunction and weight gain

False — it does exert CNS activating effects, but it does NOT cause sexual dysfunction and is among the agents less likely to cause weight gain

Besides being an atypical antidepressant, what else is buproprion indicated for?

Tobacco dependence/nicotine withdrawal

Adverse effects and pt populations in which buproprion is contraindicated

Seizures — makes it a contraindication in anorexia nervosa and bulimia pts

MAO inhibitors act on monoamine oxidase enzymes. What are the normal functions of these enzymes (A and B)?

MAO-A — breaks down serotonin, NE, and dopamine MAO-B — breaks down dopamine

MAOIs ________ (reversibly/irreversibly) inhibit monoamine oxidase enzymes

Irreversibly

Indications for MAOIs

Depression (not first line!) May be more useful in atypical and resistant depression

Pts on MAOIs should avoid ______-containing foods like aged wine, cheese, and cured meats

Tyramine [tyramine is normally broken down by MAO-A in GI tract. On MAOIs, tyramine enters circulation and acts as sympathomimetic agent —> hypertensive crisis]

List 4 MAOIs

Isocarboxazid Tranylcypromine Phenelzine Selegiline

Which of the MAOIs is a selective MAO-B inhibitor making it a useful tx in Parkinsons?

Selegiline

T/F: Maprotiline is an atypical tetracyclic antidepressant

True

Mirtazapine is a tetracyclic atypical antidepressant. What is its MOA?

Blocks alpha-2 receptors —> increases presynaptic release of serotonin and NE Blocks 5HT2 and 5HT3 receptors Inhibits H1 histamine receptors

T/F: Mirtazapine is associated with AE of sexual dysfunction

False

Adverse effects of Mirtazapine

Sedation | Weight gain

What are the two 5-HT2 receptor modulators?

Trazodone | Nefazodone

MOA of trazodone

Antagonizes 5HT2 receptors and inhibits 5-HT reuptake (alpha-1 receptors) Blocks H1 histamine receptors

AEs of trazodone

Priapism Orthostatic hypotension Sexual dysfunction Serotonin syndrome

Weak inhibitor of both SERT and NET; potent antagonist of postsynaptic 5HT2A Carries black box warning for hepatotoxicity — not commonly prescribed anymore

Nefazodone

Although their MOA for bipolar is undelineated, what are 3 anti-seizure agents prescribed as mood stabilizers?

Carbamazepine Lamotrigine Divalproate/valproic acid

Anti-seizure agent used for acute bipolar I (with or without psychotic features)

Divalproate/valproic acid

Anti-seizure agent used for acute and maintenance treatment of acute mania and mixed episodes (bipolar I); major CYP450 inducer

Carbamazepine

Anti-seizure agent used for maintenance therapy in bipolar I and II

Lamotrigine

Indications for lithium therapy

Acute and maintenance tx of mania/bipolar I d/o Augmentation in unipolar depressive pts with inadequate response to antidepressants Off label — reduced risk of suicide and all-cause mortality in pts with mood disorders

MOA of lithium therapy

Inhibits Ca-dependent and depolarization-provoked release of NE and DA Inhibits receptor blockers and substances known to stimulate and inhibit G protein synthesis/actions [may reflect lithium’s ability to interfere with activity of both stimulatory and inhibitory G proteins by keeping them in an inactive state]

AEs of lithium

Polyuria (polydipsia) — clinical picture of nephrogenic diabetes insipidus Tremor Mental confusion/dizziness/sedation (take at bedtime) Thyroid goiter (hypothyroid) — inhibits iodination of thyroid hormone Leukocytosis (stimulates MCSF — increasing granulocytes) Seizures and serotonin syndrome

Drug interactions with lithium

Diuretics — esp thiazides (d/t preferential Na+ loss) ACEIs — esp lisinopril (renally eliminated) NSAIDs - through alteration of renal perfusion

All antidepressants either are, or can be, associated with a withdrawal syndrome, so slow titration downward is recommended. Symptoms include dizziness, HA, nervousness, nausea, insomnia, and flu-like aches. There is lower risk of this with what agents?

Long-acting agents (e.g., fluoxetine, amitriptyline) [note that even long acting and XR agents can still cause this withdrawal, just less likely]