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Anxiety and Depression Flashcards

1
Q

The monoamine theory of depression emphasized

A

deficiency of norepinephrine (NE), serotonin (5-HT) and dopamine (DA)

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2
Q

Depressed mood-> processing issues in the

A

amygdala and the prefrontal cortex

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3
Q

Sleep and appetite-> dysfunction in the

A

hypothalamus

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4
Q

Fatigue-> NE and DA dysregulation in the

A

prefrontal cortex and nucleus accumbens

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5
Q

Guilt, suiciality and worhlessness -> dysregulation in the

A

prefrontal cortex and the amygdala

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6
Q

Worry and obsession -> dysfunction of the

A

cortico-striatal-thalamo-cortical (CSTC) loops in the brain

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7
Q

GAD-> dysfunction of the circuits and the

A

amygdala that are persistent may be the cause of persistent worry, whereas a repetitive loop may be involved in OCD.

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8
Q

PTSD

A

The dysfunction of the amygdala in interpretation of traumatic events and the hippocampus in the memory and re-experiencing of these events

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9
Q

Panic attacks and phobias involve the malfunctioning of neurotransmitters that include the

A

monoamines as well as gamma-aminobutyric acid (GABA) and glutamate

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10
Q

There’s no consensus on the best treatment for

A

PTSD

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11
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors used to be called

A

TCAs (tricyclic antidepressants)

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12
Q

TCAs (tricyclic antidepressants) are now called

A

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors

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13
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs) work by

A

stopping the reuptake of NE and 5HT while also blocking serotonergic, alpha-adrenergic, histaminic, and muscarinic receptors.
Increases in NE and 5HT binding to postsynaptic receptors

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14
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs) have 2 benefits:

A

Efficacious
Low cost
(Nevertheless, the risks outweigh the benefits)

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15
Q

Some problems with Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs) are

A 
Highly sedating
Weight gain common 
Gynecomastia , decreased libido/ sexual dysfunction
Overdose potential 
Cardiac arrhythmia 
hypotension
seizures
death
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16
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): What time should you take them

A

bed time because they are sedating

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17
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): What quality causes weight gain and sedation

A

histaminergic actions

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18
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): can cause cardiac arrhythmia because they have a

A

direct alpha adrenergic and quinidine like effect on the heart

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19
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): ADRs

A

Adverse effects include urinary hesitancy/retention, lowering seizure threshold, ECG changes

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20
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Pharmacokinetics: Highly ____ and ___ ___

A

Highly lipophilic and protein bound

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21
Q

Amitriptyline and imipramine (TCAs) have active metabolites which

A

extend their half lives

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22
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Should they be used during pregnancy

A

unknown

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23
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Stopping the regimen

A

Abrupt discontinuation -> nausea, headache, vertigo, malaise and nightmares

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24
Q

Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitoring: ECG

A

Risk of conduction issues- sinus tachycardia due to NE reuptake inhibition and anticholinergic actions
Prolongation of QRS complex and PR/QT intervals due to slowing of depolarization of the cardiac muscles

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25
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitoring: Suicidal ideations
Monitor for sudden “ups” then “downs” Do not give them more than 1 week worth of medicine
26
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitor for potential to lower ____ thresholds
seizure
27
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Monitoring: Elderly
Anticholinergic and norepinephrine effects can contribute to confusion, orthostatic hypotension and falls.
28
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): ____ risks increase with use of SRIs, cannabis, and sympathomimetics
Cardiotoxicity
29
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Cardiotoxicity risks increase with use of
SRIs, cannabis, and sympathomimetics
30
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): ____ can occur with MAOIs + TCAs
Hyperpyrexia
31
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Hyperpyrexia can occur with
MAOIs + TCAs
32
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): For OCD, which TCA would you use
clomipramine
33
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Can be used for Anxiety disorders due to
serotonergic and noradrenergic effects
34
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): For Panic Disorder, which TCA would you use
imipramine
35
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): imipramine is for
Panic Disorder
36
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): clomipramine is used for
OCD
37
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): for Insomnia you would give
Doxepin, amitriptyline and trazodone
38
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Amitriptyline and imipramine are for
Neuropathic pain
39
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): for Neuropathic pain use
Amitriptyline and imipramine are for
40
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Doxepin, amitriptyline are used for
insomnia (and so is trazadone)
41
Non Selective Norepinephrine-Serotonin Reuptake Inhibitors (TCAs): Some random problems they can be used for
Enuresis in children > 6 years old | Eating disorder
42
SSRIs: ___ has the longest half life - up to 16 days
Fluoxetine
43
SSRIs: __ __ washout period when considering MAOIs
2 week (at least 3 with fluoxetine)
44
SSRIs: Monitor in ___ renal and hepatic impairment
severe
45
SSRIs: pregnancy
Avoid use in the first and last trimesters of pregnancy | Sertraline is safest, paroxetine is NOT safe
46
SSRIs: St. John’s Wort and SAMe may increase risk of
serotonin syndrome
47
SSRIs: use in children: for OCD use
Fluoxetine Fluvoxamine Sertraline
48
SSRIs: use in children: for Major depression use
Fluoxetine | Escitalopram
49
Serotonin partial agonist reuptake inhibitor (SPARI) example
Vilazodone
50
Vilazodone (Serotonin partial agonist reuptake inhibitor) is used for
adult major depressive disorder
51
SSRIs: Sexual dysfunction
35% of patient may experience sexual dysfunction -> may decrease dose or change agent in the same class
52
Serotonin syndrome symptoms
nausea, diarrhea, chills, sweating, hyperthermia, hypertension, myoclonic jerking, tremor, agitation, ataxia, disorientation, confusion and delirium
53
Serotonin syndrome : Drug causes:
tramadol, meperidine, St.John’s wort, dextromethorphan, decongestants
54
SSRIs: Withdrawal symptoms are likely with the agents that have
short half lives (paroxetine, sertraline, citalopram, and escitalopram)
55
SSRIs: All of them need to be tapered except for
Fluoxetine because it has a long half life
56
SSRIs: Citalopram: Limit of 40mg per day due to
QT prolongation
57
SSRIs: Citalopram: Age consideration
Age over 60 years at higher risk (if over 60 Maximum dose of 20mg daily and QTc>500 ms)
58
SSRIs: uses
``` Depression Anxiety Panic disorders OCD (fluvoxamine- only approved use) Bulimia Premenstrual Dysphoric disorder Post-traumatic Stress disorder Generalized anxiety disorder Social phobia ```
59
SSRIs: Benefits
Due to minimal effects on norepinephrine, DA, histamine, or acetylcholine there are few adverse reactions due to the blockade of these receptors Anxiety, restlessness, drowsiness, constipation, and orthostasis
60
SSRIs: Disadvantages
Reduced sexual desire, delayed or absent orgasm, premature ejaculation, and erectile disturbances are most common with SSRIs Occurs in about a month Use of sildenafil or tadalafil may be considered
61
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Examples
Venlafaxine, duloxetine, desvenlafaxine, levomilnacipran, milnacipran, nefazodone
62
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Mechanism of action
Blocks the reuptake mechanism of NE and 5HT, allowing greater availability of these neurotransmitters to bind with receptors in the brain
63
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Metabolism and excretion
Metabolized extensively in the liver
64
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Caution
Duloxetine may exacerbate narrow-angle glaucoma and can increase serum transaminase levels
65
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Adverse Effects: Venlafaxine and duloxetine
Headache, somnolence, dizziness, insomnia, nervousness, nausea, dry mouth, constipation, and abnormal ejaculations Appetite and weight decreases May increase BP
66
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Adverse Effects: Milnacipran
Nausea, headache, constipation, hot flush, dizziness, hyperhidrosis, palpitations, sexual dysfunction in men
67
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Adverse Effects: Levomilnacipran
Nausea, constipation, hyperhidrosis, tachycardia; dose related- erectile dysfunction and urinary hesitancy
68
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: All are approved to treat
major depressive disorders and bipolar mood disorders
69
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Venlafaxine
Anxiety disorders - GAD, social phobia, PTSD | May be effective for adults with depression and ADHD
70
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Duloxetine
Neuropathic pain Overactive bladder Diabetic neuropathy
71
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Venlafaxine: Withdrawal symptoms
Withdrawal symptoms- paresthesias, dizziness, nausea, vomiting
72
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Considerations for Duloxetine
Doses greater than 60mg/day not considered to be of greater efficacy Monitor liver function
73
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Levomilnacipran
Major depressive disorder
74
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Uses: Milnacipran
Fibromyalgia only
75
Serotonin-norepinephrine reuptake inhibitors (SNRIs): NOT first choice for patients with:
uncontrolled HTN, preexisting sleep disturbance and autonomic instability Overdose can be lethal
76
Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Indications
Treatment of major depressive disorder, including seasonal affective disorder, adjunct smoking cessation
77
Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Considerations
If a second daily dose is required, give second dose not later than 5 hours before bedtime due to its stimulating effects Seizure risk at high doses- max daily dose 450mg
78
Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Adverse effects
Dry mouth, sweating, tremors, nervousness | Lower incidence of sexual side effects
79
Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion: Mechanism of action
Increases NE and DA by weakly inhibiting their neuronal reuptake
80
Serotonin-agonist reuptake inhibitors (SARIs): Nefazodone and trazodone: Mechanism of action
Inhibit the reuptake of 5HT and blocks the postsynaptic 5HT2 receptor
81
Serotonin-agonist reuptake inhibitors (SARIs): Nefazodone and trazodone: Place in therapy
Use side effects for treatment of insomnia
82
Serotonin-agonist reuptake inhibitors (SARIs): Nefazodone: Black box warning-
hepatotoxicity
83
Serotonin-agonist reuptake inhibitors (SARIs): trazodone:
Associated with priapism and anticholinergic side effects | Not first line therapy due to sedation and orthostatic hypotension
84
Norepinephrine- and Serotonin specific agonists (NaSSAs): Mirtazapine: Mechanism of action
5HT agonist and reuptake inhibitor that blocks the reuptake of NE Blocking 5HT2 and 5HT3 specifically results in less sexual, gastrointestinal, and anxiogenic side effects. The blocking of histamine also results in drowsiness and weight gain No antimuscarinic side effects of NNSRIs
85
Norepinephrine- and Serotonin specific agonists (NaSSAs): Mirtazapine: Place in therapy
Depression in a patient with difficulty sleeping and weight loss
86
Monoamine oxidase inhibitors (MAOIs): examples
Phenelzine, tranylcypromine, isocarboxazid, selegiline
87
Monoamine oxidase inhibitors (MAOIs): Monoamine oxidase is an enzyme that contributes to the degradation of the monoamines-
DA, 5HT, and NE.
88
Monoamine oxidase inhibitors (MAOIs): Mechanism
The MAOIs permanently block onoamine oxidase. It takes about 2 weeks to replace MAO. The catecholamines and 5HT will rise, and so will dietary tyramine and phenylethylamine levels because MAO is needed to metabolize them.
89
Monoamine oxidase inhibitors (MAOIs): Adverse effects-
occipital headache radiating frontally, sweating, photophobia, palpitations, stiffness in the neck, nausea or vomiting
90
Benzodiazepines: Short acting agents
Oxazepam and triazolam
91
Benzodiazepines: Intermediate acting agents
Alprazolam, lorazepam, estazolam, temazepam
92
Benzodiazepines: Long acting agents
Diazepam, quazepam, clorazepate, chlordiazepoxide, flurazepam
93
Benzodiazepines: Mechanism of action-
decrease reactivity of the brain by enhancing GABA neurotransmission, which lengthens hyperpolarization of the impulse, slowing down responses to successive impulses
94
Benzodiazepines: Place in therapy
Anxiolytic, anterograde amnesia, anticonvulsant, muscle relaxation and sedation
95
Benzodiazepines: Advantages
Rapid onset of action Tolerability Little CV effect
96
Benzodiazepines: Disadvantages
Dependence and withdrawal Risk of overdose, respiratory depression and death Sedation, impaired motor coordination and cognition Depressive symptoms worsen Abrupt discontinuation can lead to seizures and withdrawal symptoms

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