Depression Flashcards
1
Q
CNS Neurotransmitters
A
Acetylcholine Gamma-aminobutyric acid Dopamine Glutamate Norepinephrine
2
Q
PNS Neurotransmitters
A
Acetylcholine
Norepinephrine
3
Q
Sympathetic System
A
Acetylcholine
Dopamine
Epinephrine
Norepinephrine
4
Q
PNS Neurotransmitters
A
Acetylcholine
5
Q
Depression Prevalence
A
Affects up to 19 million Americans
-31 million adults report having had at least one episode of major depression in their lifetime
Annual costs of $43 billion equal to the annual health care costs for coronary heart disease
Can affect all age groups
- Women 2 to 3 times more likely to develop depression than men - If left untreated, 15% of adult patients will commit suicide
6
Q
Diagnosis of Depression
A
Depressed mood or loss of interest/pleasure in activities for at least two weeks
plus
At least four of the following seven factors in the same two week period
- Change in sleep pattern
- Change in appetite/weight
- Fatigue
- Psychomotor agitation or retardation
- Feelings of worthlessness/guilt
- Difficulty thinking, concentrating or indecisiveness
- Recurrent thoughts of death, suicidal ideation, plans, attempts
7
Q
Premenstrual Dysphoric Disorder Diagnosis
A
Five or more of the following occuring during the final week before the onset of menses: Marked affective lability Markedly depressed mood Decreased interest Lethargy Sleep pattern change Marked irritability Marked anxiety Difficulty concentrating Change in appetite Physical symptoms
8
Q
Monoamine Oxidase Inhibitors
A
Tranylcypromine
Isocarboxazid
Phenelzine
Selegeline
9
Q
Childhood Bipolar Disorder is now
A
Disruptive Mood Dysregulation Disorder
10
Q
New Depression diagnoses in DSM-V
A
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
11
Q
Tricyclic Depressants
A
Secondary Amines
Tertiary Amines
Tertracyclic Amine
12
Q
Tetracyclic Amine
A
Maprotiline
13
Q
Tertiary Amines
A
Amitriptyline Clomipramine Doxepin Imipramine Trimipramine
14
Q
Selegeline mechanism of administration
A
Topical patch
15
Q
Secondary Amines
A
Nortriptyline
Desipramine
16
Q
MOA MOIs
A
Effects the enzyme monoamine oxidase so the body loses its ability to breakdown monoamines which increases the levels of NE in the body.
17
Q
Nobody uses
A
MOIs
18
Q
Indications for Phenelzine
A
Symptomatic treatment of atypical, nonendogenous, or neurotic depression
19
Q
Dosage forms of Phenelzine
A
Tablet
20
Q
Dosing of Phenelzine
A
Oncea day or every 2 days
21
Q
Selegeline indications
A
Treatment of major depressive disorder.
22
Q
Dosage form of Selegeline
A
Topical Patch
23
Q
Dosing of Selegeline
A
Once a Day
24
Q
Black Box Warning of MOIs
A
Suicidal Thinking/ Behavior
-Age groupings
25
If on an MOI consult your physician if:
MAO Inhibitors may not play well with others!
Doesn't play well with certain foods.
26
MOI ADRs
```
Dizziness
Lightheadedness
Drowsiness
Fatigue
Weakness
Blood pressure effects
```
27
Food interactions of MOI
```
Tyromine-containing foods:
Pizza
Cheeses
Duff Beer
Mountain Dew
Fava Beans
Chocolate chip cookies
Yogurt
```
28
Metabolic Effect of MOIs
Hypoglycemic possible
29
Class Drug of MOIs
Phenelzine
30
Phenelzine
Phenelzine
15 mg
Once daily
-Maintenance Dose
31
Selective Seratonin Reuptake Inhibitors Class Drug
Sertraline
32
Sertraline
Sertraline
100 mg
Once daily
33
Indications for Duloxetine
Acute and maintenance treatment of major depressive disorder
Generalized anxiety disorder
Management of diabetic peripheral neuropathic pain
Management of fibromyalgia
Chronic musculoskeletal pain (e.g., chronic low back pain, osteoarthritis)
34
Beginning Dosing of Phenelzine
60 mg
| Titrate down to 15 mg per day.
35
Tricyclic Antidepressants to know
Nortriptyline
| Amitriptyline
36
MOA Tricyclic Antidepressants
```
Block receptor sites:
Seratonin
Adrenergic
Histamine
Muscarinic acetylcholine
Acetylcholine
```
37
Older patients do not tolerate ________well.
Tricyclic Antidrepressants
38
If you have to use a tricyclic antidepressant in an older patient use:
Secondary Amines
* Nortriptyline
* Desipramine
39
Do plasma levels correlate with therapeutic effect of tricyclic antidepressants?
Plasma levels don’t directly correlate to therapeutic effect
Dosing is based on observation, side effects and clinical response
40
Dosing of Antidepressants
Once a day versus multiple doses per day- once a day is fine.
Most such as amitriptyline, nortriptyline, imipramine can be effective with a single bedtime dose that equals the total daily recommended dose
Put the doses together and take at night.
41
ADRs of Tricyclic Antidepressants
Histamine receptor blockade - Sedation
Alpha adrenergic blockade - Postural hypotension
Anticholinergic effect - Blurred vision, dry mouth, constipation
Cardiac - Arrhythmias, sinus tachycardia, prolongation of conduction time
42
Tricyclic Antidepressants Class Drug
Amitriptyline
43
Amitriptyline
Amitriptyline
150 mg
Once a day at bedtime
44
Selective Seratonin Reuptake Inhibitors
```
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine - Paxil
Sertraline - Zoloft
Vilazodone - Viibrid
Vortioxetine - Brintelix
```
45
Indications for Sertraline
```
Major depression
Obsessive-compulsive disorder
Panic disorder
Premenstrual dysphoric disorder
Post-traumatic stress disorder
Social anxiety disorder
```
46
Serotonin/ NE Reuptake Inhibitors Class Drug
Cymbalta
47
Cymbalta
Cymbalta
60 mg
Once Daily
48
SSRI MOI
Blocks 5-HT re-uptake transporter to prevent reuptake of seratonin increasing seratonin levels in the body.
49
Depression is due to low levels of
Norepinephrine
50
SSRIs also treat
anxiety disorders
51
Side effects of SSRIs
Sexual Dysfunction
52
Paxil is especially bad due to ...
erectile dysfunction side effect.
53
Often times the SSRI is picked based off of their...
side effect profile.
54
Kinetics of SSRIs
Organ Dysfunction
Renal impairment adjustments generally not needed.
Hepatic impairment may result in increased levels.
55
SSRI Drug Interactions
MOI - BAD
Addictive effect to result in serotonin syndrome - BAD!
Watch with St.John's Wart
56
ADRs of SSRIs
Increased fall risk
Lower bone mineral density
Sexual dysfunction
Decreased libido, ejaculation failure
SIADH - Syndrome of inappropriate antidiuretic hormone. Check sodium levels.
Constipation, diarrhea, nausea, dizziness, headache, insomnia, etc., etc., etc.
57
SIADH with SSRIs are often seen with...
older patients.
Check their sodium levels. Dilutional effect - treat with a diuretic.
58
SSRI Class Drug
Sertraline
59
Sertraline
Sertraline
100 mg
Once daily
60
How long until you see changes in depression?
1-3 weeks
61
Selective Serotonin Norpinephrine Reuptake Inhibitors
```
Desvenlafaxine
Duloxetine
Levomilnacipran
Milnacipran
Venlafaxine (Flexor)
```
62
SSRIs
```
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Vilazodone
Vortioxetine
```
63
SNERI Side Effects
Vary greatly within category.
64
Issues with Venlafaxine
At higher doses, raises blood pressure
Higher rate of treatment-emergent mania than other agents
More “activating” than others
Dose-dependent weight loss
65
Differences in Side Effects between Duloxetine and Venlafaxine seen with
Headaches (Venlafaxine higher)
Insomnia (Venlafaxine higher)
Agitation (Same)
HTN (Same)
66
Side Effects of S/NERIs
```
Somnolence
Headache
Nausea
Fatigue
Palpitation
Insomnia
Agitation
Abnormal Dreams
Anxiety
HTN
```
67
Withdrawal Issues
SSRIs and SNRIs are not addictive but abrupt cessation can cause withdrawal-type symptoms
68
Withdrawal-type symptoms
```
Nausea
Headache
Dizziness
Lethargy
Flu-like symptoms
```
69
When do withdrawal symptoms occur?
2-3 days post-discontinuation
70
High risk drugs for withdrawal like symptoms
Paroxetine
| Venlafaxine
71
Bupropion is a
Norepinephrine/Dopamine Reuptake Inhibitor
72
Buproprion Forms and Names
Immediate release, sustained release, extended release, Zyban™ versus Wellbutrin™
73
ADRs of Bupropion
Seizure threshold lowering so…
| Anaphylactic reactions
74
One factor to note when prescribing Buproprion is
Shorter time of onset of action.
75
Bupropion works at
nicotinic receptor site.
76
Mirtazapine (Remeron) is a
Serotonin Antagonist
77
MOA of Mirtazapine
Blocks multiple receptors accounting for therapeutic effects and side effects.
78
Onset of activity in Mirtazapine...
... may be faster.
79
Is Mirtazapine tolerated in the elderly?
Maybe?
80
Adverse Side Effects of Mirtazapine
Appetite Increase
Drowsiness
Cholesterol Increase
81
People sometimes use Remeron in elderly people to...
increase appetite.
82
Serotonin Modulators
Trazodone
Vilazodone
Nefazodone
83
Seratonin modulators are associated with...
... hepatotoxicity.
Illegal in all other countries.
84
ADRs of seratonin modulators
Drowsiness
Hypertension
Weight gain
85
Trazodone side effect
Incredible Drowsiness
86
What can be used as an add on therapy to an SSRI?
Trazodone
Augmentation therapy which is done by a psychiatrist.
87
Are all antidepressants equally effective?
YES!!
88
Which antidepressant do you choose?
Lower incidence of adverse events with newer agents has been seen as an advantage
89
Overall efficacy of antidepressants
Overall efficacy
60% to 70% response rate
Improvement may be seen in 1 to 2 weeks with maximum effect seen in 4 to 6 weeks
90
What can be seen with all antidepressants?
Increased risk of suicidal thoughts and behaviors in children, adolescents and young adults
Covers all antidepressants that were or will be on the U.S. market agents
Study in latter 2006 showed that antidepressant use may protect against completed suicide in children and adolescents
Higher rates of SSRI prescriptions associated with lower rates of suicide (ages 5 through 12)
91
Depression in the Elderly
7 million of the nation’s seniors have depression and 1 million suffer with major depressive disorder
In women 1% prevalence; men 0.4%
Minor depression in the elderly is more prevalent than MDD
15-25% of minor depressions evolve into a major depressive episode within 2 years
Suicide risk in the elderly
92
Preferred antidepressant agents in the elderly
Sertraline
Bupropion (extended release)
Citalopram - The agents help avoid many of the common problematic drug interactions
93
Results of antidepressant therapy in the elderly
Partial treatment effect within 3 to 4 weeks; full therapeutic response may take months
94
Select antidepressant based on
```
Past treatment history
Likelihood of adverse effects
Patient preference
Overdose toxicity
Cost
```
95
What do you do when you have therapeutic failure with an antidepressant?
Try an agent in same or different class
-Up to 50% response rate to second agent possible
Combination therapy
96
Theories of why antidepressants work
You get the edge needed to help for mild depression.
Give drugs to those with severe depression.
Give it a shot!!
