Depression Flashcards
what are 1st line meds?
SSRI - citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
*most effective and well tolerated
SNRI - venlafaxine, desvenlafaxine, duloxetine (but not levomilnacipran)
Dual Acting (NDRI) - bupropion, mirtazapine
Other (serotonergic) - vortrioxetine
what are 2nd line meds?
levomilnacipran (SNRI), moclobemide (MAOI), quetiapine (SGA), trazodone (serotonin receptor antagonist), vilazodone (SRI & partial agonist) & TCAs (Amitriptyline, Nortriptyline, Clomipramine)
what are 3rd line meds?
MAOI: phenelzine, tranylcypromine
when can patients expect to see improvement?
2-4 weeks, however may notice some improvement in sleep, appetite and mood in 1-2 weeks
a minimum therapeutic dose should be achieved in __ weeks, and increased if necessary over ___ weeks.
a minimum therapeutic dose should be achieved in 2 weeks, and increased if necessary over 4-6 weeks.
can antidepressants be abruptly discontinued? why or why not?
if used for >6 weeks, will cause discontinuation syndrome
what are symptoms of discontinuation syndrome? when do they start and end?
FINISH (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances eg. dizziness, hyperarousal). Symptoms start in few days, and may last 1-2 weeks.
how to avoid discontinuation syndrome?
taper by 25% every week over 4-6 weeks
what antidepressants cause more discontinuation symptoms?
paroxetine and venlafaxine
how long is the treatment duration?
minimum 9 months and up to 2 years if psych comorbidities, residual symptoms, frequent/chronic/severe episodes
when to switch to another antidepressant?
during week 3-8 if side effects intolerable or persist more than 2 weeks, or if not responding to dose increases.
when switching between antidepressants, what factors determine whether to switch within or between drug class?
switch within if there is some improvement
switch between if there is no improvement
how to switch between antidepressants not requiring washout?
crossover technique - dose of the first agent is tapered while the dose of the new antidepressant is gradually increased
which antidepressants require a washout when switching TO? how long?
when switching to an irreversible MAOI, must have washout period that is 5 half-lives of first antidepressant
which antidepressants require a washout when switching FROM? how long?
when switching from:
- MAOI, a 2 week washout is needed
- Moclobemide, a 5 day washout is needed
- Fluoxetine to iMAOI, a 5 week washout is needed
- Fluoxetine to other, 4-7 day washout is needed
what are tx options when there is a partial response to treatment?
-add on SGA (aripiprazole, olanzapine, quetiapine, risperidone, brexpiprazole) for short term only & monitor for EPS, wt gain, CV s/e
-other: lithium, triiodothyronine, bupropion
can antidepressants be used in pregnancy?
yes, with some caveats and exceptions:
-paroxetine causes CV malformations
-fluoxetine may cause malformations but controversial
-use lowest effective dose
-may cause neonatal withdrawal sx (tremor, irritability, sleep/resp disturbances)
-use during 3rd trimester may increase risk of pulmonary hypertension
can antidepressants be used while breastfeeding?
yes, consider sertraline, citalopram or escitalopram
which antidepressants are the most sedating?
mirtazapine and TCAs
which antidepressants cause the most weight gain?
mirtazapine and TCAs and some SSRI/SNRI
which antidepressants cause the most sexual dysfunction?
paroxetine and SSRI/SNRIs
which antidepressants cause the least sexual dysfunction?
bupropion and mirtazapine
which antidepressants cause insomnia?
bupropion
which antidepressants cause weight loss?
bupropion
which antidepressants cause QT prolongation?
citalopram, escitalopram, mirtazapine
which antidepressant causes most anticholinergic side effects?
paroxetine (dry mouth, constipation)
reversible MAOI
reversible = phenelzine and tranylcypromine
- fatal DDI (SSRI, TCS, levodopa, alcohol, meperidine, sympathomimetics)
- fatal food interactions with tyramine rich foods eg. aged cheese, overripe/spoiled/expired/fermented, fava, soy
- s/e: edema, ortho hypo, insomnia, sexual dysfunction
irreversible MAOI
irreversible = moclobemide
- fatal DDI (SSRI, TCS, levodopa, alcohol, meperidine, sympathomimetics + opioids, antipsychotics, selegiline, cimetidine)
- s/e: nausea, insomnia, dizziness
TCAs
amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine
- anticholinergic s/e (dry mouth, blurred vision, constipation, urinary hesitancy, tachycardia, delerium)
- antihistaminergic s/e (sedation, weight gain)
other s/e: ortho hypo, sexual dysfunction, decreased seizure threshold
SSRI
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
common s/e on initiation: stomach upset (take w food) except f), headache, dizziness, drowsiness, anxiety (usually resolve after 2w)
Sertraline must be w food for efficacy
SNRI
venlafaxine, desvenlafaxine, duloxetine, levomilnacipran
common s/e: nausea, drowsiness
are there any supplements for depression?
St. John’s Wort - potential 1st line for mild-mod
S-adenosyl-L-methionine - 2nd line for mild-mod
L-methylfolate - beneficial adjunct to SSRI
Omega-3 & Vit D - no clinically significant benefit
dual action antidepressants
bupropion -agitation, insomnia, wt loss, CI in anorexia, bulemia, seizures
mirtazapine -wt gain, sedation, QT
serotonin modulators
trazodone -drowsiness, ortho hypo, nausea, headache, dry mouth, priapism
vortrioxetine -nausea, constipation, d/c sx
