Anxiety and Depression

Question 1

Neurobiology of Depression

Answer 1

Theories:
Classic monoamine theory- emphasis on deficiency of NE, 5HT, and DA
Complex dysregulation of brain circuits in different parts of the brain

Question 2

Neurobiology of Anxiety

Answer 2

Neurotransmitters, such as GABA, glutamate, NE, and 5HT, have all been associated with cortico-striato-thalmo-cortical (CSTC) loops & information processing in the amygdala in all of the anxiety disorders

The neurobiology leads to more understanding of why certain medications that involve increasing GABA and 5HT have been helpful in the treatment of anxiety disorders

Question 3

What anxiety/depression med class can be used to treat smoking?

Answer 3

Norepinephrine-Dopamine Reuptake Inhibitors q

Question 4

What foods should be avoided with MAOI use?

Answer 4

Tyramine-containing foods such as aged meats and cheeses and fermented products (wine, beer, sauerkraut, soy sauce)

Question 5

5 Effects of Benzodiazepines

Answer 5

1. anxiolytic effect
2. anterograde amnesia
3. anticonvulsant effect
4. muscle relaxation
5. sedation

Question 6

Goals of Anxiety Treatment

Answer 6

Reduction of symptoms

Self-management of symptoms without medications

Understanding etiology/contributing symptoms

Patient Education:
Providing coping skills
Altering hypothalamus-pituitary axis responses

Question 7

Goals of Depression Treatment

Answer 7

Treat to achieve remission

Push dosing on an aggressive schedule for best impact

Understand contributing factors
- Providing counseling/coping skills

Question 8

Nonpharmacological Approaches to Anxiety/Depression Treatment

Answer 8

Exercise

Cognitive behavioral therapy

Exposure therapy

Eye movement desensitization and reprocessing

Short-term psychodynamic psychotherapy

Question 9

Monitoring Pts. who take Anxiety and Depression meds

Answer 9

Assess patient frequently for response to treatment, possible side effects, safety, increased suicidal ideation, and adherence to treatment

When considering frequency of follow up:
The severity of the illness, co-occuring medical conditions, available support systems, progression of symptom change, and the patient’s cooperation with treatment should be assessed.

Question 10

Nonselective Norepinephrine-Serotonin Reuptake inhibitors

Answer 10

Previously referred to as tricyclic antidepressants (TCAs)

Inhibit the reuptake of NE and 5HT while also blocking serotonergic, alpha-adrenergic, histaminic, and muscarinic receptors

Have high side effect profile, not considered first line

Death occurs with overdose with 1 week supply

Care required with refill and amounts with new onset of depression, hx of suicide, high-risk populations

Question 11

Use of Nonselective Medications

Answer 11

Sleep facilitator
- Low dose at bedtime because of common sedation side effect

Chronic Pain Syndromes
- Ability to get longer sleep duration linked with contribution to healing and quality of life

Question 12

Selective Serotonin Reuptake Inhibitors (SSRIs)

Answer 12

Initial drug choice for many patients

Block transport mechanism for unbound 5HT, making more available to bind to the postsynaptic 5HT receptor

Interact with many other drugs

Little evidence for superior effectiveness of one SSRI over another

Serotonin syndrome: a potentially life-threatening condition resulting from excess serotonin agonist activity

Question 13

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Answer 13

Increase levels of both serotonin and norepinephrine (NE) by inhibiting their reuptake into cells in the brain

The addition of NE makes these drugs lethal in overdose

Drugs: Venlafaxine (Effexor & Effexor XR), duloxetine (Cymbalta), and desvenlafaxine (Pristiq)

Also used for neuropathic pain
Used for reduction of vasomotor changes in menopause

Question 14

Norepinephrine-Dopamine Reuptake Inhibitors

Answer 14

Inhibitors of the neuronal uptake of NE and DA
Block receptor sites in reward center- used to treat smoking

Increased risk for seizures
Lower risk of sexual dysfunction reported

Not effective in treating symptoms of anxiety because it may actually exacerbate anxiety and agitation

Bupropion: Wellbutrin, Wellbutrin SR, Wellbutrin XL

Question 15

Serotonin Agonist Reuptake Inhibitors

Answer 15

Inhibit the reuptake of 5HT and block their subtypes

With long-term use, have the ability to increase serotonin release through the desensitization of 5-HT1A receptors

Causes drowsiness and dizziness, thus often given at night

Usually not recommended as first line, especially for men with risk of priapism

Two available: nefazodone and trazodone

Question 16

Norepinephrine- and Serotonin-Specific Agonist

Answer 16

Block 5HT-2 and 5HT3 receptors, resulting in increased levels of NE and 5HT

Also block histamine, causing drowsiness and weight gain as side effects

Mirtazapine (Remeron)

Question 17

Monoamine Oxidase Inhibitors (MAOIs)

Answer 17

Block monoamine oxidase by binding to the enzyme and permanently inactivating it

• Synthesis of replacement MAO requires about 2 weeks
• Allows for levels of DA, NE, and 5HT to rise

Should ONLY be prescribed by a mental health provider

Question 18

Benzodiazepines/GABA-ergics

Answer 18

Enhance GABA neurotransmission, which then lengthens hyperpolarization of the impulse, thus slowing down responses to successive impulses
- the net effect is to decrease reactivity of the brain

Not considered first line because of abuse potential

Divided into short-, intermediate, and long-acting agents

Non-benzodiazepine GABA agonist: Buspirone (Buspar)

Considered only for short-term use without tolerance and dependent onset
Abuse issue now on par with narcotic abuse