Depression Flashcards
What neurotransmitters are believed to be involved in the cause of depression?
*****Serotonin (5-HT) - most improtant Glutamate Acetylcholine (ACh) **Dopamine (DA) **Norepinephrine (NE) Epinephrine (EPI)
What tools are used in diagnosing depression?
HDRS (aka Ham-D) score for medical office use
DSM-5
What are the criteria for depression diagnosis using DSM-5?
M SIG E CAP
Mood Sleep - increased or decreased Interest/pleasure - diminished Guilt or feelings of worthlessness Energy - decreased Concentration - decreased Appetite - increased/decreased Psychomotor agitation or retardation Suicidal ideation
*** Must exhibit at least 5 of the above mentioned symptoms
Why is it important to rule out bipolar disorder prior starting an antidepressant medication for the treatment if depression?
To avoid induced mania or causing rapid-cycling between bipolar depression and mania
True or False:
Benzodiazepines can be used as adjectively to the treatment of depression but never as mono-therapy to manage presentation of anxiety.
True
What drugs can cause or worsen depression
Methylphenidate and other stimulants Methadone or chronic Opioid use Clonidine Methyldopa Procainamide Cyclosporine Isotretinoin Beta Blockers (especially propranolol)
What are some natural products which can be used to treat depression?
St. John’s wort
SAMe (S-adenosyl-L-methionine)
Valerian
What is the first-line treatment for mild, moderate, and severe depression?
Mild: Psychotherapy or medication
Moderate/Severe: Medication with or without psychotherapy
What is the first-line drug treatment for depression?
SSRI or SNRI
When are MAOI used in the treatment of depression?
Only in patients unresponsive to other treatments
What is the protocol when discontinuing antidepressants drugs?
Must be tapered off over several weeks
except for Fluoxetine
What are some withdrawal symptoms seen with the discontinuation of antidepressant drugs?
Anxiety Agitation Insomnia Dizziness Flu-like symptoms
Which SSRI/SNRI are the biggest offender of withdrawal symptoms upon discontinuation?
Paroxetine
Venlafaxine
Which SSRI/SNRI does not need to be tapered off and why?
Fluoxetine
b/c it has a really long half-life
What is an adequate time to treat with an antidepressant before determining it doesn’t work?
When can we diagnose a patient is Treatment-Resistant depression?
6 to 8 weeks
Treatment-Resistant if on 2 meds and no change in symptoms
What atypical anti-psychotic drugs are approved to be used along with antidepressants in treatment resistant patients?
Aripiprazole
Olanzapine + Fluoxetine
Quetiapine ER
During pregnancy and breastfeeding, if it is determined that drug therapy for depression is needed, what drugs is recommended?
SSRI
with the exception of paroxetine
Tricyclics are also commonly used
with the exception of doxepin
Which SSRI CANNOT be used in pregnancy?
Paroxetine
due to increased risk of cardiac effects
What drug is approved for the treatment of postpartum depression?
Brexanolone (Zulresso)
IV infusion over 60 minutes
All antidepressant BBW
Can increase suicidal thought or actions in children, teenagers or young adults
What is the max dosing on Citalopram?
40mg/day
What is the max dosing on Citalopram in the elderly ≥ 60 years old?
20mg/day
What is the max dosing on Escitalopram in the elderly ≥ 60 years old?
10mg/day
What is the max dosing on Escitalopram?
20mg/day
Which SSRI is recommended in patients with cardiac risk?
Sertraline
SSRI ADE
Insomnia Nausea Dry moth Diaphoresis Weakness Tremor Dizziness Headache Decreased libido (b/c of 5-HT effects)
SSRI/SNRI warning
QT prolongation (discontinue if QTc > 500 msec)
SIADH
Hyponatremia
Bleeding
What indications, other than depression, is Venlafaxine used for?
GAD
Panic disorder
Social Anxiety Disorder
What indications, other than depression, are SSRIs used for?
OCD
What is the MDD of Venlafaxine IR and ER?
IR: 375 mg/day
ER: 225 mg/day
SNRI ADE
Increased HR Increase BP Dry mouth Excessive sweating and constipation Bleeding
MOA of Tricyclics
Mainly inhibits NE and 5-HT re-uptake
Also block ACh and histamine receptors (this is what causes the ADE)
Tricyclics agents
Tertiary amines
- Amitriptyline (Elavil)
- Doxepin (Solenor)
Secondary amine
- Nortriptyline (Palmelor)
Tricyclics ADE
Blurred visions Dry mouth Urination retention Constipation Weight gain
Tricyclics warning
QTc prolongation (discontinue if QTc > 500 msec)
Agents which inhibit re-uptake of Dopamine and Norepinephrine
Bupropion (Wellbutrin, Zyban)
Bupropion contraindication
Contraindication in patients with seizure disorders, history of anorexia or bulimia
If a patient has concern with antidepressants decreasing libido, which drug can be recommended?
Bupropion (Wellbutrin, Zyban)
Mirtazepine (Remeron)
Bupropion ADE
Dry mouth
Insomnia
Tremors/seizures (dose related)
Weight loss
What is the MDD of Bupropion and why?
450 mg/day
b/c of seizure risk
Why aren’t Monoamine Oxidase Inhibitors rarely used?
B/c they have a high risk of:
- Serotonin syndrome when combined with other meds
- Drug-drug and food interaction which can be fatal if missed (e.g. tyramine-rich food)
- Hypertensive crisis when combined with other meds
To avoid Serotonin Syndrome what is the washout period when switching b/w MAOI and SSRI/SNRI/TCA/Bupropion?
5-week with Fluoxetine b/c the long half-life
2-weeks with all others
Whats one major drug-drug interaction with MAOI
SSRI/SNRI/TCA/Bupropion (and tyramine-rich food)
Increased risk of Serotonin Syndrome
What is the dose for Trazodone when being used for sedation?
50 - 100 mg QHS
Trazodone ADE
Sedation (risk of falls in the elderly)
Priapism
Mirtazapine ADE
Sedation (risk of falls in the elderly)
Increased appetite
Weight gain
Other than depression, what else is Mirtazapine used for?
To increase appetite in malnutrition patients usually in the elderly
Which antidepressant should be recommended for patients who would like to loss weight?
Bupropion
Which antidepressant should be recommended for patients who have neuropathic pain?
Duloxetine
Which antidepressant should be recommended for patients who have insomnia and depression?
Mirtazapine
Antipsychotics BBW
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at high risk of Death
