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PSYCH Therapeutics > Depression > Flashcards

Depression Flashcards

1
Q

DSM5 Diagnostic Criteria :
1. Must have how many of the following on MOST DAYS within 2 weeks ?

  1. D
  2. A
  3. Substantial ___
    5.I or H
  4. F or L
  5. Poor ___ or ability to think or __
  6. Feelings of ____ or ___
  7. P or R (observed)
  8. Recurrent thoughts of ___
  9. out of the 5 required, 1 of 2 of the following must be included?
A
  1. 5
  2. Depressed or irritable mood nearly all day occurring most days
  3. anhedonia or loss of interest
  4. weight loss or gain (>=5% of body weight)
  5. Insomnia, hypersomnia
  6. fatigue or low energy
  7. concentration , indecisiveness
  8. worthlessness, inappropriate guilt
  9. psychomotor agitation , retardation
  10. death or suicide with or without plan
  11. Anhedonia or depressed mood
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2
Q

What are some risk factors ?
1. E
2. Gender ?
3. History ? (2)
4. Comorbidities ? (2)
5. Meds/substances : (5)
6. Diet?
7. lack of ?
8. ___ events

A
  1. Environmental : loss of spouse, loved one, dysfunctional childhood, divorce/stressful events
  2. Female, postpartum
  3. Prev episode or suicide attempt, family hx
  4. Medical and SUD
  5. Barbiturates, Bdz’s, alcohol, cannabinoids, opiates
  6. Imbalance of omega 6 fatty acid compared to omega 3 fatty acid may incr risk
  7. Social support
  8. Psychosocial
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3
Q

Secondary Causes of Depressive Sx’s :
Note, these must be ruled out before you can make a diagnosis

  1. Medical causes (5 main ones)
  2. Medication causes (6)
A
  1. Hypothyroidism , MS, CAD/CVA/MI/CHF, Fibromyalgia/Pain disorder, Vit D deficiency

-DM, Parkinson’s, Alz, Cancer, HIV/AIDS , RA

  1. BZD’s, IFNAlpha/PegIFN, Isotretinoin, Opiates, Tramadol, naltrexone
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4
Q

Duration of Treatment :
1. during acute phase, when can u see improvement? full benefit?
2. Continuation phase is ?
3. maintenance phase is?
4. Whats required for all pts ?

A
  1. 1-2 weeks, 4-12 weeks
  2. 4-9 months at acute phase dose
  3. lifetime tx for high risk
  4. acute and continuation phase
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5
Q

SSRI’s :
1. Name 7
2. For the following AE’s, state which drug they’re worst with and which one is common :
A. CNS (Sedation, insomnia, HA/Vivid dreams/nightmares)
B. GI effects (2)
C. Anticholinergic Effects (1)
D. Bleeding/Anemia

  1. Which AE occurs in 30-73% of pt’s?
  2. Worst with which drugs? (2)
  3. Which can cause withdrawal syndrome? (2)
  4. Miscellaneous Ae’s ? (8)
  5. What’s a BBW for SSRI’s?
    -because of this BBW, what do u need to do?
A
  1. Fluoxetine, Sertraline, Paroxetine, Fluvoxamine, Citalopram, Escitalopram, Vilazodone
  2. Sedation : worst with fluvox, paroxetine
    Insomnia : worst with fluoxetine
    Ha/Vivid dreams/nightmares =common

B. N/V/D constipation : worst with sertraline, paroxetine

C. Worst with paroxetine (Dry mouth, constipation)

D. All drugs have potential, due to platelet serotonin depletion

  1. Sexual dysfunction
  2. Fluoxetine and paroxetine (Delayed ejac, anorgasmia, impaired libido)
  3. Fluvox and paroxetine
  4. Sweating, SIADH, Weight gain, Bruxism, Decr BMD, extrapyrimadal sx’s, QT prolong, suicidal ideation
  5. 18-24 yrs, incr suicidal thinking/behavior during first 2 months of treatment
  • Need to taper all antidepressants rather than abrupt DC
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6
Q

Which drug has Qt prolongation ?

Max daily dose?

Max daily dose for patients w/hepatic impairment, > 60, or who are CYP2c19 PM, or concomitant cimetidine?

Use caution in patients with ?
Avoid in patients with ?
Before starting Citalopram, what needs to be corrected?
Incr ___ in pt’s with CHF or heart problems

ALL antidepressants have what risk?

A

CITALOPRAM

40mg/day

20mg/day

CHF, bradyarrhythmias, predisposition to hypokalemia or hypomagnesemia

congenital long QT syndrome

Hypokal and Hypomag

ECG monitoring

Suicide risk

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7
Q

SNRI :
1. Name 4
2. Common AE”s for the class? (7)
3. Venlafaxine Ae’s specifically? (2)
4. Duloxetine? (2)
5. Levomilnacipran? (5)
6. Which drug associated w/incr risk for death vs SSRI in the case of overdose?
7. What to do in elderly population or those with anxiety disorders?

A
  1. Venlafaxine , Duloxetine, Desvenlafaxine, Levomilnacipran
  2. GI effects (nausea, constipation, diarrhea), insomnia/somnolence, sexual dysfunction, dizziness, dry mouth, sweating, suicide risk
  3. HTN (dose related), Withdrawal
  4. Hepatitis, and cholestatic jaundice
  5. HTN, tachycardia, mydriasis, urinary retention, seizures
  6. Venlafaxine (usually in combo w/ETOH and drugs), but less risk than TCA’s
  7. Start low and go slow!
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8
Q

Atypical Antidepressants :
1. Serotonin receptor antags such as? (3)
2. Name 3 others

  1. trazodone is usually used as ? which formulation approved for depression?
  2. what’s last line of these agents for depression and why?
  3. Phenylpiprazines : AE’s? (5)
  4. Mirtazapine : Indications? (2)
  5. AE’s? (2) but has no____ (2)
  6. Bupropion : FDA indications (2)
  7. IR , SR, ER dosing frequency
  8. Bupropion AE’s? (6)
  9. CI in which population ? (2)
  10. CYP interactions for wellbutrin?
  11. Can incr levels of? (4)
A

1.Phenylpiprazines : Nefazodone, Trazodone,
-Mirtazapine

  1. Bupropion, Vortioxetine, Dextromethorphan-Bupropion
  2. Sedative-hypnotic , Trazodone XR
  3. Nefazodone , Hepatotoxic
  4. Sedation/dizzy, confusion, Orthostasis, Priapism (Traz mainly), Anxiety and panic attacks
  5. depression (FDA) and nausea
  6. sedation (low doses), weight gain .
    -Nausea or sexual dysfunction
  7. Depression, smoking cessation
  8. q6hrs, q8hrs, q24hrs
  9. Insomnia, Agitation , weight loss, incr BP, HA, seizures
  10. Seizure disorders, ED’s
  11. CYP2D6 inhibitor
  12. venlafax, desipramine, dextromethorph, vortiox
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9
Q

Vortioxetine (Trintellix) :
1. Indications?
2. Ae’s? (3) .. May have less what ?
3. Dosing. ?
4. will have decr levels due to cyp inducers such as ? (2)

A
  1. MDD, May be helpful in ADHD sx’s
  2. N/V/Constipation , may have LESS sexual dysfunction than ssri’s and snri’s
  3. titration from 10mg to 20 mg daily
  4. Carbamazepine and Phenytoin
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10
Q

TCA’s
1. Name some tertiary (4) vs secondary (3)
2. Neuro ae’s? (6)
3. GI/GU ae’s?
4. CV ae’s? (5)
5. Other ae’s such as ?
6. Which have greater ae’s?
7. In elderly, should do what and avoid ?
8. NOT preferable in which pt’s?

A
  1. Tertiary : Amitriptyline, Doxepin, Imipramine, Clomipramine
    Secondary : Protriptyline, desipramine, nortriptyline
  2. Sedation , mental status changes, respiratory depression, lethargy, confusion, lower seizure threshold
  3. Constipation, weight GAIN, dry mouth, urinary retention
  4. Orthostasis, tachycardia, incr qtc, TdP, Vtach
  5. Sexual dysfunction, switch to mania
  6. Tertiary TCA’s
  7. decr dose, avoid tertiary
  8. pt’s with suicidal ideation or past suicide attempts
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11
Q

MAOI’s : Phenelzine and Selegiline EMSAM
1. AE’s?
-CNS (3)
-CV (3)
-Endocrine
-GI/GU
2. EMSAM specific adrs?

A
  1. Sedation/insomnia , HA, switch to mania
  • Ortho hypo, decr HR, hypertensive crises
  • Anorgasmia/Sexual impotence , SIADH
  • Dry mouth, constipation, urinary hesitancy, weight GAIN
  1. HA, insomnia, application site rxns
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12
Q

Do not use MAOI’s within 5 weeks of discontinueing ___ or 2 weeks of discontinuing other ____,_____,___ or 3 weeks of discontinuing ___

How long must u wait after DC of MAOI to swich to another antidepressant ?

EMSAM only is CI with which 2 drugs?

A

Fluoxetine, SSRI, TCA, MAOI, Vortioxetine

2 weeks

Carbam, Oxcarbam

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13
Q

Guidelines :
1. Therapeutic trial should be how long?
2. If no response to monotherapy, what should u do?
3. If partial response to monotherapy at optimized dose, what should you do?

A
  1. 4 to 6 weeks of optimized/therapeutic dose
  2. Switch within or between pharmacological classes
  3. augmentation with psychotherapy and augmentation with NON-MAOI or NON-Antidepressant medication
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14
Q

Discontinuation of Therapy :
How long should patients be treated before considering a taper?

All ___ should be gradually titrated down and discontinued over ___

Warn pt’s about sx’s of __ espeically with (4) ?

When should we consider long term therapy?

A
  1. 4-9 months or about 7 months
  2. SSRI’s. several days
  3. withdrawal. venlafaxine, paroxetine, levomilnacipran, desvenlafaxine
  4. those with recurrent episodes, first episode after 60 yrs of age
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15
Q

Serotonin withdrawal syndrome :
1) due to ?
2) especially for meds? (7)
3) Sx’s?
4) onset?
5) Duration ?

A
  1. Abrupt discontinuation of meds
  2. short half life like doxepin, amitriptyline, imipramine, desipramine, parox, fluvox, venlafax
  3. flu like sx’s, dizzy, insomnia, nausea, shooting pains in extremeities, anxiety, lethargy
  4. 48 hrs after last dose
  5. 3 days to 2 weeks but can be longer
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16
Q
  1. What can happen with multiple serotonergic meds given? (SSRI’s SNRI’s, TCA,s MAOi’s, Tramadol, SJW) ?
  2. WHats been reported with SSRI and SNRI alone or in combo with triptans, MAOi’s, antipsychs/dopamine antags?
  3. Whats incr when using anticoags/antiplatelets with serotonergic agents especially SSRI’s?
  4. Incr of qt prolongation and arrhythmias with?
  5. Incr sedation wen using sedating antidepresssants and ___
  6. MAOI’s combined with SSRI’s, SNRIs, TCAs, tramadol, methadone, decongestants?
A
  1. Serotonin syndrome (GI, neurologic changes, CV, psych)
    -abdom cramping, N/V/D, manic sx’s, confusion
  2. Neuroleptic malignant syndrome (Lead pipe rigidity, unstable BP, tachycardia, fever, mental status changes, myalgia, rhabdo, renal failure)
  3. risk of bleeds
  4. citalopram
  5. etoh
  6. hypertensive crises
17
Q

Advantages of SSRi’s and SNRI’s :
1. SSRi’s are safer in ?
-Have less?
-Easy ___
-Useful for which disorders?

  1. SNRI’s are useful for ?
    -No ____ required for ?

Advantages of MIRTAZAPINE :
1. Patient tolerance bc of less ?
2. No ___
3. Good in pt’s with ? (3)
4. Can use with SSRI’s with low risk of?
5. Dosed ___

Advantages of BUPROPION :
1. No ___
2. Good for ?
3. Can be used with ___ w/o risk of serotonin syndrome
4. incr levels of ___

A
  1. overdose
    -titration
    -dosing schedule
    -anxiety, ED, menstrual
  2. multiple pain disorders
    -tritration , duloxetine, desvenlafaxine
  3. Nausea
    2, sexual dysfunction
  4. agitation, insomnia, SSRI intolerance
  5. serotonin syndrome
  6. once dialy
  7. alpha1, H1, M1 effect and no sexual dysfunction
  8. psychomotor retardation, hypersomnia, anergic depression, ADHD, smoking cessation
  9. SSRIs and SNRIS
  10. Dextromethorphan
18
Q

Disadvantages of Mirtazapine : Name 4

of Bupropion? 7

A
  1. Sedation
  2. fatigue/low energy
  3. weight gain
  4. orthostasis
  5. Divided dose required unless using XL
  6. Titration required
  7. CI’s (ED and seizures)
  8. Agitation, insomnia, anxiety sx’s
  9. Lower seizure threshold
  10. BP concerns
  11. false positives on urine drug screening for amphetamines
19
Q

Selecting an Antidepressant :
1. Pt’s with low energy and anhedonia? (4)
- Avoid meds ? (2)

  1. Pt’s who are anxious and irritable?
    -Avoid? (2)
  2. Pt’s who dont want sexual dysfunction ? (2)
    -Avoid? (1)
  3. Pt’s who dont want weight gain
    -Avoid (4)
  4. Pt’s with Comorbidities such as :
    HTN (3) , Seizures (2) , Parkinson’s (1)
  5. Elderly patients?
  6. Pregnancy?
A
  1. Dulox, venlafax, levomilnacipran, bupropion
    -Parox, mirtaz
  2. SSRI’s
    - Meds that incr anxiety initially (SNRI’s and bupropion)
  3. Buprop, mirtaz –> avoid SSRIs
  4. Buprop
    -Avoid paroxetine, Mirtaz, MAOI’s and TCAs
  5. HTN : Avoid venlafax, TCA, MAOI’s
    Seizures : Avoid bupropion and TCA’s
    Parkinsons: Bupropion is preferred, avoid antipsychs!
  6. SSRI’s but careful of paroxetine in dementia patients, careful of drugs exacerbating SIADH or hyponatremia, and sedative hypnotics
  7. Psychotherapy (CBT or ECT)
    -Avoid paroxetine (cardiovasc malforms)
    -Low levels of infant exposure w/sertraline and citalopram
20
Q

Non pharm :
1. Psychotherapy such as?
2. Interventional Therapy such as?

A
  1. Cognitive behavioral therapy
    -Interpersonal therapy
  2. bright light therapy
    -electroconvulsive therapy
    - vagal nerve stim
    - repetitive transcranial magnetic stim

PSYCH Therapeutics (11 decks)

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