Chapter 63: Depression Flashcards
Which neurotransmitters are believed to be involved in depression
serotonin (5HT), glutamine, Ach, DA, NE and Epi
What is the most widely used depression assessment scale?
Ham-D
How is depression diagnosed per DSM-5 criteria
at least 5 of the following symptoms during the same 2 week period (must include depressed mood or diminished interest/pleasure) remember: M SIG E CAPS
- Mood – depressed
- Sleep – increased/decreased
- Interest/pleasure – diminished
- Guilt or feeling or worthlessness
- Energy – decreased
- Concentration – decreased
- Appetite – increased/decreased
- Psychomotor agitation or retardation
- Suicidal ideation
Key drugs that can worsen depression
Atomoxetine (Strattera) Indomethacin Efavirenz (in Atripla) Rilpivirine (in Complera, Odefsy) BB (especially propranolol) Hormonal contraceptives Anabolic steroids Benzodiazepines Systemic steroids Interferons Varenicline Ethanol
Why should benzodiazepines not be used alone in depression
They can worsen and/or mask depression and can be problematic in patients with concurrent substance abuse disorders
What natural products may be helpful for treating depression
St. John’s wort, SAMe or valerian
Of the natural products that can be used for depression, which can increase the risk of serotonin syndrome
Both St. John’s wort and SAMe
If a drug does not work after a suitable trial of at least ____, treatment should be reassessed
4-8 weeks
For most patients, which class/classes of antidepressants should be used?
SSRI or SNRI
MAO inhibitors such as phenelzine, tranylcypromine and isocarboxazid is restricted to which types of patients
Patients unresponsive to other treatments
When is the risk for serotonin syndrome the most severe
when an MAOi is administered with another serotonergic medication
Symptoms of serotonin syndrome include
severe nausea, dizziness, HA, diarrhea, agitation, tachycardia, or hallucinations
When d/c an antidepressant, it must be tapered over several weeks to avoid withdrawal. Which drug is the exception to this rule
fluoxetine, which self-tapers because of its long half-life
Which two antidepressants carry a higher risk of withdrawal symptoms and must be tapered upon d/c
Paroxetine and venlafaxine
What is treatment resistant depression
depression that does not fully respond to two full treatment trials
The _______ guidelines state that patients should receive a 4-8 week trial of medication at a therapeutic dose before concluding that a drug is not working
American Psychiatric Association (APA)
If the patient is not improving or has an incomplete response to an antidepressant:
- Change to a new antidepressant
- Increase the antidepressant dose
- Use a combination of antidepressants with different MOA
- Augment with buspirone or a low dose of an atypical antipsychotic.
- Augmentation with lithium, thyroid hormone (i.e., T3), or in some cases, electroconvulsive therapy (ECT)
Agents approved as augmentation therapy with antidepressants are:
aripiprazole (Abilify), olanzapine + fluoxetine (Symbyax), quetiapine ER (Seroquel XR) and brexpiprazole (Rexulti)
In pregnant and postpartum depression, SSRIs are often used initially, with the exception of _____, due to _____
paroxetine; potential cardiac effects
There is a warning regarding SSRI use during pregnancy and the potential risk of _____
persistent pulmonary HTN of the newborn (PPHN)
T/F: breastfeeding should be avoided when using antidepressants
F; it helps for physical and emotional symptoms & is beneficial for the baby
Which medications are generally preferred for postpartum depression
SSRIs or TCAs (with the exception of doxepin, per ACOG recommendations); Brexanalone (Zulresso) is FDA-approved for PPD
All antidepressants carry a boxed warning of ______
a possible increase in suicidal thoughts or actions in some children, teenagers, or young adults within the few months of treatment or when the dose is changed
What needs to be dispensed with all antidepressants
MedGuides
Physical symptoms such as low energy improve within __ weeks but psychosocial symptoms, such as low mood, may take _____
1-2 weeks
a month or longer
MOA of SSRIs
increase 5-HT by inhibiting its reuptake in the neuronal synapse
Citalopram brand name
Celexa
Citalopram max dose
Max dose in elderly (> 60 years)
40 mg/day
20 mg/day
Escitalopram brand name
Lexapro
Escitalopram max dose
Max dose in elderly (> 60 years)
20 mg/day
10 mg/day
Fluoxetine brand name
Prozac
Fluoxetine has another brand name (Sarafem) which is used for
premenstrual dysphoric disorder (PMDD)
Paroxetine brand name
Paxil
Paroxetine has another brand name (Brisdelle) which is used for
moderate-severe vasomotor symptoms associated with menopause
Sertraline brand name
Zoloft
What are CI to SSRIs
Do not use with MAOi, linezolid, IV methylene blue or pimozide
Brisdelle has a CI with
pregnancy
SSRI warnings include
QT prolongation, SIADH/hyponatremia, fall risk, bleeding
SSRI side effects
- Sexual SE
- Somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, HA
- Osteopenia/osteoporosis, restless leg syndrome
Most activating SSRI
fluoxetine; take dose in AM
Most sedating SSRIs
paroxetine, fluvoxamine; take dose in PM
All SSRIs are available as a solution except
fluvoxamine
which SSRI is preferred in patients with cardiac risk
sertraline
How long should you wait when switching between MAOi and SSRIs
2 week washout period
The typical washout period between all MAOi and SSRI has one exception which is ____ & this drug has a washout period of ____ if switching from it to an MAOi
fluoxetine; 5 week washout period
QT prolongation occurs mostly with which SSRIs
Citalopram and escitalopram
Which medications and natural products can increase bleeding risk when taken with SSRIs & SNRIs
anticoagulants, antiplatelets, NSAIDs, select natural products (e.g., gingko, garlic, ginseng, glucosamine, fish oils), thrombolytics
Which SSRIs are 2D6 inhibitors
Fluoxetine, paroxetine and fluvoxamine
Tamoxifen requires conversion to its active form by CYP2D6. Decreased tamoxifen effectiveness occurs with fluoxetine and paroxetine. Which medication is preferred in combination with tamoxifen
Venlafaxine (an SNRI)
Which medications have less sexual side effects compared to SSRIs
Vilazodone (Viibryd) and Vortioxetine (Trintellix)
SNRI MOA
increase 5-HT by inhibiting its reuptake in the neuronal synapse. SNRIs also inhibit reuptake of NE
Venlafaxine brand name
Effexor XR
Venlafaxine uses
Depression, GAD, panic disorder, SAD
Max dose of Venlafaxine
375 mg/day (IR)
Duloxetine brand name
Cymbalta
Duloxetine uses
Depression, peripheral neuropathy, fibromyalgia, GAD, chronic musculoskeletal pain
Desvenlafaxine brand name
Pristiq
SNRI contraindications
MAOi can potentially cause a lethal drug interaction: hypertensive crisis; linezolid, IV methylene blue
SNRI warnings
SIADH/hyponatremia, fall risk, bleeding
SNRI have similar side effects d/t the decrease in 5-HT reuptake. What side effects are due to increased NE
↑ HR, dilated pupils, dry mouth, excessive sweating and constipation, increased BP
What is the washout period between SNRIs and MAOi
14 days
Which SNRI has additive QT prolongation risk
Venlafaxine
Which SNRI is a moderate 2D6 inhibitor and will cause decreased tamoxifen effectiveness when used together
Duloxetine
TCAs primarily inhibit NE and 5-HT reuptake. They also block ______
Ach and histamine receptors
Which category of TCAs are selective for NE
Secondary amines
Which category of TCAs have a worse SE profile
Tertiary amines (amitriptyline, imipramine, clomipramine, trimipramine, and doxepin)
Amitriptyline brand name
Elavil
Nortriptyline brand name
Pamelor
TCA contraindications
Do not use with MAOi, linezolid or IV methylene blue
TCA side effects
- QT prolongation with overdose (monitor for suicidal ideation, as overdose can quickly cause fatal arrhythmias)
- Orthostasis
- Dry mouth, blurred vision, urinary retention, constipation, weight gain, risk of falls in elderly (BEERS criteria)
Which TCAs are tertiary amines
- Amitriptyline (Elavil)
- Doxepin
- Clomipramine (Anafranil)
- Imipramine (Tofranil)
- Trimipramine
Which TCAs are secondary amines
- Nortriptyline (Pamelor)
- Amoxapine
- Desipramine (Norpramin)
- Mapotiline
- Protriptyline
If going to or from a TCA and MAOi, how long is the washout period
2 weeks
Bupropion brand name
Wellbutrin SR, Wellbutrin XL
Bupropion should not exceed ____ mg/day due to seizure risk
450
Bupropion CI
Seizure disorder; history of anorexia/bulimia; do not use with MAOi, linezolid, IV methylene blue or other forms of bupropion
Bupropion is also used under another brand name for smoking cessation called
Zyban
Which generic form of bupropion is approved for SAD
bupropion XL
bupropion side effects
- Dry mouth, CNS stimulation (insomnia, restlessness), tremors/seizures (dose-related), weight loss
- Sexual dysfunction is rare
Washout period between MAOi and bupropion
14 days
Isocarboxazid brand name
Maraplan
Phenelzine brand name
Nardil
Tranylcypromine
Parnate
Selegiline transdermal patch brand name
Emsam
T/F: Selegiline transdermal patch is a MAO-B selective inhibitor
True
CI drugs that increase serotonin & should not be taken with MAOi d/t risk of serotonin syndrome and hypertensive crisis
linezolid, lithium, tramadol, methadone, St. John’s Wort, meperidine, SSRIs, SNRIs, TCAs, mirtazapine, buspirone, carbamazepine, cyclobenzaprine, dextromethorphan
Which foods are rich in tyramine and should be avoided with MAOi
aged cheese, pickled herring, yeast extract, air-dried meats, sauerkraut, soy sauce, fava beans and some red wines and beers. Foods can become high in tyramine when they have been aged, fermented, picked or smoked
Mirtazapine brand name
Remeron, Remeron SolTab
Mirtazapine is used commonly in oncology and skilled nursing to help with ____ & to ↑ _____
sleep (dosed QHS); appetite
Mirtazapine SE
Sedation, ↑ appetite, weight gain
What is another indication for trazadone besides depression
Sleep
Trazadone CI
Do not use with MAOi, linezolid or IV methylene blue
SE of trazadone
Sedation, risk of priapism
Nefazodone is rarely used d/t a boxed warning of ______
hepatotoxicity
Mirtazapine & trazadone have an additive risk of
QT prolongation
Which drugs have a lower risk of sexual dysfunction
bupropion and mirtazapine
Aripiprazole brand names
Abilify, Ability Maintena
Quetiapine brand name
Seroquel, Seroquel XR
Antipsychotics used for treatment-resistant depression have a boxed warning for
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at ↑ risk of death
Olanzapine/fluoxetine (Symbyax) CI
do not use with pimozide, tioridazine, & caution with other drugs/conditions that cause QT prolongation
Aripiprazole SE
anxiety, insomnia, akathisia
Olanzapine SE
sedation, weight gain, ↑ lipids, ↑ glucose
Quetiapine SE
sedation, orthostasis, weight gain, ↑ lipids, ↑ glucose
