Depression Flashcards
Major depression symptoms
depressed most of day, most days; diminished interest in activities, dec weight/wt inc; insomnia, hypersomnia, fatigue; feeling worthless, guilty; dec ability to concentrate, recurrent thoughts of death
Subgroups of depression
psychotic, atypical, seasonal, postpartum, melancholia, catatonic
Pathophysiology of depression
reduced neurotransmitters: serotonin, norepi, DA, mostly invloving limbic and hypothalamus
Treatment options for depression
psychotherapy, electroconvulsive therapy, antidepressants
Electroconvulsive therapy
unilateral/ bilateral seizures that change level of neurotransmitters, response faster than drugs, may need 6-12 months of therapy, most pts respond, be careful w/ stoke or MI
Antidepressant treatment
onset requires weeks, appears to restore the neurotransmitter mediated balance in the brain between serotonin, norepi, and DA, 60-70% efficacy no matter the agent, don’t d/c abruptly, shouldn’t be on 2 from same class
SSRIs
paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitaloprom (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), vortioxetine (Brintellix)
SSRI MOA
inhibits the reuptake of serotonin at the pre-synaptic serotonin transporter pump, inc brain serotonin levels, not fatal if overdose
SSRI ADRs
CNS abnormalities, GI upset, st change, hyponatremia, decreased libido
Fluoxetine (Prozac)
Long T1/2- active metabolites, , activating, causes insomnia, wt loss, minor dopamine antagonist
Fluoxetine (Prozac) dosage
20 mg PO daily, only one available once a week option, 90 mg PO weekly, good for noncompliant pts, must adhere first 2 weeks
Parocetine (Paxil)
wt gain and sedation prominent, take at bedtime, 20-40 mg PO once daily
Sertraline (Zoloft)
25-100 mg PO once daily, middle of the road in terms of effects on sleep and appetite, DA agonist (Minor), good for parkinson’s
Citalopram (Celexa)
20-40 mg PO daily, only effects serotonin, not DA or Ach, fewest ADRs, better for mild to mod depression
Fluoxamine (Luvox)
50-100 PO daily, only indicated for OCD, can also be used to boost activity of antipsychotic agents
All SSRIs are
highly protein bound, inhibit P450 system, increase effects of TCAs, inc/dec lithium, dec clearance of trazodone and diazepam, inc toxicity of MAOIs, may displace protein bound drugs
SNRIs
Venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafacine (Pristiq)
SNRI MOA
inhibit neuronal serotonin and nor epi reuptake results in inc brain serotonin and norepi levels
Venlafaxine (effexor)
take with food, may be effective for resistant depression, ADR exceptions, less sexual side effects, HTN
Venlafaxine (effexor) dosage
75-150mg PO BID, used most frequently as XR formulation: 75-150 PO daily
Desvenlafaxine sodium (Pristiq)
Longer T1/2 than venlafaxine,, requires adjustment for impaired renal function, ADR profile is very similar to venlafaxine
Duloxetine (Cymbalta)
40-60 mg PO daily, quicker onset, effective in one week? used reg for diabetic peripheral neuropathy, hepatoxic
Tricyclic antidepressants
Amitriptyline (Elavil), doxepin (sinequan), nortriptyline (Pamelor), imipramine (tofranil), clomipramine (Anafranil), desipramine (Norpamin)… and more
MOA of TCA
inhibit the of reuptake of norepi and/or serotonin, causing a relative inc in [neurotransmitter], can be fatal in overdose
TCA ADRs
most common: ach effects, sedation and orthostatic hypotension, TCAs lower the seizure threshold and may precipitate seizures, tachycardia, arrhythmias, elderly are at risk of sedation and hyTN
Amitriptyline
10-100mg PO daily, generally at bedtime, used reg for insomnia in young pop
Trazodone (Desyrel)
inhibit serotonin reuptake, 100 mg PO once daily at bedtime, often used in combo w/SSRIs for insomnia, no ACh ADRs, may cause priapism, take w/ food
Bupropion (Wellbutrin) MOA
mild DA reuptake inhibitor, little effect on norepi, no effect on seritonin or monoamine oxidase
Bupropion (Wellbutrin)
Contraindicated in pts w/ seizure disorders and psychosis, lack of cardiovascular, ACh, and sexual side effects, Wt loss, insomnia, agitation, HA, a DOC for smoking cessation, also available as wellbutrin SR/XL
Mirtazapine (Remeron)
enhances central norep and serotonin activity by antagonizing central pre-synaptic a2 receptors, often as adjunct (30mg), monotherapy for insomnia, possibly faster onset
Mirtazapine (Remeron) ADRs
somnolence, at low dose, dizziness, increased appetite/wt gain, orthostatic hyTN, and hallucinations
MAOIs
Phenelzine (Nardil), Selegiline (Eldepryl, Zelapar), tranylcypromine (parnate)- none use very often, must have 2 week washout period when switching from other vice versa
MAOI MOA
impair degradation of norepinephrine, serotonin, and dopamine leading to inc neurotransmitter conc; prevents metabolism of tyramine in GI and liver causing release of norepi and severe HTN, rarely use w/ another class
MAOI ADRs
orthostatic hypotension, delayed ejaculation, wt gain, and edema, can switch bipolar pts into mania, liver toxic, lot of DIs
Withdrawal of antidepressants
1-5 days after d/c, fatigue, insomnia, dizziness, tremor, confusion, agitation, memory probs
Treatment of withdrawals
resume antidepressant if possible, reassurance and supportive care, not life threatening rxns, can be disturbing
Serotonin syndrome
symptoms complex characterized by mental status changes, agitation, diaphoresis, diarrhea*, incoordination and tachy
Cause of serotonin syndrome
believed to be from serotonergic hyperstimulation, can develop when taking a combo of serotonergic meds or when changing from one serotonergic drug to another, also from DI that applify the seroonergic effect of single drug
Treatment serotonin syndrome
d/c all serotonergic meds, supportive care
Suicide warning for antidepressants
boxed warning on most if not all agents, inc in suicide thinking and behavior, not completed attempts
Treatment resistance
clinical trial have documented that most persons do not recover completely from depression w/ 1st drug therapy, many will require therapy w/ 2 or more concurrent agents, for recurrent disease, must treat x2years
