Chapter 63: Depression Flashcards
Which neurotransmitters are believed to be involved in depression
most important?
serotonin (5HT), NE, glutamine, Ach, DA, and Epi
serotonin may be the most important
What is the most widely used depression assessment scale?
Hamilton Depression Rating Scale (Ham-D/HDRS)
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)
- 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
remember: M SIG E CAPS
Key drugs that can worsen depression
Atomoxetine (Strattera) Indomethacin Efavirenz (in Atripla) Rilpivirine (in Complera, Odefsy) BB (especially propranolol) Hormonal contraceptives Anabolic steroids antidepressants Benzodiazepines Systemic steroids Interferons Varenicline Ethanol
What disorder should be ruled out prior to starting any anti-depressant and why?
bipolar
prevent inducing mania or rapid-cycling
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, valerian, 5-HTP
Of the natural products that can be used for depression, which can increase the risk of serotonin syndrome
Both St. John’s wort, SAMe, 5-HTP
wich natural product for depression can cause sedation?
Valerian
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
SSRIs are often used first line in pregnancy besides which SSRI and why?
paroxetine
potential cardiac effects
What is the possible risk of SSRI use in pregnancy?
persistent pulmonary HTN of the newborn (PPHN)
preferred agents for depression during breastfeeding
SSRIs or TCAs (except doxepin)
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, hallucinations, muscle rigidity
When d/c an antidepressant, it must be tapered over several weeks to avoid withdrawal EXCEPT which druge?
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)
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)
Fluoxetine should be taken in the morning due to being activating. What is the fluoxetine formulation that should be taken at bedtime and why?
fluoxetine/olanzapine (Symbyax)
sedating
Paroxetine brand name
Paxil
Paroxetine has another brand name (Brisdelle) which is used for
moderate-severe vasomotor symptoms associated with menopause
paroxetine is (sedating/activating)
sedating
take qhs
Sertraline brand name
Zoloft
What are CI to SSRIs
Do not use with MAOi, linezolid, IV methylene blue or pimozide
Brisdelle (paroxetine) has a CI with
pregnancy
SSRI warnings include
QT prolongation (dose limit for citalopram and escitalopram), SIADH/hyponatremia, fall risk, bleeding
SSRI side effects
- Sexual SE
- Somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, HA
Most activating SSRI
fluoxetine; take dose in AM
Most sedating SSRIs
paroxetine, fluvoxamine; take dose in PM
which SSRI is preferred in patients with cardiac risk
sertraline
How long should you wait when switching between MAOi and SSRIs?
With which exception?
2 week washout period
fluoxetine needs 5 week washout due to long t1/2
QT prolongation occurs mostly with which SSRIs
Citalopram and escitalopram
Max dose of citalopram = 40, max escital = 20 mg
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
which has drug interaction with what drug?
Fluoxetine, paroxetine and fluvoxamine
tamoxifen DDI - decr. effectiveness
Tamoxifen requires conversion to its active form by ____. Decreased tamoxifen effectiveness occurs with fluoxetine and paroxetine. Which medication is preferred in combination with tamoxifen
CYP2D6
Venlafaxine (an SNRI)
Which medications have less sexual side effects compared to SSRIs
Vilazodone (Viibryd) and Vortioxetine (Trintellix)
how should vilazodone (Viibryd) be taken?
take with food
I v(w)ill take my vilazodone after im (vilazo)done with food
SNRI MOA
increase 5-HT by inhibiting its reuptake in the neuronal synapse also inhibit reuptake of NE
Venlafaxine brand name
Effexor XR
Venlafaxine uses
Depression, GAD, panic disorder, SocialAD
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 as SSRIs d/t the decrease in 5-HT reuptake. What are the added on SEs?
↑ HR, dilated pupils, dry mouth, excessive sweating and constipation, increased BP (greatest risk with venlafaxine >150mg)
due to NE component
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
increase anticholinergic properties
Which category of TCAs have a worse SE profile
Tertiary amines (amitriptyline, imipramine, clomipramine, trimipramine, and doxepin)
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
Bupropion brand name
Wellbutrin SR, Wellbutrin XL
Zyban indication
(bupropion)
smoking cessation
contrave indication
bupropion/naltrexone
for weight loss
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 side effects
- Dry mouth, CNS stimulation (insomnia, restlessness), tremors/seizures (dose-related), weight loss
- Sexual dysfunction is rare
Washout period between MAOi and bupropion, SSRIs, SNRIs, TCAs
14 days
Isocarboxazid brand name
Marplan
Phenelzine brand name
Nardil
Tranylcypromine
Parnate
Selegiline transdermal patch brand name
Emsam
Selegiline transdermal patch is a ____ selective inhibitor
MAO-B
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.
high in tyramine if 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 trazodone besides depression
Sleep
Trazodone CI
Do not use with MAOi, linezolid or IV methylene blue
SE of trazodone
Sedation, risk of priapism
Nefazodone is rarely used d/t a boxed warning of ______
hepatotoxicity
Mirtazapine & trazodone have an additive risk of
QT prolongation, serotonergic
Which drugs have a lower risk of sexual dysfunction
bupropion and mirtazapine
high risk with SSRIs/SNRIs
Aripiprazole brand names
Abilify, Ability Maintena
Quetiapine brand name
Seroquel
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
Esketamine MOA, administration, DEA class
NMDA receptor antagonist
Nasal spray
C-III
requires REMS program
