Depression Flashcards
Risk of reoccurance
Episode 1: 50-60%
Episode 2: 70%
Episode 3: 90%
Diagnosis
> or equal 5 with at least 1 being depressed or loss of interest
SIGE CAPS
Sleep, intertest decrease, guilt/worthlessness, energy loss, concentration difficulties, appetite loss, psychomotor agitation, suicidal ideation
Physiological
sleep, appetite, fatigue, clumsiness
Phycological
dysphoric mood, loss of interest, guilt, worthlessness
Cognitive
concentration difficulties, suicidal ideation
Biogenic amine
Reserpine causes depression by depleting NE and 5-HT from vesicles
NE and 5-HT are effective in depression
Genetic polymorphisms in SERT
Alterations in 5-HT1A/C and alpha 2 receptors
Neuroendocrine
Alterations in Hypothalamic-pituritary-adrenal axis (HPA)
Overactivity of the axis that causes increased activity of CRF
CRF1:arousal, anxiety, disruption in sex and sleep
Neurotropic
Depression, stress and pain patients have decreased BDNF levels
Loss of sprouts and hippocampal volume leads to depression
Antidepressant increase BDNF levels and hippocampal volume
MAO-I
MAO normally degrades NE and 5-HT
MAO-A: NE AND 5-HT
MAO-B: DA
Inhibition: increased amount of NE and 5-HT in vesicles released in synapse
Phenelzine and Tranylcypromine
drug resistant depression
Non-selective (irreversible)
Moclobemide
MAO-A selective (reversible)
Selegiline
MAO-B selective (reversible)
SE of MAO-I
HA, drowsiness, dry mouth, weight gain, orthostatic hypotension, sexual dysfunction
Hypertensive crisis: AVOID TYRAMINE
MAO normally degrades tyramine
Except selegiline 6 mg/24hr patch
Risk of serotonin syndrome: TCA, SSRI, L-DOPA
MUST HAVE 2 WEEK WASHOUT PERIOD BEFORE SWITCHING ANTIDEPRESSANT (5 WEEKS FOR FLUOXETINE)
TCA
Tertiary amines
Block SERT, NET, histamine 1, muscarinic, alpha -1
Imipramine
tertiary amine
metabolized to desipramine
Trimipramine
tertiary amine
Clomipramine
tertiary amine
causes orgasm when yawning
Amitriptyline
metabolized to nortriptyline
Doxepin
tertiary amine
SE of TCA tertiary amines
sedation, confusion, reduced seizure threshold
anticholinergic
orthostatic hypotension, tachycardia
weight gain, sexual dysfunction
MOA of TCA secondary amines
blocks NET and SERT
Desipramine
secondary amine
Nortriptyline
secondary amine
Maprotiline
secondary amine
SE of TCA secondary amines
less side effects
SSRI MOA
inhibit SERT that increases amount of 5-HT in synapse
Fluoxetine
take in the morning
little sedation, autonomic
weight loss
long t1/2
activating potential
Paroxetine
take at bedtime
sedation, weight gain
Must taper due to ANTICHOLINERGIC EFFECTS
Septal wall defect risk in fetus–>caution in pregnancy
Citalopram
QTc prolongation
Escitalopram
Sertraline
GI upset
Fluvoxamine
Vilazodone
SSRI +5-HT1A partial agonist
Reduce sexual dysfunction effects of SSRI
Take with food: nausea and increases bioavailability
Cannot be used with SSRI/SNRI
Vortioxetine
SSRI + 5-HT1A partial agonist
Reduces sexual dysfunction
Nausea, vomiting, constipation
Cannot be used with SSRI/SNRI
SSRI Side effects
Headache, N/V, sexual dysfunction, insomnia, tremor, anxiety, increased bleeding risk, hyponatremia, decreased bone density
Withdrawal from SSRI
brain zaps, vertigo, dizziness, sweating, insomnia, confusion
SLOW TAPER (10-25%) 1-2 WEEKS
Serotonin syndrome symptoms
hyperthermia, muscle rigidity, restlessness, myoclonus, hyperreflexia, sweating, shivery, seizures
Serotonin syndrome treatment
d/c treatment and manage symptoms
serotonin antagonists
BZD to manage myoclonus
MOA of SNRI
Blocks NET and SERT
Venlafaxine
> 150mg/day to have NE effects
Desvenlafaxine
active metabolite of venlafaxine
nausea (50%)
No CYP interactions
Duloxetine
Nausea
Hepatotoxicity
baseline LFT
every 6 months
Maprotiline
blocks NET
Mirtazapine
5-HT2/3, H1, Alpha 2 antagonist
Sedation, weight gain
Agranulocytosis
Increase cholesterol
can be taken with SSRI/SNRI
Bupropion XL
Blocks NET, DAT
Stimulating–> insomnia, appetite suppression
CI in seizures and eating disorders
Can be used with SSRI/SNRI
Trazodone
5-HT2A antagonist + blocks SERT
Sedation
Orthostatic hypotension
priapism
Filbanserin
5-HT2A/C antagonist
5-HT1A agonist
RAPID ACTING
FDA Approved augmentation agents
Aripiprazole
Brexpiprazole
Cariprazine
Quetiapine
Treatment of Postpartum depression
SSRI (Fluoxetine or Paroxetine) SNRI (Venlafaxine)
Brexanolone
postpartum depression
Allopregnanolone levels are increased during pregnancy–>desensitizes GABA-A receptors
After birth, allopregnanolone levels return to normal –>brexanolone resensitizes GABA-A receptors
REMS
60 hr infusion
