Chapter 63: Depression Flashcards

1
Q

Which neurotransmitters are believed to be involved in depression

A

serotonin (5HT), glutamine, Ach, DA, NE and Epi

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2
Q

What is the most widely used depression assessment scale?

A

Ham-D

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3
Q

How is depression diagnosed per DSM-5 criteria

A

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
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4
Q

Key drugs that can worsen depression

A
Atomoxetine (Strattera)
Indomethacin
Efavirenz (in Atripla)
Rilpivirine (in Complera, Odefsy)
BB (especially propranolol)
Hormonal contraceptives
Anabolic steroids
Benzodiazepines
Systemic steroids
Interferons
Varenicline 
Ethanol
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5
Q

Why should benzodiazepines not be used alone in depression

A

They can worsen and/or mask depression and can be problematic in patients with concurrent substance abuse disorders

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6
Q

What natural products may be helpful for treating depression

A

St. John’s wort, SAMe or valerian

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7
Q

Of the natural products that can be used for depression, which can increase the risk of serotonin syndrome

A

Both St. John’s wort and SAMe

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8
Q

If a drug does not work after a suitable trial of at least ____, treatment should be reassessed

A

4-8 weeks

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9
Q

For most patients, which class/classes of antidepressants should be used?

A

SSRI or SNRI

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10
Q

MAO inhibitors such as phenelzine, tranylcypromine and isocarboxazid is restricted to which types of patients

A

Patients unresponsive to other treatments

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11
Q

When is the risk for serotonin syndrome the most severe

A

when an MAOi is administered with another serotonergic medication

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12
Q

Symptoms of serotonin syndrome include

A

severe nausea, dizziness, HA, diarrhea, agitation, tachycardia, or hallucinations

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13
Q

When d/c an antidepressant, it must be tapered over several weeks to avoid withdrawal. Which drug is the exception to this rule

A

fluoxetine, which self-tapers because of its long half-life

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14
Q

Which two antidepressants carry a higher risk of withdrawal symptoms and must be tapered upon d/c

A

Paroxetine and venlafaxine

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15
Q

What is treatment resistant depression

A

depression that does not fully respond to two full treatment trials

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16
Q

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

A

American Psychiatric Association (APA)

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17
Q

If the patient is not improving or has an incomplete response to an antidepressant:

A
  • 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)
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18
Q

Agents approved as augmentation therapy with antidepressants are:

A

aripiprazole (Abilify), olanzapine + fluoxetine (Symbyax), quetiapine ER (Seroquel XR) and brexpiprazole (Rexulti)

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19
Q

In pregnant and postpartum depression, SSRIs are often used initially, with the exception of _____, due to _____

A

paroxetine; potential cardiac effects

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20
Q

There is a warning regarding SSRI use during pregnancy and the potential risk of _____

A

persistent pulmonary HTN of the newborn (PPHN)

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21
Q

T/F: breastfeeding should be avoided when using antidepressants

A

F; it helps for physical and emotional symptoms & is beneficial for the baby

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22
Q

Which medications are generally preferred for postpartum depression

A

SSRIs or TCAs (with the exception of doxepin, per ACOG recommendations); Brexanalone (Zulresso) is FDA-approved for PPD

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23
Q

All antidepressants carry a boxed warning of ______

A

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

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24
Q

What needs to be dispensed with all antidepressants

A

MedGuides

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25
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
26
MOA of SSRIs
increase 5-HT by inhibiting its reuptake in the neuronal synapse
27
Citalopram brand name
Celexa
28
Citalopram max dose | Max dose in elderly (> 60 years)
40 mg/day | 20 mg/day
29
Escitalopram brand name
Lexapro
30
Escitalopram max dose | Max dose in elderly (> 60 years)
20 mg/day | 10 mg/day
31
Fluoxetine brand name
Prozac
32
Fluoxetine has another brand name (Sarafem) which is used for
premenstrual dysphoric disorder (PMDD)
33
Paroxetine brand name
Paxil
34
Paroxetine has another brand name (Brisdelle) which is used for
moderate-severe vasomotor symptoms associated with menopause
35
Sertraline brand name
Zoloft
36
What are CI to SSRIs
Do not use with MAOi, linezolid, IV methylene blue or pimozide
37
Brisdelle has a CI with
pregnancy
38
SSRI warnings include
QT prolongation, SIADH/hyponatremia, fall risk, bleeding
39
SSRI side effects
- Sexual SE - Somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, HA - Osteopenia/osteoporosis, restless leg syndrome
40
Most activating SSRI
fluoxetine; take dose in AM
41
Most sedating SSRIs
paroxetine, fluvoxamine; take dose in PM
42
All SSRIs are available as a solution except
fluvoxamine
43
which SSRI is preferred in patients with cardiac risk
sertraline
44
How long should you wait when switching between MAOi and SSRIs
2 week washout period
45
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
46
QT prolongation occurs mostly with which SSRIs
Citalopram and escitalopram
47
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
48
Which SSRIs are 2D6 inhibitors
Fluoxetine, paroxetine and fluvoxamine
49
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)
50
Which medications have less sexual side effects compared to SSRIs
Vilazodone (Viibryd) and Vortioxetine (Trintellix)
51
SNRI MOA
increase 5-HT by inhibiting its reuptake in the neuronal synapse. SNRIs also inhibit reuptake of NE
52
Venlafaxine brand name
Effexor XR
53
Venlafaxine uses
Depression, GAD, panic disorder, SAD
54
Max dose of Venlafaxine
375 mg/day (IR)
55
Duloxetine brand name
Cymbalta
56
Duloxetine uses
Depression, peripheral neuropathy, fibromyalgia, GAD, chronic musculoskeletal pain
57
Desvenlafaxine brand name
Pristiq
58
SNRI contraindications
MAOi can potentially cause a lethal drug interaction: hypertensive crisis; linezolid, IV methylene blue
59
SNRI warnings
SIADH/hyponatremia, fall risk, bleeding
60
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
61
What is the washout period between SNRIs and MAOi
14 days
62
Which SNRI has additive QT prolongation risk
Venlafaxine
63
Which SNRI is a moderate 2D6 inhibitor and will cause decreased tamoxifen effectiveness when used together
Duloxetine
64
TCAs primarily inhibit NE and 5-HT reuptake. They also block ______
Ach and histamine receptors
65
Which category of TCAs are selective for NE
Secondary amines
66
Which category of TCAs have a worse SE profile
``` Tertiary amines (amitriptyline, imipramine, clomipramine, trimipramine, and doxepin) ```
67
Amitriptyline brand name
Elavil
68
Nortriptyline brand name
Pamelor
69
TCA contraindications
Do not use with MAOi, linezolid or IV methylene blue
70
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)
71
Which TCAs are tertiary amines
- Amitriptyline (Elavil) - Doxepin - Clomipramine (Anafranil) - Imipramine (Tofranil) - Trimipramine
72
Which TCAs are secondary amines
- Nortriptyline (Pamelor) - Amoxapine - Desipramine (Norpramin) - Mapotiline - Protriptyline
73
If going to or from a TCA and MAOi, how long is the washout period
2 weeks
74
Bupropion brand name
Wellbutrin SR, Wellbutrin XL
75
Bupropion should not exceed ____ mg/day due to seizure risk
450
76
Bupropion CI
Seizure disorder; history of anorexia/bulimia; do not use with MAOi, linezolid, IV methylene blue or other forms of bupropion
77
Bupropion is also used under another brand name for smoking cessation called
Zyban
78
Which generic form of bupropion is approved for SAD
bupropion XL
79
bupropion side effects
- Dry mouth, CNS stimulation (insomnia, restlessness), tremors/seizures (dose-related), weight loss - Sexual dysfunction is rare
80
Washout period between MAOi and bupropion
14 days
81
Isocarboxazid brand name
Maraplan
82
Phenelzine brand name
Nardil
83
Tranylcypromine
Parnate
84
Selegiline transdermal patch brand name
Emsam
85
T/F: Selegiline transdermal patch is a MAO-B selective inhibitor
True
86
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
87
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
88
Mirtazapine brand name
Remeron, Remeron SolTab
89
Mirtazapine is used commonly in oncology and skilled nursing to help with ____ & to ↑ _____
sleep (dosed QHS); appetite
90
Mirtazapine SE
Sedation, ↑ appetite, weight gain
91
What is another indication for trazadone besides depression
Sleep
92
Trazadone CI
Do not use with MAOi, linezolid or IV methylene blue
93
SE of trazadone
Sedation, risk of priapism
94
Nefazodone is rarely used d/t a boxed warning of ______
hepatotoxicity
95
Mirtazapine & trazadone have an additive risk of
QT prolongation
96
Which drugs have a lower risk of sexual dysfunction
bupropion and mirtazapine
97
Aripiprazole brand names
Abilify, Ability Maintena
98
Quetiapine brand name
Seroquel, Seroquel XR
99
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
100
Olanzapine/fluoxetine (Symbyax) CI
do not use with pimozide, tioridazine, & caution with other drugs/conditions that cause QT prolongation
101
Aripiprazole SE
anxiety, insomnia, akathisia
102
Olanzapine SE
sedation, weight gain, ↑ lipids, ↑ glucose
103
Quetiapine SE
sedation, orthostasis, weight gain, ↑ lipids, ↑ glucose