Depression Flashcards
Though the pathophysiology of depression is not fully understood, which neurotransmitters have been implicated?
serotonin, dopamine, norepinephrine, glutamate, acetylcholine, epinephrine
Which assessment tool is the most frequently used for depression?
Ham-D aka HDRS
Of the symptoms listed in SIG E CAPS, ____ must be present in a ____ week period for a diagnosis of MDD.
5 in a 2 week period
An important potential comorbidity that must be screened for in depressive patients is ________.
bipolar disorder (antidepressants can exacerbate mania or cause rapid cycling of mood)
Which drugs/drug classes can cause or worsen depression?
ADHD drugs (atomoxetine) indomethacin antiretrovirals (mostly efavirenz) beta-blockers hormones antidepressants (lol) BZDs steroids varenicline
What medical conditions can contribute to depression or its development?
stroke, hypothyroidism, Parkinson dx, dementia, MS, low vitamin D, malignancy
Which two OTC supplements may have some efficacy in treating depression?
St. John’s Wort and valerian
St. John’s Wort is a potent CYP _______.
inducer
Since response to antidepressants is highly variable between patients, initial choice of therapy is based on what 3 things?
side-effect profile, safety concerns, and patient-specific symptoms
Which class of drugs used to treat depression is reserved for patients who have failed other treatments due to drug-drug and drug-food interactions?
MAO inhibitors
What are 5 options for patients experiencing a suboptimal response to therapy?
1) dose increase of current drug
2) combination of multiple antidepressants with different mechanisms of action
3) adding buspirone or low dose atypical antipsychotic
4) lithium or thyroid hormone augmentation
5) ECT
What is the general approach to treating depression in pregnancy?
Mild depression may not require medical treatment - use psychotherapy first and see if medication is necessary. More severe cases will likely require treatment through the pregnancy due to risk of poor maternal and fetal outcomes if left untreated. However, all drugs carry fetal risk. SSRIs are generally preferred, but have a few pearls. Paroxetine is contraindicated due to cardiac effects, and SSRIs as a class carry a risk of persistent pulmonary hypertension of the newborn.
Postpartum depression is most frequently treated with which two drug classes? Which medication is not used per ACOG guidelines?
SSRIs or tricyclic antidepressants most commonly used, doxepin not recommended
All antidepressants carry a boxed warning for what adverse outcome?
increase in suicidality
Between physical and psychological symptoms, which is usually the first to improve after starting pharmacotherapy for depression?
physical - psychological may take over a month to improve with daily medication use
What is the maximum daily dose of citalopram?
depends on age - 40 mg if less than 60, 20 mg if older
Match the medication(s) with the antidepressant(s) it is contraindicated with:
A- thioridazine 1. sertraline sol.
B- alosetron or tizanidine 2. all
C- disulfiram 3. fluox/parox
D- linezolid, pimozide 4. fluvox
A/3
B/4
C/1
D/2
The dose of escitalopram in the elderly should not exceed ____.
10 mg
What is the max daily dose of fluoxetine?
80 mg
What is the max daily dose of fluvoxamine?
300 mg/day - divide BID if TDD is to be > 100 mg
What is the max daily dose of sertraline?
200 mg
What two SSRIs can be used for PMDD?
fluoxetine and sertraline
What are the class side effects of SSRIs?
dry mouth, decreased libido, nausea, somnolence or insomnia, diarrhea, tremor, dizziness
Which SSRI is should be taken in the morning due to its activating property?
fluoxetine
Which SSRIs are typically the most sedating and should be taken at night?
paroxetine/fluvoxamine
Which antidepressants have the highest frequency of diarrhea?
sertraline (20%)
fluoxetine (up to 18%)
fluvoxamine (up to 18%)
Which SSRI is preferred in patients with cardiac risk?
sertraline
What are the class warnings for SSRIs?
SIADH, hyponatremia, QT prolongation, bleeding
What is the dose conversion between IR and CR paroxetine?
10 mg IR = 12.5 mg CR
Which SSRI has the longest half-life?
fluoxetine (can self-taper with discontinuation)
What is the receptor pharmacology of vilazodone (Viibryd)?
SSRI + partial 5-HT1A agonist
Describe the dosing of vilazodone.
Upward titration has to occur due to nausea. Starts at 10 mg daily for a week, doubling the dose every seven days either once (20 mg/day) or twice (40 mg/day - max).
Vilazodone should be taken ______ food.
WITH (significantly reduces nausea)
Describe the receptor pharmacology of vortioxetine (Trintellix).
SSRI + 5HT3 antagonist + 5HT1a agonist
What is one advantage of the novel/multimodal SSRIs over traditional SSRIs?
less sexual dysfunction (alright alright)
What are the symptoms of serotonin syndrome?
agitation, diarrhea, diaphoresis, tremor, tachycardia/HTN, mydriasis, muscle rigidity
A washout period of _____ should occur before starting an SSRI in patients currently receiving a MAO inhibitor.
14 days (except fluoxetine - 5 weeks due to long half-life)
Which CYP enzyme is frequently inhibited by SSRIs that is also usually the primary metabolizer of antipsychotics used in combination with them?
2D6
Match the antidepressant to the CYP enzymes it inhibits:
A- fluoxetine 1. 2C19/2D6
B- fluvoxamine 2. 2D6
C- paroxetine 3. 2C9/2C19/3A4/2D6/1A2
A/1
B/3
C/2
Which anticancer drug requires conversion by CYP2D6 that may be inhibited by SSRIs?
tamoxifen
Match the SNRI with its maximum daily dose:
A. desvenlafaxine 1. 120 mg
B. levomilnacipran 2. 400 mg
C. venlafaxine 3. 375 mg
D. duloxetine
B and D/1
A/2
C/3
What is the dose limiting side effect of duloxetine?
nausea
Which SNRI is a moderate 2D6 inhibitor?
duloxetine
Which added side effects do SNRIs have due to increased norepinephrine?
increased HR and BP, dry mouth, sweating, constipation, mydriasis (can precipitate episode of narrow angle glaucoma)
TCAs have additional activity at which receptors (which contributes to their side effect profile)?
Ach and histamine
Between secondary amines and tertiary amines, which has the greater amount of side effects due to increased anticholinergic properties?
tertiary amines (amitriptyline, doxepin)
If taken once daily, amitriptyline should be used in the ________.
evening - may divide larger daily doses
The dosing of amitriptyline and doxepin for depression is the same: ________ mg/day.
100-300
Amitriptyline has the added indication (with lower dosing) for ________ and _______.
neuropathic pain and migraine prophylaxis
The most fatal adverse effect of TCA overdose is _________.
fatal arrhythmias
What are the anticholinergic side effects of TCAs?
dry mouth, constipation, blurred vision, urinary retention
What are the neurotransmitter properties of bupropion?
dopamine and norepi reuptake inhibitor
What are the brand names and matching indications for bupropion?
Zyban - smoking cessation
Wellbutrin - depression
Contrave - weight loss (with naltrexone)
What are the dosing frequencies of Wellbutrin SR, Wellbutrin XL, and bupropion IR?
IR - TID
SR - BID
XL - QD
What are contraindications to bupropion use?
seizure disorders and previous anorexia/bulimia
When used for smoking cessation, bupropion has a warning for _______.
neuropsychiatric events (mood changes, hallucinations, paranoia, etc.)
What are 3 examples of MAO inhibitors?
phenelzine, isocarboxazid, tranylcypromine
What are the two most dangerous adverse events associated with MAO inhibitors if drug-drug or drug-food interactions are missed?
hypertensive crisis and serotonin syndrome
Mirtazapine is a _____ (class) used mostly for _____ and has side effects related to its uses (_______ and _______).
TCA, sleep/increase appetite, sedation and appetite increase/weight gain
Which adjunctive antidepressant comes as a nasal spray?
esketamine (spravato)
Which antidepressant can leave ghost tablets in the stool?
desvenlafaxine
Which MAO inhibitor comes in a patch formulation? What is the brand name?
selegiline (Emsam)
