Depression Flashcards by Yuko Porter

Depression symptoms

Depressed mood
Anhedonia
Sad
Guilt
Hopeless (red flag)

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Diagnosis
Depressive Disorder
Must meet 5

Weight loss or weight gain
Insomnia or hypersomnia
Psychomotor agitation
Fatigue
Feelings of worthlessness
Dec concentration
Suicide thought

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Monoamine oxidase

Metabolizes monoamines → dec NT
Inhibition of this enzyme → inc NT

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Selective Serotonin Reuptake Inhibitors (SSRIs)

Fluoxetine
Paroxetine “etine”
Citalopram
Escitalopram
Sertraline
Fluvoxamine

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SSRIs
a) action
b) dose

a) Inhibit serotonin transporter
b) once a day in the morning

No data that SSRI is more effective
to other meds

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SSRIs
ADRs

Serotonergic side effects
– Activation or sedation
– Nausea
– Sleep disturbances
– Sexual side effects
– Weight gain

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Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
a) Medication name
b) Action

a)
Venlafaxine
Desvenlafaxine
Duloxetine
b)
Inhibit neuronal reuptake of 5HT and NE

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Venlafaxine
a) action

5-HT reuptake inhibition across dosage range

We don’t see norepinephrine reuptake inhibition until doses >200 mg/day
Dose related increases in blood pressure

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Venlafaxine
Two formulations
XR?IR?

XR
– dosed once daily
IR
– dosed two to three times daily

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Venlafaxine
ADRs

Nausea, GI
Insomnia
Sexual side effects
Inc blood pressure
Sweating
Agitation

The same as Desvenlafaxine

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Desvenlafaxine
a) action

Active metabolite of Venlafaxine (Venlafaxine is a prodrug converted in the body)

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Duloxetine
a) action

Balanced NE and 5HT reuptake inhibition across dosage range

FDA approved for neuropathic pain associated with DM

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Duloxetine
ADRs

Similar to venlafaxine
Significant rates of nausea (dose and schedule)

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Bupropion
action?

Inhibition of DA and NE reuptake
Also FDA approved for smoking cessation
禁煙

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Bupropion
ADRs?

Lowers seizure threshold
Already experience seizure
= increased incidence of seizure

Lower incidence of sexual side effects

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Mirtazapine
a) action
b) characteristic

a)
Enhances NE and 5HT activity
Sedating antihistaminic effect
b)
Taken at bedtime
Low rate of sexual dysfunction

More side effect at lower doses!!!
-Inc NE activity at higher dose

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Mirtazapine
ADRs

Significant weight gain

Trazodone
a) action
b) characteristic

a)
enhances 5HT activity
b)
Very sedating – used to treat insomnia
Doses <300 mg used for insomnia

Trazodone
ADRs

Antidepressant activity at higher doses
Sedation,
Nausea, GI upset
Priapism 持続勃起症

Tricyclic Antidepressants
Medication name

Used for years but not using these days
Amitriptyline
Desipramine
Imipramine
Nortriptyline

Tricyclic Antidepressants
a) action
b)characteristic

a)
inhibition of NE and 5HT reuptake
b)
Anticholinergic
dry mouth, dry eyes, constipation, blurred vision, urinary retention
Alpha-adrenergic
orthostasis
Very sedating

Tricyclic Antidepressants
What is the most biggest waring sing?

Lethal in overdose (as little as 3x daily dose)!!!
Cardiac arrhythmia is cause of death

Tricyclic Antidepressants
ADRs

Weight gain
Glucose dysregulation
Effects on cardiac conduction

Monoamine Oxidase Inhibitors (MAOIs)
Medications name

Phenelzine
Selegiline
Tranylcypromine

Monoamine Oxidase Inhibitors a) action b)characteristic

a) Reserved for treatment of resistant depression. b) Drug food interactions: limit foods high in tyramine like aged cheese, cured meats, sauerkraut, beer

Monoamine Oxidase Inhibitors ADRs

Causes massive increase in BP -Hypertensive crisis: risk for stroke and vascular damages Tyramine increases norepinephrine + MAOIs increases NE 🡪 hypertensive crisis Many ADRs

Specialty Antidepressants Agents

Brexanolone Esketamine

Brexanolone a) action b)characteristic

a) Indicated for postpartum depression Aqueous formulation of allopregnanolone (active metabolite of progesterone). b) An IV infusion administered over 60 hrs with continuous monitoring $34,000 very expensive! + may take mom away from baby for those 60 hrs. Not commonly given but still an option

Esketamine a) action b)characteristic

a) Indicated for treatment of resistant depression b) Nasal spray Only available at treatment centers Monitored for 2 hrs Use associated with sedation, dissociation(disconnected from body), and abuse/misuse(people often abuse ketamine) $20,800-$33,800/year very expensive!

Treatment Stages Significant reduction

Response but not complete resolution

Treatment Stages Resolution symptoms

Remission -The same level when it's start

Treatment Stages Remission of at least 6 months 6 month

Recovery The episode be treated was over!!

Treatment Stages Return of depressive symptoms within 6 months

Relapse Happen BEFORE recovery Effect goes down

Treatment Stages New episode of MDD after recovery from initial one

Recurrence The episode was over, but new episode

Phases of Treatment a)Acute Phase b) Continuation Phase

a) Initial 6-12 weeks of treatment b) reatment bridging remission to recovery Typically 6-9 months Continuation of antidepressant at full therapeutic dosage Antidepressant may be discontinued at the conclusion of the continuation phase

Phases of Treatment Maintenance Phase

Continuation of an antidepressant at full therapeutic dosage for extended periods of time, perhaps indefinitely * Not necessary for all patients * May be beneficial in patients at high risk of relapse or recurrence

Choice of antidepressant based on?

Past history of response Side effect profile Comorbid psychiatric or medical conditions Potential for drug interactions Cost

Treatment Goal

Remission Improved overall functioning Dec the risk of experiencing another episode of depression Inc amount of time until another episode in those who experience recurrence

Managing ADRs Insomnia

Caffeine?? dec more stimulants Morning dosing Reduce dose Change antidepressant Adjunct with a sleep medication

Managing ADRs Anxiety

inc with initiation of antidepressant treatment Minimize or avoid caffeine intake Reduce dose and titrate gradually Beta-blocker or benzodiazepine (to help with inc HR in anxiety)

Managing ADRs Nausea

Start low, titrate dosage up Take with food Decrease dose Change antidepressant

Managing ADRs Sexual

Dec antidepressant dose Switch to another antidepressant – Bupropion Add on a medication – Sildenafil Wait to see if the patient builds up a tolerance to the side effect