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NAPLEX > Chapter 63: Depression > Flashcards

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
Q

Physical symptoms such as low energy improve within __ weeks but psychosocial symptoms, such as low mood, may take _____

A

1-2 weeks

a month or longer

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26
Q

MOA of SSRIs

A

increase 5-HT by inhibiting its reuptake in the neuronal synapse

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27
Q

Citalopram brand name

A

Celexa

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28
Q

Citalopram max dose

Max dose in elderly (> 60 years)

A

40 mg/day

20 mg/day

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29
Q

Escitalopram brand name

A

Lexapro

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30
Q

Escitalopram max dose

Max dose in elderly (> 60 years)

A

20 mg/day

10 mg/day

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31
Q

Fluoxetine brand name

A

Prozac

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32
Q

Fluoxetine has another brand name (Sarafem) which is used for

A

premenstrual dysphoric disorder (PMDD)

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33
Q

Paroxetine brand name

A

Paxil

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34
Q

Paroxetine has another brand name (Brisdelle) which is used for

A

moderate-severe vasomotor symptoms associated with menopause

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35
Q

Sertraline brand name

A

Zoloft

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36
Q

What are CI to SSRIs

A

Do not use with MAOi, linezolid, IV methylene blue or pimozide

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37
Q

Brisdelle has a CI with

A

pregnancy

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38
Q

SSRI warnings include

A

QT prolongation, SIADH/hyponatremia, fall risk, bleeding

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39
Q

SSRI side effects

A
  • Sexual SE
  • Somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, HA
  • Osteopenia/osteoporosis, restless leg syndrome
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40
Q

Most activating SSRI

A

fluoxetine; take dose in AM

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41
Q

Most sedating SSRIs

A

paroxetine, fluvoxamine; take dose in PM

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42
Q

All SSRIs are available as a solution except

A

fluvoxamine

43
Q

which SSRI is preferred in patients with cardiac risk

A

sertraline

44
Q

How long should you wait when switching between MAOi and SSRIs

A

2 week washout period

45
Q

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

A

fluoxetine; 5 week washout period

46
Q

QT prolongation occurs mostly with which SSRIs

A

Citalopram and escitalopram

47
Q

Which medications and natural products can increase bleeding risk when taken with SSRIs & SNRIs

A

anticoagulants, antiplatelets, NSAIDs, select natural products (e.g., gingko, garlic, ginseng, glucosamine, fish oils), thrombolytics

48
Q

Which SSRIs are 2D6 inhibitors

A

Fluoxetine, paroxetine and fluvoxamine

49
Q

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

A

Venlafaxine (an SNRI)

50
Q

Which medications have less sexual side effects compared to SSRIs

A

Vilazodone (Viibryd) and Vortioxetine (Trintellix)

51
Q

SNRI MOA

A

increase 5-HT by inhibiting its reuptake in the neuronal synapse. SNRIs also inhibit reuptake of NE

52
Q

Venlafaxine brand name

A

Effexor XR

53
Q

Venlafaxine uses

A

Depression, GAD, panic disorder, SAD

54
Q

Max dose of Venlafaxine

A

375 mg/day (IR)

55
Q

Duloxetine brand name

A

Cymbalta

56
Q

Duloxetine uses

A

Depression, peripheral neuropathy, fibromyalgia, GAD, chronic musculoskeletal pain

57
Q

Desvenlafaxine brand name

A

Pristiq

58
Q

SNRI contraindications

A

MAOi can potentially cause a lethal drug interaction: hypertensive crisis; linezolid, IV methylene blue

59
Q

SNRI warnings

A

SIADH/hyponatremia, fall risk, bleeding

60
Q

SNRI have similar side effects d/t the decrease in 5-HT reuptake. What side effects are due to increased NE

A

↑ HR, dilated pupils, dry mouth, excessive sweating and constipation, increased BP

61
Q

What is the washout period between SNRIs and MAOi

A

14 days

62
Q

Which SNRI has additive QT prolongation risk

A

Venlafaxine

63
Q

Which SNRI is a moderate 2D6 inhibitor and will cause decreased tamoxifen effectiveness when used together

A

Duloxetine

64
Q

TCAs primarily inhibit NE and 5-HT reuptake. They also block ______

A

Ach and histamine receptors

65
Q

Which category of TCAs are selective for NE

A

Secondary amines

66
Q

Which category of TCAs have a worse SE profile

A 
Tertiary amines
(amitriptyline, imipramine, clomipramine, trimipramine, and doxepin)
67
Q

Amitriptyline brand name

A

Elavil

68
Q

Nortriptyline brand name

A

Pamelor

69
Q

TCA contraindications

A

Do not use with MAOi, linezolid or IV methylene blue

70
Q

TCA side effects

A
  • 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
Q

Which TCAs are tertiary amines

A
  • Amitriptyline (Elavil)
  • Doxepin
  • Clomipramine (Anafranil)
  • Imipramine (Tofranil)
  • Trimipramine
72
Q

Which TCAs are secondary amines

A
  • Nortriptyline (Pamelor)
  • Amoxapine
  • Desipramine (Norpramin)
  • Mapotiline
  • Protriptyline
73
Q

If going to or from a TCA and MAOi, how long is the washout period

A

2 weeks

74
Q

Bupropion brand name

A

Wellbutrin SR, Wellbutrin XL

75
Q

Bupropion should not exceed ____ mg/day due to seizure risk

A

450

76
Q

Bupropion CI

A

Seizure disorder; history of anorexia/bulimia; do not use with MAOi, linezolid, IV methylene blue or other forms of bupropion

77
Q

Bupropion is also used under another brand name for smoking cessation called

A

Zyban

78
Q

Which generic form of bupropion is approved for SAD

A

bupropion XL

79
Q

bupropion side effects

A
  • Dry mouth, CNS stimulation (insomnia, restlessness), tremors/seizures (dose-related), weight loss
  • Sexual dysfunction is rare
80
Q

Washout period between MAOi and bupropion

A

14 days

81
Q

Isocarboxazid brand name

A

Maraplan

82
Q

Phenelzine brand name

A

Nardil

83
Q

Tranylcypromine

A

Parnate

84
Q

Selegiline transdermal patch brand name

A

Emsam

85
Q

T/F: Selegiline transdermal patch is a MAO-B selective inhibitor

A

True

86
Q

CI drugs that increase serotonin & should not be taken with MAOi d/t risk of serotonin syndrome and hypertensive crisis

A

linezolid, lithium, tramadol, methadone, St. John’s Wort, meperidine, SSRIs, SNRIs, TCAs, mirtazapine, buspirone, carbamazepine, cyclobenzaprine, dextromethorphan

87
Q

Which foods are rich in tyramine and should be avoided with MAOi

A

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
Q

Mirtazapine brand name

A

Remeron, Remeron SolTab

89
Q

Mirtazapine is used commonly in oncology and skilled nursing to help with ____ & to ↑ _____

A

sleep (dosed QHS); appetite

90
Q

Mirtazapine SE

A

Sedation, ↑ appetite, weight gain

91
Q

What is another indication for trazadone besides depression

A

Sleep

92
Q

Trazadone CI

A

Do not use with MAOi, linezolid or IV methylene blue

93
Q

SE of trazadone

A

Sedation, risk of priapism

94
Q

Nefazodone is rarely used d/t a boxed warning of ______

A

hepatotoxicity

95
Q

Mirtazapine & trazadone have an additive risk of

A

QT prolongation

96
Q

Which drugs have a lower risk of sexual dysfunction

A

bupropion and mirtazapine

97
Q

Aripiprazole brand names

A

Abilify, Ability Maintena

98
Q

Quetiapine brand name

A

Seroquel, Seroquel XR

99
Q

Antipsychotics used for treatment-resistant depression have a boxed warning for

A

Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at ↑ risk of death

100
Q

Olanzapine/fluoxetine (Symbyax) CI

A

do not use with pimozide, tioridazine, & caution with other drugs/conditions that cause QT prolongation

101
Q

Aripiprazole SE

A

anxiety, insomnia, akathisia

102
Q

Olanzapine SE

A

sedation, weight gain, ↑ lipids, ↑ glucose

103
Q

Quetiapine SE

A

sedation, orthostasis, weight gain, ↑ lipids, ↑ glucose

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