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Bcpp > Depression > Flashcards

Depression Flashcards

0
Q

Other criteria for MDD besides sigecaps

A

Depressed mood or lack of interest pleasure

  • dont meet criteria for mixed episode
  • same two weeks, 5 sx nearly every day incl depression/interest pleasure loss
  • sx cause significant effect on distress or impact social, employment, adl
  • Not due to a substance or other dz eg hypothyroid
  • not accounted for by bereavement - sx persist for >2 months or are characterized by morbid preoccupation with worthlessness, suiicide, psychosis sx, psychomotor
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1
Q

Criteria for major depressive disorder

A 
Five 5 of following: nearly every day
During same  2 week period 
One of sx must be loss of interest/pleasure OR depressed mood
Sig e caps
Sleep
Interest decreases (anhedonia)
Guilt or worthlessness (not major criteria)
Energy decrease
Concentratin decrease
Appetite decrease (or increase)
Psychomotor retardation (or agitation)
Suicidal thoughts
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2
Q

Risk factors for mdd

A 
Female
Native American
Middle age
Widow separated divorced
Other psych dx- substance abuse, panic do, GAD
Personality do: avoidant,
Dependent, paranoid, schizoid
Stressful life events
Medical condition eg dm ca stroke
First degree relative with mdd
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3
Q

Sx in first 1-3 days of depression that improve

A

Decreases agitation and anxiety, improved sleep and appetite

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4
Q

Sx that improve in 1-3 weeks

A

Increased activity and sex drive

Improvement in self care, concn, memory, thinking, psychomotor normalizes

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5
Q

Sx that improve in 2-4 weeks

A

Some relief of depressed mood
Return of pleasure experience
Fewer hopeless feelings
Subsiding of suicidal thoughts

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6
Q

Duration of AD therapy

A

First major dep episode:
At least 6-12 months

Two or more lifetime episodes:
Continue tx for 15 months to 5 years

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7
Q

How to discontinue antidepressant

A

Fluoxetine - no taper needed due to half life of 7-9 days and norfluoxetine 7-15 days

Other SSRI taper over 2-4 weeks
*withdrawl sx include nightmares, GI upset, dizzy, chills, anxiety irritable insomnia

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8
Q

Does serotonin syndrome contraindicated future antidepressant tx?

A

No, just avoid offending agent, use lowest dose and titrate slowly.

Tx of serotonin syndrome

  • dc seronergic drug(s)
  • fluids IV
  • benzos for agitation, hyper reflexes hyperthermia myoclonus
  • cyproheptadine for moderate severe - 2mg q2h till sx improve
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9
Q

Citalopram notes

A

Prolong QT so ECG pre-rx in CHF, bradyarrhythmias, coadministered meds that prolong QT
20 mg prolongs 8.5ms, 40mg prolongs 12.6ms, 60mg prolongs 18.5ms.
No more than 40mg qday due to no more efficacy in higher doses
Max dose 20mg in pt with: hepatic impairment, age over 60, cyp19 poor netabolizers, taking cimetidine

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10
Q

Medications that can INCREASE tCA levels by cyp 2D6 inhibition

A 
Cimetidine
Fluoxetine
Paroxetine
Haloperidol 
Phenothiazines (chlorpromazine, fluphenazine, promethazine)
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11
Q

Medications that can DECREASE TCA levels by 2D6 enzyme induction

A

Barbiturates
Phenytoin
Carbamazepine

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12
Q

Pharmacology of des and venlafaxine, and of duloxetine

A
  • sort of like TCA with less se’s

Des and venlafaxine inhibit serotonin and norepinephrine reputable as well as weak inhibitors of dopamine reuptake

Duloxetine is selective for serotonin and norepinephrine

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13
Q

Moa of TCA

A

Increase synaptic concentration of norepinephrine and serotonin by reuptake inhibition

  • all have slightly different moa and anticholinergic and other se’s leading different se’s
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14
Q

Metabolism of SNRI

A

Desvenlafaxine is active metab of venlafaxine
Venla 2d6 half life 5 hr
Desvenla 3a4 t1/2 10-11 hrs
Duloxetine 1a2, 2d6, 12 hr t1/2

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15
Q

MOA of MAO-I drugs

A

Inhibit MAO which is enzyme responsible for degradation of NE, serotonin, DA

MAO-A - primarily responsible for NE, serotonin, tyramine metabolism

MAO-B dopamine metabolism (eg selegiline, but over 9mg a and b are inhibited

All us Mao -I are irreverisiblr so takes 2 weeks for enzymes to return after medication dc

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16
Q

Drug interactions of MAO-I’s

A
  • due to dangers, wait 4-5 half lives of drug or active metabolite before start MAO-I
  • at least 2 weeks after stopping MAO-I to start interacting drug
Include: SSRI, TCA, SNRI other serotonin drugs
Amphetamines
Carbamazepine
Decongestants
Dextromethorphan- serot syn risk
Ephedrine
Epinephrine
Meperidine (cardiac instability and coma)
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17
Q

Dietary restrictions MAOI’s

A

Aged products
Smoked
Picked
Yeast extracts

Aged: cheddar, meat, beer, wine
Smoked: meat fish sausage salami

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18
Q

Indication for nefazodone

A

Mdd (FDA ok)

Non fda| for PTSD

19
Q

MOA of nefazodone, trazodone

A

Weak inhibition of serotonin and norepinephrine reuptake
Weak alpha 1 blocker
Serotonin 5ht-2 antagonist
Histamine blocker (trazodone >nef)

20
Q

Drug interactions of nefazodone, trazodone

A

Nefazodone inhibits 3a4 (statins cbz digoxin alprazolam triazolam)

Trazodone - is metab by 3a4 but no clinically significant drug intxns

21
Q

Vilazodone

A

Inhibits pre synaptic serotonin like SSRI
Also partial agonist at 5ht1a receptor

  • take with food improves bioavailability
  • 10mg x 7d then 20mg qdayx 7d
    Target 40mg qday
  • ADR include diarrhea nv insomnia
  • with 3a4 inhibits use 20mg qday
22
Q

Mirtazapine

A

Lower doses - appetite stimulation

More Sedating at lower doses

Food minimally affects F

Some metab by 2d6 3a4 1a2 but no significant drug interactions

23
Q

Bupropion

A

Apparently can decrease levels of cbz and increase levels of cimetidine - refer to p 226 for more info

24
Q

St. John’s wort

A

Standardize extract 0.3% hypericin - 300mg tid for mild mod dep
Adv effects GI sexual headache anxiety kind of like SSRI
- weak MAO inhibitor and inhibits serotonin Doapmjne and norepinephrine with approximate equal affinity

Weak inducer of 3a4 2d6 1a2
-MaNY DRUg INTERACTIONS
Decrease efficacy of cyclosporine - organ rejection has occurred
-protease inhibitor
Non nucleoside reverse transcriptase inhibitors
Oral contraceptives
Digoxin
Warfarin 
Theophylline
SSRI
25
Q

1st line tx of depression

A

Consider CBT psychotherapy, maybe non pharm like light for SAD
First pharmacological selection
SSRI bupropion mirtazapine SNRI

26
Q

2nd pharmacological selection

A

Different SSRI or other 1st line as mono therapy
OR
Augment with antidepressant with different mechanism than medication chosen above

27
Q

3rd pharmacological choice-

A
  • augment with AD with different mechanism or TCA

Augment with lithium or thyroid

28
Q

4th pharmacological selection
And
5th line

A
  • change to different augmenting agent
  • or consider ECT or Vgus nerve stim

5th: continue to select alternate combo of various mechanism AD till adequate symptom improvement achieved

29
Q

Definition of treatment resistant depression

A

Not responded to 2 separate trials of different antidepressants of adequate dose and duration in current episode

  • after 2 trials the likelihood of responding to future trials significantly declines
  • up to 46% don’t get adequate response
30
Q

Approach to treatment resistant depression

A

1 optimize current therapy for dose, adherence, duration, se’s .
Continue tx for longer period 9-12 weeks

31
Q

Combo antidepressant

A 
Safe and effective combo include
- SSRI or SNRI plus 
       * Plus mirtazapine or bupropion
Or
- SSRI plus TCA 
** use two different MOA, not same therapeutic class
32
Q

Switching AD medications

A

Various strategies
- cross titration
Slowly taper off taper on
- benefits include prevent relapse and withdrawal
- risks include serotonin syndrome and complicated instructions
Or
Discontinuation strategy - stop when current med done then start new med
- risks include withdrawal sx benefits include ease of switching

33
Q

Antidepressant augmentation with lithium

A 
Level target 0.6-1.2
Recommended dose 900mg/day
- response can occur within 48-72 hrs, full effect 2-3 weeks
Effective with ANY antidepressant
-13-fold decrease in suicide rate
34
Q

Stimulant as ad augmentation

A

Improves sx of fatigue concentration and interest, not depression

35
Q

Augment - pindolol

A
  • potentiate an depressant effects of SSRI but no diff at end of study
  • well tolerated
  • more study needed to determine role
36
Q

Dopamine agonist
Folic acid
For augmentation of depression

A

Bromocriptine - effective as imipramine for tx of depression

Pramipexole - has been studied as adjunct AD
GI sx limit potential for use
No FDA approval and no dose established
Folio acid - may be result rather than cause of depression
Limited data supports efficacy of folic acid (400 mcg) and l-methylfolate (7.5 mg) as augment tx

37
Q

Thyroid for depression augmentation

A

May be effective for pts with subclinical hypothyroid
May produce more rapid response
T3 is most studied, recommended dose 25-50 mcg/day

38
Q

atypical antipsychotic augmentation for depression

A

Aripiprazole and quetiapine XR are approved for adjunctive tx

Aripiprazole 2-5 mg once dusky
Quetiapine XR start 50mg qhs up to 150 in 3 days (max 300mg)

39
Q

Pregnant and lactation with depression

A

Interested maternal depression associate with bad outcomes for baby - Low birth rate postnatal complication etc

  • shared decision making
  • no confirmed birth defects with use of medications - SSRI SNRI TCA
  • MAO–I animal studies indicate teratogenic - should switch to other agents

St. John’s wort contraindicated during PG

40
Q

Lithium for augmentation

A

900 mg per day
Level 0.6-1.2
May get quick onset 48-73 hrs then full effect 2-3 weeks

41
Q

Antipsychotics approved for augmentation of depression

A

Quetiapine XR start 50mg qday

Aripiprazole start 2-5mg qday

42
Q

Pregnancy most dangerous SSRI

A

Paroxetine D others are C

43
Q

Safest TCA in pregnancy

A

Maprotiline B

44
Q

Most dangerous antidepressant in pregnancy

A

MAO inhibitor

Bcpp (16 decks)

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