Depression Flashcards
Describe SSRI use for depression
- 1st line in uncomplicated px (physically healthy, outpatient, no CI)
- Citalopram = fewest DIs; sertraline is 2nd least
- All are about equally effective; choice of one over another depends on pt profile and drug profile
- If pt fails trial due to non-response or limiting adverse effect -> ensure adherence and maximize dose (try to wait 8 weeks until increasing)
- If pt experiences partial response -> consider adding 2nd antidepressant, lithium, or LT4 or switch agent
- If pt fails this -> switch agent
- Flat dose response (most px respond at lowest effective dose)
- Advantage -> less SE vs. TCAs b/c more selective
- AE = nausea, agitation, nervousness, restlessness, insomnia/ drowsiness
- Toxic effects -> tremor, sinus tachycardia, N/V/D, seizures, serotonin syndrome
What are the sx of SSRI withdrawal syndrome? When do they occur and how long do they last?
- *FINISH -> flu-like sx, insomnia, nausea, imbalance, sensory disturbance, hyperarousal
- Occur w/in 1-3 days (up to 1 week)
- Last up to 7-14 days (may be several weeks)
Describe venlafaxine
- Similar to SSRIs at low doses, but similar to TCAs at high doses
- AE = BP increases (dose dependent; risk greater w/ increased age), dose-related GI effects, dizziness, sexual dysfunction, dry mouth
Describe TCA use for depression
- Last option for most px
- Nortriptyline generally better tolerated than amitriptyline and clomipramine
- Has antihistaminic effects -> sedation, weight gain
- Has anticholinergic effects, so caution in BPH and glaucoma (desipramine has least ACh effects)
- At usual doses, cardiac effects -> hypertension, tachycardia, antiarrhythmic properties, orthostatic hypotension
- Toxic effects in overdose -> CV (sinus tachycardia, ventricular arrhythmias, hypotension), CNS (coma, delirium, seizures), urinary retention
- Withdrawal sx -> cholinergic & adrenergic rebound = dizziness, N/D, insomnia, hot or cold flashes
- If d/c, taper over 2-4 weeks
Describe bupropion use for depression
- Good option for those previously on venlafaxine who can’t tolerate AE
- AE = insomnia, agitation, anxiety, seizures (at high doses), dry mouth, N/V, rash, headache
- Advantages -> less sexual dysfunction and little weight gain
- CI = seizures, anorexia
Describe mirtazapine use for depression
- AE = orthostatic hypotension (not great for elderly); can be fairly sedating
- Advantages -> little sexual dysfunction and less serotonergic effects (so little weight gain)
Describe MAOI use for depression
- Indicated for atypical or resistant depression
- Only antidepressant that requires washout when switching
- AE = orthostatic hypotension, dry mouth, constipation, sexual side effects, insomnia
- Dosed in AM and mid-day to avoid overstimulation
Which antidepressants can be used in combination?
- Venlafaxine + bupropion
- SSRI + bupropion
- SSRI + TCA
What is the typical tx duration for antidepressants?
- 4-9 months after remission
- Lifelong if < 40 y/o and 2+ episodes OR any age & 3+ episodes
Sx and tx of serotonin syndrome
- *Diagnosis of exclusion
- Cognitive/behavioural = agitation, mental status changes (confusion, hypomania)
- Autonomic = diarrhea, fever, shivering
- Neuromuscular = incoordination tremor, myoclonus, hyperreflexia
- Tx = supportive care, BZD for neuromuscular sx, tylenol for fever, cyproheptadine 4 mg q4h for severe sx
Depression in pregnancy
- Weigh risks vs. benefits to mother and fetus!!
- Most evidence for safety of fluoxetine
- Can do ECT and psychotherapy (CBT)
- After delivery, watch for direct drug effects and transient withdrawal sx in infant
Depression in breastfeeding
- Safe = paroxetine, sertraline*, fluoxetine, nortriptyline
- Monitor infant daily for changes in sleep, feeding patterns, and behaviour
Depression in children/ adolescents
- 1st line for moderate to severe major depression = fluoxetine and citalopram
- 2nd line = other SSRIs (paroxetine has most AE)
- 3rd line = venlafaxine
- Best outcomes when combine antidepressant w/ CBT
- Monitor suicidal thoughts!!
Red flags for antidepressants (when to avoid certain ones)
- Avoid bupropion and TCAs in seizures
- Avoid SSRIs, venlafaxine, TCAs, and MAOIs in sexual dysfunction
- Avoid TCAs, MAOIs, and mirtazapine if pt doesn’t want weight gain
- Avoid TCAs if possible in elderly (urinary retention, excessive sedation)
Case specific assessment questions for depression
- Are you having suicidal thoughts?
- Are you having psychotic sx? (hallucinations, delusions)
- Are you still able to go to school/work? (impairment in functioning warrants tx)
Non-pharms for depression (general)
- Cognitive behavioural therapy
- Interpersonal
- Bright light therapy
- Exercise and good nutrition
What can be done to manage AE of antidepressants?
Normally can decrease dose or switch agent if very bothersome to pt
General monitoring for depression
- Pt should monitor sx daily
- Anxiety and insomnia improve in 3-5 days
- Energy and somatic sx in 2-3 weeks
- Sleep patterns in 4-6 weeks
- Depressed mood and sexual dysfunction in 4 weeks
- Monitor suicidal thoughts (especially in children)
General follow up for depression
- Pharmacist follow-up in 1-2 weeks when meds are added or increased to see about side effects
- Consistently follow-up w/ pt regarding depressive sx to see if deprescribing is appropriate
- Continue full dose for at least 6-12 months after remission (when sx go away)
Describe monitoring for depression when adding therapy
- Monitor for symptom improvement and side effects of the medication daily/weekly
- If now taking 2 serotonergic drugs, monitor for serotonin syndrome
(common sx = excitement, anxiety, muscle rigidity, fever, tremor, increased HR; on pg. 151)
– Typical onset for serotonin syndrome = 1 h to 1 day (so if pt is experiencing similar sx after 1 week of taking the drug, can attribute it to normal SE of the drug)
– Generally, doesn’t occur from just 1 drug (possible at max. dose), generally happens when pt uses 2-3 serotonergic drugs - If new med -> all adverse effects on page 152
- **Most common SE of SSRI’s are GI effects and headaches
Describe when to go to a Dr for depression when adding therapy
- Go to doctor/talk to pharmacist if side effects become unbearable, or if you feel like this medication isn’t working
- For women -> go to Dr. if you become pregnant b/c we may need to switch to a safer antidepressant
Describe when to go to emergency for depression when adding therapy
Go to emergency if you do experience serotonin syndrome, you are having suicidal thoughts, any dramatic mood changes (lots of energy; can indicate bipolar which normally presents first as depression)
Describe non pharms for depression when adding therapy
- Diary of symptoms
- CBT, psychotherapy
- Mindfulness, meditation
- Exercise and good nutrition
Describe follow up for depression when adding therapy
- I will follow up with you 5 days to discuss any side effects you might be experiencing as well as your adherence
- I will also follow up with you in 2 and 4 weeks to discuss if you are seeing any sx improvement with the medication
- I would like to give this at 4-6 weeks before we re-assess if you need a dose increase or to be switched to a different antidepressant
A patient asks “how long will I have to take my antidepressant”
- At least 1 year after a good response is achieved
- Response/remission typically takes 6-12 weeks to see
Describe monitoring for depression after hospitalization (starting new med, increasing dose)
- Monitor for sx improvement and side effects of medication daily/weekly
- Common SE of meds -> in RxFiles pg. 152
- Anxiety and insomnia improve in 3-5 days
- Energy and somatic sx improve in 2-3 weeks
- Sleep patterns improve in 4-6 weeks
- Depressed mood and sexual dysfunction improve in 4 weeks
- **Common for physical sx to remain after mood has increased
Describe when to go to a Dr for depression after hospitalization (starting new med, increasing dose)
Go to doctor if you don’t notice any sx improvement within 2-3 months
Describe when to go to emergency for depression after hospitalization (starting new med, increasing dose)
Go to emergency if you experience any suicidal thoughts, any dramatic mood changes, or any serious SE to the drug
Describe non pharms for depression after hospitalization (starting new med, increasing dose)
- Diary of symptoms
- CBT, psychotherapy
- Mindfulness, meditation
- Exercise and good nutrition
Describe follow up for depression after hospitalization (starting new med, increasing dose)
- I will follow up with you in 1 week to discuss any side effects of the medication
- And I will follow up with you in 1-2 months to discuss sx improvement. Unfortunately, it does take time for this medication to work and for you to see improvement, but I am always here to answer any questions you have
