Antidepressants & Mood Stabilizers-Prescribing Pearls Flashcards
Patient AB: 20 year old college student whose girlfriend of 2 years broke up with him abruptly last week. Since breakup, feeling depressed, intermittently tearful, broken sleep, poor appetite, preoccupied with thoughts of girlfriend. Functioning adequately in school.
Offer antidepressant?
Why or why not?
No, b/c this is a normal response to loss. It has only been 1 week. Still able to function with effort. Not suicidal. Normal prior to breakup.
What we can do: Consider giving him a sleep aid (non-addictive). Possible psychotherapy.
Patient DB: 26 year old woman who was abruptly fired from her high paying job 1 month ago. Initially “in shock” but over the past 2 weeks, she is feeling very sad, tearful, very poor sleep, feelings of hopelessness, low motivation, lost 8 lbs, socially isolating. No thoughts of suicide.
Offer antidepressant?
Why or why not?
Yes, b/c 2 weeks is an important marker. Isolating herself. Nonfunctional b/c not looking for a job. Weight loss. Can’t sleep (worse than other patient’s can’t sleep). Severe hopelessness.
What is the role of a stressor in depression?
stressor doesn’t diminish the possibility of major depressive disorder. As long as duration & severity & impact on functioning is sufficient. Criteria met…
**bereavement is sorta an exception to this.
What are the 3 things you hone in on with a patient with depressive symptoms?
& severity of symptoms
duration
impact on daily functioning
**also consider level of stress & suffering.
What is the risk of prescribing an antidepressant to a patient with a depressive episode & no hx of mental illness?
if they have bipolar disorder the antidepressant could prompt an episode of mania.
What are the clues of bipolar depression?
personal history of mania. manic episode-bipolar I.
family history of mania
atypical depression
early onset
multiple poor responses to antidepressants
What is atypical depression?
2 reverse neurovegetative signs
ex: all they want to do is sleep
all they want to do is eat
usu: can’t sleep or eat
How do you choose an initial antidepressant?
probably SSRI
if they have a hx of an antidepressant the works well-stick with it.
consider side effects.
What are the patient centered factors to consider in describing a certain type of antidepressant?
prior experience with antidepressants co-morbidities: obesity, mild erectile dysfunction, bulimia nervosa pregnancy or likely to get pregnant other current meds family hx: mania antidepressant response-positive expectation, placebo effect idiosyncratic-preconceived notions insurance/affordability preference
People with active bulimia nervosa had what reaction to Wellbutrin?
increased risk of seizures
What percentage of pregnancies are unplanned?
50%
What are clinical factors to consider in prescribing a first time SSRI?
evidence says all antidepressants are equally effective
different side effects
What are prescriber centered factors in prescribing a first time SSRI for patient?
prescriber favorites
primacy & recency bias
sales & marketing: availability of samples, vouchers, reciprocity effects
What is the primacy bias?
first 3 times I started someone on effexor–>it worked like a gem! I will always prescribe this.
What is the recency bias?
the last 3 times I used zoloft everyone had terrible side effects. I will no longer prescribe this.
What are the common side effects of SSRIs?
GI sedation restlessness/agitation insomnia sexual dysfunction
What info should you provide to the patient in informed consent?
reasonable patient standard side effects: most common & most serious how to take how long until it will work how long to stay on it instill hope!
If a patient has zero effect at 4 weeks…what does this predict?
predicts poor ultimate response
offer a switch of drug at this point.
If a patient has some benefit at 4 weeks…what does this predict?
wait longer to see if the med works & consider a dosage increase
If the treatment fails…what do you do now?
revisit diagnosis
consider comorbidities (are they taking drugs)
consider unaddressed situational issues (domestic violence)
psychotherapy
When you switch meds…what do you switch to?
Switch class. Different MOA.
What are the most common meds to offer in treatment of mania?
sedating atypical antipsychotic (risperidone, olanzapine, quetiapine) LITHIUM Valproic acid (depakote)
What is the advantage to lithium & disadvantage for treatment of manic episodes?
advantage: anti-suicidal
disadvantage: narrow therapeutic window, lab monitoring, teratogen, renal issues, thyroid issues
What are the advantages & disadvantages to valproic acid in treatment of manic episodes?
advantage: safe & effective
dis: PCOS, teratogen, weight gain, lab monitoring
