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
