Depression Flashcards
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
The causes of depression are poorly understood, but involve some combination of genetic, biologic, and environmental factors. Neurotransmitters believed to be involved with depression include: __________________________
serotonin (5-HT)
norepinephrine (NE)
epinephrine (Epi)
dopamine (DA)
glutamate
acetylcholine (ACh)
________ may be the most important neurotransmitter (NT) involved with feelings of well-being.
(5-HT) serotonin
Diagnosis and treatment of depression is difficult since it is not possible to measure brain chemical imbalances. Diagnosis relies on symptom assessment according to the __________
(DSM-5) Diagnostic and Statistical Manual of Mental Disorders, 5th edition
The _______1_______ is the most widely used depression assessment scale. It is designed to be used in a medical office. The patient rates their symptoms of depression on a numerical scale, and the total score indicates whether or not depression is present.
This is used ________2___
- Hamilton Depression Rating Scale (HDRS or Ham-D)
- after someone is diagnosed with depression. It measures the effectiveness with depression treatment.
Generally, a score of less than 7 indicates the absence of depression.
7-17 = mild depression
18-24 = moderate depression
25 and higher = severe depression
Depression Diagnosis: DSM-5 Criteria
- At least ________ of the following symptoms present during the same two week period (must include Depressed Mood OR Diminished interest/pleasure)
*Remember M SIG E CAPS
- At least 5 of the following symptoms present during the same two-week period (must include Depressed Mood OR Diminished Interest/Pleasure)
Mood- depressed*
Sleep- Increased/decreased
Interest/Pleasure - diminished*
Guilt or feelings of worthlessness
Energy - decreased
Concentration - decreased
Appetite - Increased/decreased
Psychomotor agitation or retardation
Suicidal ideation
It is necessary to rule out ________1________ prior to initiating antidepressant therapy to avoid _____2______ or causing rapid-cycling (cycling rapidly between bipolar depression and mania).
Screening forms to assess mood and identify symptoms include questions such as:
(cycling rapidly between bipolar depression and mania).
1) bipolar disorder
2) inducing mania
I get into moods where I feel very “speeded up” or irritable.
When depression and anxiety occur together, ______________ should NOT be used alone; they can worsen and/ or mask depression and can be problematic in patients with concurrent substance use disorders.
benzodiazepines (BZDs)
Key Drugs that Cause or Worsen Depression:
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Cardiovascular medications: Beta-blockers (especially Propranolol)
ADHD medications: atomoxetine (Strattera)
Analgesics: Indomethacin
Antiretrovirals (NNRTIs):
Efavirenz (in Atripla)
Rilpivirine (in Complera, Odefsey)
Hormones:
Hormonal contraceptives
Anabolic steroids
Other:
benzodiazepines
systemic steroids
interferons
varenicline
ethanol
Natural Products: that may be helpful for treating depression, but there is less evidence of efficacy than with standard treatments.
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St. John’s wort
SAMe (S-adenosyl-L-methionine)
valerian
5-HTP (5-hydroxytryptophan)
Which natural products can increase the risk for Serotonin Syndrome and SHOULD NOT be used with other serotonergic agents?
St. John’s wort
SAMe (S-adenosyl-L-methionine)
5-HTP (5-hydroxytryptophan)
“St. Johns wort is a broad spectrum CYP450 enzyme inducer with many significant drug interactions, and it can cause PHOTOTOXICITY.”
“Valerian can cause sedation.”
Drug Treatment for Depression:
Treatment for depression can require one or more trials of medication.
If a drug does not work after a suitable trial of at least ______________, treatment should be reassessed. If there is no response then ___________
A thorough patient History is CRITICAL. (Should Help Guide Therapy)
What worked in the past?
What did NOT work?
Any relatives that have depression? What medications have been successful for them?
4-8 weeks
increase dose, switch drug or add on a drug
The effectiveness of the different antidepressant classes is generally comparable.
*The Initial Choice of medication should be based on: _____1________
*For most patients an _______2__________ is preferred OR with “specific concurrent conditions” ________3______ OR ___________4_____
1 - the side effect profile, safety concerns, and patient-specific factors.
2- SSRI or SNRI
3- mirtazapine
4- bupropion
What other specific patient factors “comorbid conditions” need to be considered when deciding patient therapy
- insomnia
- overweight/obese
- neuropathy
Is feeling sad the same as being depressed? _________
The loss of a loved one, losing a job, or ending of a relationship are difficult experiences for a person to endure.
It is normal for feelings of sadness or grief to develop in response to such situations. Those that are experiencing loss, often describe themselves as feeling depressed.
NO, being sad is NOT the same as being depressed.
In Grief, painful feelings come in waves, often with positive memories of the deceased and one’s self-esteem is usually maintained.
However, in Major Depression, Mood and/or Interest are decreased for about 2 weeks, symptoms are Persistent, and feelings of worthlessness and self-loathing are common.
once persistent symptoms impact quality of life this can lead to depression.
A diagnosis of depression is also called ____________
Major depressive disorder or Unipolar depression
- it is when someone has recurrent episodes of depression
Depression is multifactorial. Groups of people that experienced substance abuse or trauma (physical or sexual assault) are at a higher risk of depression.
Drug treatment for depression often involves increasing ____________
serotonin (5-HT) neurotransmitter
Bipolar Disorder:
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Mood
Energy
Clarity of thinking
Bipolar Disorder:
Can be represented by 2 polar opposite ends.
On one end there would be ____1___
On the other end there would be ____2____
1- Mania “extremely elevated mood/energy”
2- Depressive episodes, where the individual will report with symptoms similar to depressive symptoms when making a diagnosis and assessment
Antidepressants can induce mania (high energy, extreme mood). Antidepressants can also cause rapid-cycling between depression and mania. So, it is important to rule out bipolar disorder before initiating an antidepressant for depression.
Antidepressants can be used in bipolar disorder but often with a mood stabilizer like lithium.
Do NOT use _____________ alone for depression
benzodiazepines
- they do not have a role in depression management
- they do not treat underlying problem
- can mask the symptoms of depression
Boxed Warnings for benzodiazepines include:
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Abuse, misuse, and addiction
physical dependance
withdrawal symptom’s
sedation, respiratory depression and death
C-IV, so should not be used in someone with active or Hx of substance abuse. **Remember substance is an environmental factor that can contribute to depression
Treatment Overview: (Treatment Options for Depression)
After an individual is diagnosed with depression the goal is to ______________. But what type of initial treatment is best to resolve those symptoms?
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resolve the symptoms of depression.
Psychotherapy
Natural Products
Pharmacotherapy
Initial Treatment for Mild symptoms can include:
Psychotherapy “cognitive behavioral therapy” or medication or combination of both
Initial treatment for Moderate -Severe symptoms can include:
Psychotherapy + medication, combination has shown to be more effective than either alone.
St, Johns wort induces the enzymes that affect OCPs
Oral Contraceptive Pills, so these medications will be metabolized at a faster rate. Leading to less serum drug levels and making them less effective.
Same can be said with transplant medications.
Depression is often overlooked and untreated in pregnant women. This is a serious problem because untreated depression in pregnancy can cause __________
negative outcomes such as premature birth, low birth weight, or postnatal complications,
Managing depression in someone that is planning to become pregnant:
If patient is already on an antidepressant, then tapering off medication is an appropriate choice for some people. Only appropriate if the female does not experience any setbacks in depression control while off medication. Antidepressant should be slowly tapered off 1-2 months. best would be done in someone with mild depression and who is symptom free for at least 6 months.
Before and During Pregnancy:
- Taper off medications, IF possible
- Psychotherapy preferred for Mild depression
- If medications are needed ______1_____ are preferred with the exception of ________2______ due to _______3______
1) SSRIs
2) paroxetine
3) potential cardiac effects
” DO NOT USE paroxetine in pregnant patients” - increased teratogenic effects
Although SSRIs are preferred in pregnant women for the treatment of depression, there is a warning regarding their use during pregnancy which is ________________________.
the potential risk of persistent pulmonary hypertension of the newborn (PPHN)
this is when pulmonary vascular resistance of the new born remains elevated after birth and results in severe hypoxemia.
Postpartum Depression is sometimes mislabeled as the _________
“baby blues”
the baby blues are normal and are a temporary feeling that occurs after delivery. Patients can be more emotional and may have changes in sleep, increased stressed, caused by hormone fluctuations. Should go away with a couple weeks.
In contrast, Postpartum Depression is serious and while it can look like the baby blues at first, these symptoms persist and are more severe. Such as _______________
___3______ can help with the emotional and physical symptoms.
Drug safety when breastfeeding is essential. ___________4_______ are generally preferred, with the exception of ______5____
- suicidal thoughts
- inability to care for the newborn
3) breastfeeding
4) SSRIs or tricyclics
5) doxepin (Silenor, Zonalon), per ACOG recommendations, doxepin can worsen depression and suicidal thoughts and should be avoided.
_______________, is a C-IV drug FDA-approved for postpartum depression.
Brexanolone (Zulresso), It is given as a continuous IV infusion over 60 hours.
All Antidepressants carry a BOXED Warning for:
Suicidal Thoughts and Behaviors
-antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors.
“book text” - possible increase in suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed.
Due to safety concerns (drug-drug and drug-food interactions) the use of oral Non-selective monoamine oxidase inhibitors (MAO inhibitors) is ____________ to patients unresponsive to other treatments.
restricted
Since many antidepressants increase serotonin levels, Serotonin Syndrome can occur with the administration of ___________________1__________
The risk is most severe when an ________2______ is administered with another serotonergic medication. _______3___ increase the risk.
1) one or more serotonergic medications
(SSRIs, SNRIs, mirtazapine, trazodone, opioids, tramadol, lithium, buspirone, triptans, dextromethorphan and St. John’s wort)
2) MAO inhibitor
3) Higher doses
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- Agitation
- Dizziness
- Hallucinations
- Diarrhea
- Severe nausea
- Muscle rigidity
- Headache
- Tachycardia
If an antidepressant is being discontinued, it should generally be tapered over __________________ to avoid withdrawal.
Withdrawal symptoms include: ______
several weeks
anxiety, agitation, insomnia, dizziness, and flu-like symptoms
___________ and _________ carry a higher risk of withdrawal symptoms and must be tapered upon discontinuation.
- An exception to this rule is _____________, which self-tapers because of its long half life.
paroxetine & venlafaxine
fluoxetine
____________ are required for ALL antidepressants.
MedGuides
With antidepressants: Patients must be counseled on the __________ AND _________
Lag effect with these medications
AND
Suicide Prevention
Counseling with Antidepressants:
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- All Antidepressant medications must be used daily and will take time to work
- All Antidepressants can take 1-2 weeks to feel a benefit from this drug and 6-8 weeks to feel the full effect on mood
- All Antidepressants can cause suicidal ideation
(Physical symptoms such as low energy improve within 1-2 weeks, but psychological symptoms, such as low mood, may take a month or longer.)
- Physicians and pharmacists must educate patients, family and caregivers about the risk of suicidality and screen for suicide risk
- If a patient reports suicidal ideation, refer the patient to the emergency department, the suicide hotline or elsewhere for help. If someone has a plan to attempt suicide, it is more likely that the threat is immediate.
What are the Contraindications with SSRIs?
DO NOT USE with MAO inhibitors, linezolid (Zyvox), IV methylene blue or pimozide (1st generation atypical antipsychotic), pimozide toxicity can occur
What are the Warnings with SSRIs?
-***QT prolongation
” An abnormal prolonged QT interval is > 440 ms (milliseconds)
BUT > 500 ms is worrisome for torsades de pointes” “twisting of the peaks”, a life-threatening heart rhythm disturbance.
The Risk of QT prolongation is greatest with
Higher doses of Citalopram & Higher doses of Escitalopram. This is a dose-dependent adverse effect.
If someone is a CYP2C19 poor metabolizer OR on 2C19 inhibitors along with citalopram or escitalopram this will also put the patient at risk for QT prolongation.
- ***(SIADH) Syndrome of Inappropriate Antidiuretic Hormone: is when the body makes too much antidiuretic hormone (ADH). ADH helps the kidneys control the amount of water your body loses through the urine. So in SIADH the body retains too much water. Since there is much more water in the blood, many different things are diluted like (Na) sodium.
/hyponatremia,
***fall risk (Beer’s criteria: use caution in elderly, avoid if history of falls/fractures or use of CNS depressants)
***Additive Bleeding risk, when used with anticoagulants/antiplatelets/NSAIDs/select natural products “Ginko/Garlic/Ginger/Ginseng/Glucosamine/Fish Oils”/thrombolytics)
What are the side effects with SSRIs?
*** Sexual Side effects, such as low libido and functional problems (erectile dysfunction)
*** “they are CNS depressants” so CNS effects:
- somnolence, insomnia, dizziness, headache, weakness, tremor
Nausea, Dry mouth
Which SSRIs should be taken in the morning?
fluoxetine, most activating
Which SSRIs should be taken in the evening?
paroxetine, fluvoxamine, are very sedating agents.
Which SSRI is not FDA indicated for depression but for (OCD) Obsessive Compulsive Disorder?
fluvoxamine
If a lab report shows low sodium, check to see if the patient is on an ____________. Can contribute to lab abnormality.
SSRI
What is the normal range for Na?
normal range: (135-145 mEq/L)
Which SSRI does not need to be tapered due too it’s long half life?
fluoxetine
If we want to switch a patient from fluoxetine 20mg daily to fluoxetine delayed release 90mg once every week, How would we do so?
Start 7 days after the last daily dose.
Which fluoxetine product is indicated for (PMDD) premenstrual dysphoric disorder?
*Sarafem(fluoxetine)
Which fluoxetine product is indicated for treatment resistant depression?
(Symbyax)- fluoxetine + olanzapine
initial: 6mg/25mg every day at bedtime
what is the conversion between IR paroxetine and CR paroxetine?
10mg IR = 12.5mg CR
Which SSRI is preferred in patients who have cardiac risk?
sertraline
What are the SSRI combined mechanism drugs?
(Viibryd) vilazodone
(Trintellix) vortioxetine
