Chapter 35 - Antidepressants Flashcards
1
Q
What is the most common psychiatric disorder?
A
depression
2
Q
What are the clinical features of depression?
A
-depressed mood
-loss of pleasure or interest
-insomnia
-anorexia
-loss of concentration
-feelings of guilt, worthlessness, helplessness
-suicidal thoughts
3
Q
How long do symptoms need to last to be considered depression?
A
present most of the day, nearly every day, for at least 2 weeks
4
Q
What are possible factors that contribute to depression?
A
-genetics
-childhood (ACEs)
-low self-esteem
-life stress
5
Q
The monoamine hypothesis of depression says…
A
depression is thought to be caused by functional insufficiency of monoamine NTs
6
Q
When we say depression is complex we mean…
A
there is likely no ‘one’ cause
7
Q
Explain the association between inflammation and depression:
A
-activation of immune system and inflammation change BBB
-BBB allows entry of pro-inflammatory proteins that change brain and cause depression
8
Q
When is electroconvulsive therapy used?
A
-when drugs and psychotherapy don’t work
-rapid response needed
-severe depression
-suicidal patients
-elderly patients at risk of starving
9
Q
What is TMS?
A
transcranial magnetic stimulation
10
Q
When do initial responses to antidepressants begin?
A
1-3 weeks after starting therapy
11
Q
Maximal responses of antidepressants may not be seen for ___ weeks
A
12
12
Q
What is considered a failed response to antidepressants?
A
drugs taken for 1 month with no success
13
Q
How does efficacy of antidepressants vary?
A
it doesn’t they are nearly all equal
14
Q
How do antidepressants affect suicidal tendencies?
A
-may increase them during early treatment
-especially in young adults
15
Q
What changes should patients starting antidepressants be watched for?
A
-suicidal behaviour
-worsening mood
-behaviour changes
16
Q
What does SSRI stand for?
A
selective serotonin reuptake inhibitor
17
Q
When were SSRIs introduced?
A
1987
18
Q
What is the most commonly prescribed antidepressant?
A
SSRIs
19
Q
SSRIs are as effective as ________________ but don’t cause…
A
tricyclic antidepressants; SSRIs don’t cause hypotension, sedation, anticholinergic effects
20
Q
Does overdose on SSRIs cause cardiac toxicity?
A
no
21
Q
How common is death by SSRI overdose?
A
not common
22
Q
How do SSRIs act?
A
blocking neuronal 5-HT reuptake
23
Q
What was once the most widely prescribed SSRI in the world?
A
Fluoxetine (Prozac)
24
Q
What is Fluoxetine (Prozac) used for?
A
-bipolar disorder
-OCD
-panic disorder
-bulimia nervosa
-premenstrual dysphoric disorder
-GAD
-PTSD
-social anxiety
-ADHD
-tourettes
25
What are the adverse effects of Fluoxetine (Prozac)?
-serotonin syndrome
-teratogenesis
-bleeding disorders
-sexual dysfunction
-weight gain
-hyponatremia (older adults)
-withdrawal syndrome
26
When does serotonin syndrome start?
2-72 hours after treatment
27
What does serotonin syndrome involve?
-agitation
-confusion
-disorientation
-anxiety
-hallucinations
-poor concentration
-incoordination
-myoclonus
-hyperreflexia
-excessive sweating
-tremor
-fever
-death
28
How do you stop serotonin syndrome?
discontinuation of the drug
29
What increases the risk of serotonin syndrome?
concurrent use of MAOIs and other drugs that affect 5-HT
30
What does fluoxetine (prozac) interact with?
-monoamine oxidase inhibitors (MAOIs)
-antiplatelets
-anticoagulants
-other drugs that work on 5-HT
31
What does SNRI stand for?
serotonin/norepinephrine reuptake inhibitor
32
What group of antidepressant is Venlafaxine (Effexor)?
SNRI
33
What are SNRIs used for?
-major depression
-GAD
-social anxiety disorder
-neuropathic pain
34
SNRIs block the reuptake of...
NE and 5-HT
35
What are the side effects of SNRIs?
-nausea
-headache
-anorexia
-nervousness
-sweating
-somnolence
-insomnia
-weight loss
-diastolic hypertension
-sexual dysfunction
-hyponatremia (older adults)
-neonatal withdrawal syndrome
-withdrawal syndrome
36
Desvenlafaxine, Duloxetine, Levomilnacipran, and Venlafaxine are all ________
SNRIs
37
What is a special consideration of the absorption of Duloxetine?
food reduces rate of absorption
38
How does Duloextine travel in the bloodstream?
bound to albumin
39
How is Venlafaxine administered?
XR capsules
40
With Venladaxine and Levomilnacipran, the dose must be decreased when...
the patient has liver or kidney dysfunction
41
What does SPARI stand for?
serotonin-1A partial agonist/serotonin reuptake inhibitor
42
What group of antidepressant is Vilazodone (Viibryd)?
SPARI
43
How does Vilazodone act?
ssri and partial agonist of 5-HT1A
44
What is Vilazodone used for?
manic depressive disorder and generalized anxiety disorder
45
Vilazodone should be administered with or without food?
with food
46
Vilazodone should not be administered with food or meds with _____________ properties such as...
anticoagulant; ginko, ginger, garlic, licorice
47
What are side effects of Vilazodone?
-headache
-diarrhea
-nausea
48
Do symptoms stop suddenly when Vilazodone is discontinued?
no
49
How long does it take for Vilazodone to take effect?
up to 28 days
50
What does SARI stand for?
serotonin antagonist receptor inhibitor
51
What drug class is Vortioxetine (Trintellix)?
SARI
52
How does Vortioxetine work?
-inhibit 5-HT reuptake
-stimulate 5-HT1A receptors
-block 5-HT3, 5-HT1D, 5-HT7 receptors
-partial agonist of 5-HT1B receptors
53
What is Vortioxetine used for?
major depression in adults
54
When does Vortioxetine require a 50% dose reduction?
when taken with CYP2D6 inhibitors
55
How is Vortioxetine transported in blood?
higly protein bound
56
What are the adverse effects of Vortioxetine?
-nausea
-constipation
-suicide
-agitation
-NMS
-serotonin syndrome
-hyponatremia
-pregnancy
-bone fracture risk
57
What antidepressant group is Trazodone?
SARI
58
How does Trazodone act at high doses?
-bind to 5-HT2 receptors and acts as a 5-HT agonist
59
How does Trazodone act at low doses?
-bind to 5-HT2 receptors and acts as a 5-HT antagonist, like SSRIs
60
What receptor subtypes does SARI act on?
H1, A1, and A2
61
What is Trazodone used for?
as a sedative, even in people without depression
62
What are the adverse effects of Trazodone?
-anticholinergic
-priapism (erection)
63
How do tricyclic antidepressants act?
by blocked reuptake of NE and 5-HT
64
What is the most dangerous AE of TCAs?
cardiotoxic in OD
65
Amitrityline along with Clomipramine, Doxepin, Imipramine, Nortriptyline are all...
TCAs
66
What are TCAs used for?
-depression
-fibromyalgia syndrome
-neuropathic pain
-chronic insomnia
-ADHD
-panic disorder
-OCD
-nocturnal enuresis
67
What are the adverse effects of TCAs?
-orthostatic hypotension
-anticholinergic effects!!
-diaphoresis (sweating)
-sedation
-cardiac toxicicty
-seizures
68
TCA toxicity (anticholinergic and cardiotoxic) manifests as:
-dysrhythmias
-tachycardia
-intraventricular blocks
-complete AV block
-ventricular tachycardia
-V fib
69
How is TCA toxicity treated?
-gastric lavage
-charcoal ingestion
-IV sodium bicarbonate (dysrhythmias)
70
MAOIs are the ________ or ________ choice antidepressants for most patients.
second or third
71
How do MAOIs compare to TCAs and SSRIs?
-equally effective
-MAOIs are more hazardous
72
Eating foods rich in ___________ risk triggering hypertensive crisis in patients taking MAOIs.
tyramine
73
MAOIs are the drug of choice for _________ depression
atypical
74
Phenelzine (Nardil) is a _______
MAOI
75
How do MAOIs act?
-convert monoamine NTs (NE, serotonin, and dopamine) into active products
-inactivate tyramine and biogenic amines
76
What are the two forms of MAO in the body?
MAO-A
MAO-B
77
Reversible MAOI action lasts ________
3-5 days
78
Irreversible MAOI action lasts _________
~2 weeks
79
What are MAOIs used for?
-depression
-bulimia nervosa
-agoraphobia
-ADHD
-OCD
-panic attacks
80
What are the AEs of MAOIs?
-CNS stimulation
-orthostatic hypotension
-hypertensive crisis (via dietary tyramine)
81
How does tyramine promote hypertensive crisis?
tyramine promotes the release of NE from sympathetic neurons
82
What are the symptoms of a hypertensive crisis?
-headache
-tachycardia
-hypertension
-N&V
-confusion
-sweating
-stroke
-death
83
What foods should not be eaten when taking MAOIs?
cheese, salami, wine, beer
84
What is the treatment for hypertensive crisis?
-IV vasodilator
-sodium nitroprusside
-phentolamine (alpha antagonist)
-labetalol (A/B antagonist)
85
What does RIMA stand for?
reversible inhibitor of monoamine oxidase
86
What class of antidepressant is Moclobemide?
RIMA
87
How does Moclobemide act?
by reversibly inhibiting monoamine oxidase
88
What are the adverse effects of Moclobemide?
-dry mouth
-dizziness
-tremor
-headache
-restlessness
89
What is Moclobemide used for?
-anxiety
-phobias
-atypical depression
90
When is Moclobemide administered?
after meals
91
Can people on Moclobemide eat tyramine?
yes but not in excessive amounts
92
What does Moclobemide interact with?
-St. John's wort
-many others
93
What antidepressant class is Bupropion (Wellbutrin)?
norepinephrine and dopamine reuptake inhibitor
94
In what cases should the dose of Bupropion be decreased?
renal dysfunction
95
How does Bupropion differ from the rest of the drugs?
-no weight gain
-no sexual dysfunction
-increased seizure risk
-Zyban brand used for smoking cessation
-SR and XL tabs
96
What are the adverse effects of Bupropion?
-seizures
-agitation
-tremor
-tachycardia
-blurred vision
-dizziness
-headache
-insomnia
-dry mouth
-GI upset
97
What does Bupropion interact with?
MAOIs
98
How does Mirtazapine (Remeron) act?
-block 5-HT2, 5-HT3 & H1 receptors
-moderate blockade of A1 and muscarinic receptors
99
What are the adverse effects of Mirtazapine?
-anticholinergic (dry mouth, sedation)
-edema
-dizziness
-arthralgias (joint stiffness)
-nightmares
-weight gain
-increased QT interval
100
What is Mirtazapine used for?
-anxiety
-somatization
-depression
101
How does Mirtazapine differ from other drugs?
less sexual dysfunction
102
What antidepressant class is Esketamine (Spravato)?
glutamate receptor modulator (NMDA receptor antagonist)
103
How does Esketamine act?
non-selective, non-competitive blockade of NMDA (glutamate) receptors
104
What is Esketamine used for?
-MDD
-combined with SSRI and SNRI when no response to 2 courses of current treatment
105
WARNINGS of Esketamine:
-assess BP before and after (will peak 40min post dose, monitor till normal)
-dissociative sedation
-respiratory depress
-signs of abuse or misuse
-suicidal ideation
-CV risk (resuscitation equip avail!!!)
106
How is esketamine given?
-2 sprays intranasally
-single use
107
Esketamine isn't used or people older than ______
age 65
108
People of ___________ ancestry should have a reduced dose of Esketamine
Japanese
109
What are the side effects of esketamine?
-increased BP
-sedation
-dissociation
-headache
-vertigo
110
Esketamine administration requires:
-direct HCP supervision
-2 hr observation
111
Electroconvulsive therapy is effective and ________
rapid
112
What is an adverse effect of ECT?
memory loss of immediate events
113
Where does transcranial magnetic therapy deliver magnetic fields?
left dorsolateral prefrontal cortex
114
TMT lasts ____ sessions every ___ weeks
40 min; every 6 weeks
115
What are the adverse effects of TMT?
-transient headaches
-scalp discomfort
-eye pain
-toothache
-muscle twitching
-seizures
116
When is vagus nerve stimulation used?
long-term therapy of treatment-resistant depression - when at least 4 drugs have failed
117
What is vagus nerve stimulation?
implanted device that delivers electrical pulses to the vagus nerve
118
What are the side effects of vagus nerve stimulation?
-hoarseness
-voice alteration
-cough
-dyspnea
119
What is light therapy used for?
treatment of seasonal affective disorder and nonseasonal major depression
120
What is Psilocybin?
a 5-HT2A receptor agonist that is used for therapy in opioid addiction and mental heath conditions
