Depression Flashcards
first line antidepressant?
- mirtazapine
- SSRI
- SNRI
- bupropion
non-pharm for depression?
sleep hygiene
psychotherapy
neurostimulation (ECT, rTMS) - reserve for severe depression
what is considered adequate trial?
adequate dose + adequate duration (4-8w)
why is there a delayed response?
due to gradual downregulation of pre-synpatic autoreceptors in synapse, which in turn facilitate neurotransmitter release
how long does it take for physical sx (eg sleep & appetite) to improve?
1-2 weeks
how long does it take for mood sxs to improve?
longer, 4-8 weeks
how long should anti-depressants be continued for?
another 4-9 months after acute treatment (total 6-12 months)
why does anti-depressants take so long to have an effect?
inhibition of pre-synpatic autoreceptors take a long time
inhibit pre-synaptic autoreceptors –> inhibit release of neurotransmitted
most antidepressants have short half life, which anti-depressants have long half life?
fluoxetine, vortioxetine
what TCAs are there?
Amitriptyline –> Nortriptyline
Imipramine –> Desipramine
Dothiepin (Dosulepin)
Clomipramine
MOA of TCA
Blocks reuptake of NE & 5HT.
Anticholinergic
H1 & alpha-adrenergic antagonism
SE of TCA
GI & sexual dysfunction,
Anticholinergic, Sedation,
Weight gain , Orthostatic, BP
Arrhythmias, Seizure,
Fatal on overdoses
what SSRI are there?
Fluoxetine –>Norfluoxetine
Fluvoxamine
Escitalopram/Citalopram
Sertraline
Paroxetine
MOA for SSRI?
Blocks reuptake of 5HT
selectively.
side effects of SSRI?
GI & sexual dysfunction.
Headache, transient nervousness during initiation
Insomnia: Fluoxetine
Hyponatremia (SIADH)
Bleeding risk; EPSE
which SSRI is the most anticholinergic, sedating, increase weight & short half life (withdrawal)?
paroxetine
which cause QTc prolongation at high dose in elderly
escitalopram, citalopram
what NaSSA are there?
mirtazapine
side effects of NaSSA
Somnolence, increase appetite,
weight gain
MOA of mirtazapine
alpha- 2 adrenoceptor antagonist
increase 5HT & NE
5HT2&3, H1 antagonism
what are mirtazapine good for?
Reverse GI & sexual SE of SSRI/SNRI.
what are NDRI?
bupropion
MOA of bupropion
Blocks reuptake of NE & DA
SE of bupropion
Seizure,
Insomnia, Psychosis
Not suitable for eating d/o.
what benefit of brupropion
decrease sexual SE of SSRI/SNRI
Smoking cessation aid
what MAOi are there
moclobemide
MOA of mocloblemide
Reversible
MAOI A (RIMA)
adjunct treatment for MDD (antipsychotic)
aripiparazole, brexpiparazole, quetapine XR
what PRN hypnotics for adjunctive treatment for MDD?
benzodiazepines, z-hypnotics (zopiclone, zolpidem), antihistamine (hydroxyzine)
dose of fluoxetine?
20mg OM, max 80mg
dose of mirtazapine?
15-45mg, max 45mg
can you combine MAOi & SSRI?
no, need wash out period when switching
precautions in elderly?
avcoid TCAs
mandatory counselling for </= 24 yo
suicidality
which antidepressant suitable for underweight?
mirtazapine
which antidepressent suitable for chronic pain/neuropathy?
duloxetine
which anti-depressants has fewer CYP interactions?
mirtazapine, escitalopram, venlaflazine, desvenlafazine, vortioxetine
what is antidepressants discontinuoation syndrome?
due to abruptly stopping treatment esp paroxetine, venlaflaxine (short t1/2)
presentation of antidepressants discontinuation syndrome?
FINISH
Flu like symptoms (lethargy, fatigue, headache, achiness,
Insomnia (with vivid dreams or Nausea (sometimes vomiting),
Imbalance (dizziness, vertigo, light
headedness),
Sensory disturbances (“burning,” “tingling,”, “electric like” sensations)
Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness).
how to avoid Antidepressants Discontinuation Syndrome
gradual tapering
