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PHAR123 > Depression and Anxiety > Flashcards

Depression and Anxiety Flashcards

1
Q

How effective is drug treatment for depression and anxiety?

A

drug treatment is about 30% effective and complete remission is not common
-drug treatment takes weeks to work

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2
Q

What are some symptoms of major depression?

A

feelings of sadness, tearfulness, emptiness or hopelessness
angry outbursts, irritability or frustration even over small things
loss of interest or pleasure in normal activities
sleep disturbances
tiredness and lack of energy
reduced appetite or cravings and weight loss or gain
anxiety, agitation or restlessness
slowed thinking, speaking, movements
feeling of worthlessness
trouble thinking or concentrating
suicidal thoughts
physical problems

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3
Q

What are psychological symptoms of generalized anxiety?

A

persistent worry
overthinking plans and solutions
perceiving events as threatening
difficulty handling uncertainty
indecisiveness and fear of making wrong decision
inability to let go of worry
inability to relax
difficulty concentrating

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4
Q

What are the physical symptoms of generalized anxiety?

A

fatigue
trouble sleeping
muscle tension/aches
trembling
nervousness
sweating
nausea, diarrhea or IBS
irritable

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5
Q

What are the treatment modalities for depression and anxiety?

A

medications (particular those involved in serotonergic system)
counseling
exercise, meditation, light therapy, relaxation
multimodal approach creates synergy, one method alone is not sufficient

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6
Q

Describe the serotonergic system.

A

14 subtypes of receptors organized into 7 classes
receptor classes coupled to G proteins except for 5-HT3 which is ligand gated ion channel

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7
Q

Where does serotonin work in the body?

A

brain: mood, happiness, sleep
periphery
gut
CV system and platelets

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8
Q

What are the major brain regions involved in serotonergic pathways and their respective roles?

A

hippocampus: learning & memory
amygdala: fear & emotions
hypothalamus: neuroendocrine functions

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9
Q

Where is 5-HT produced?

A

several raphe nuclei in the brainstem

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10
Q

What does serotonin do in the body?

A

mood and emotion processing
sleep/wake cycling (promotes sleep)
aggression and impulsivity
appetite and obesity
platelet response
effects on CV system
reduces airway inflammation
GIT (modulates enteric nervous system)

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11
Q

How does serotonin reduce appetite?

A

activation of 5HT2C in hypothalamus

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12
Q

How is serotonin involved in vasodilation and the platelet response?

A

activates 5HT1 resulting in NO release=vasodilation
activates 5HT2=platelet aggregation + vasoconstriction

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13
Q

How does serotonin reduce airway inflammation?

A

5HT2 receptor activation

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14
Q

Describe serotoninergic signaling.

A

depolarization of presynaptic neuron=entry of Ca and Na
vesicles full of serotonin fuse with plasma membrane releasing 5HT into the synaptic cleft
serotonin traverses the cleft and binds with serotonin receptor on the postsynaptic nerve terminal
intracellular signaling occurs in the postsynaptic nerve resulting in a downstream effect

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15
Q

What is the monoamine hypothesis of depression?

A

depletion of monoamines causes depressive symptoms
-NE, serotonin, and dopamine
the dysregulation may have a genetic link and/or may be affected by stress or trauma, whereby receptor density or sensitivity is altered and brain function is impacted
restoring monoamines improves depression

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16
Q

What is a neurotropic factor that may be involved in depression?

A

brain-derived neurotrophic factor (BDNF)
-regulates plasticity, resilience, and neurogenesis

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17
Q

What is the impact of stress and pain on BDNF?

A

decreases BDNF
-antidepressants enhance BDNF-induced neurogenesis and
synaptic connectivity in areas like hippocampus
-structures affected may be affected anatomically by
persistent, untreated major depression due to neuronal loss
-electroshock treatment=increased BDNF

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18
Q

What are the hormonal factors associated with major depressive disorder?

A

elevated cortisol
low thyroid hormone
low estrogen
low testosterone
these may reduce BDNF transcription

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19
Q

How quickly does treatment with antidepressants increase monoamine levels?

A

quickly but the antidepressive effect lags by several weeks
-due to time required to upregulated expression of
neurotrophic factors and modulated serotonin receptors to a
more normal physiologic state

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20
Q

What are drugs that affect serotonergic signaling?

A

reserpine
-prevents vesicular accumulation of serotonin
triptans
-agonist at 5HT 1D/1B to reduce pain and reduce vasodilation
MAOIs
-inhibit serotonin breakdown
SSRIs/SNRIs/TCAs
-block 5HT reuptake at the synaptic cleft
busiprone
-partial agonist at 5HT 1A
antipsychotic drugs
-block 5HT 2A/C
anti-emetics
-block 5HT3 receptors (Na ion channel)

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21
Q

What are SSRIs the main therapy for?

A

major depression
anxiety
panic attacks
OCD
PTSD

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22
Q

How do SSRIs work?

A

inhibiting serotonin reuptake into the pre-synaptic terminus (SERT) and a reduction in “autoreceptors” in the axon and terminus of the pre-synaptic nerve so they no longer reduce serotonin release

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23
Q

What are the long term changes of SSRIs on neurotropic factors?

A

BNDF increases
SERT decrease
takes weeks

24
Q

What are some pharmacokinetic properties of SSRIs?

A

CYPD2D, CYP 2C19 inhibitors
avoid with St Johns Wort and other serotonergic drugs
-risk of serotonin syndrome
OD dosing

25
Q

What are some SSRIs?

A

sertraline
citalopram
fluoxetine
paroxetine

26
Q

What are the adverse effects of SSRIs?

A

insomnia
anxiety
reduced libido
GI (nausea, diarrhea)

27
Q

What are the uses for SNRIs?

A

major depression
generalized anxiety disorder
adjunct in chronic pain

28
Q

What is the MOA of SNRIs?

A

similar to SSRIs but also inhibit NE reuptake through NET
increase in neurotrophic factors such as BDNF

29
Q

What are off-label uses of SNRIs?

A

urinary incontinence
some features of autism
binge-eating
hot flashses
menopausal dysphoria
PTSD

30
Q

What are some pharmacokinetic properties of SNRIs?

A

CYP inhibitors
hepatic and renal routes of elimination
OD dosing, sustained release forms (ex: Effexor XR)

31
Q

What are the adverse effects of SNRIs?

A

cardiovascular (HTN)
insomnia
anxiety
reduced libido
GI (nausea, vomiting)

32
Q

What are examples of serotonin receptor antagonists?

A

trazodone
mirtazapine
mianserin
nefazodone

33
Q

What are the uses of serotonin receptor antagonists?

A

depression and anxiety with insomnia

34
Q

True or false: serotonin receptor antagonists are less efficacious than SSRIs or SNRIs but increase the antidepressant response when used in combo

A

true

35
Q

Which receptor(s) do serotonin receptor antagonists have an affinity for?

A

5HT2
also for H1, a2, SERT

36
Q

What are some pharmacokinetic properties of serotonin receptor antagonists?

A

CYP inhibitors
variable half life from 2-4h
OD dosing

37
Q

What are the adverse effects of serotonin receptor antagonists?

A

cardiovascular (HTN)
somnolence
increases appetite + weight
agranulocytosis (mirtazapine)
hepatotoxicity (nefazodone)

38
Q

What are the uses of bupropion?

A

adjunctive or alternative antidepressant
smoking cessation
potential use in ADHD (not 1st line)

39
Q

What is the MOA of bupropion?

A

inhibits NET, DAT, and alters VMAT2 to increase NE and dopamine
does not increase serotonin

40
Q

True or false: the efficacy of bupropion is very different than SSRIs and SNRIs

A

false
similar but also have lag effect

41
Q

What are some pharmacokinetic properties of bupropion?

A

hepatic and kidney function important
comes in immediate release and SR or XL

42
Q

What are the side effects of bupropion?

A

cardiovascular (tachycardia & HTN)
muscarinic (dry mouth, urinary retention, confusion)
agitation & aggression
insomnia
anxiety
reduced libido (less than others)
GI (nausea, diarrhea)
seizure (rare)

43
Q

What is the historical use of TCAs? What are they used for now?

A

historically used for depression
low doses effective for insomnia & pain as adjunct therapy

44
Q

What is the MOA of TCAs?

A

inhibit SERT and NET
also have affinity for H1, 5HT2, a1, M1-3 resulting in many side effects

45
Q

What are some pharmacokinetic properties of TCAs?

A

OD dosing
dosage adjustment based on patient response not plasma levels
CYP2D6 slow metabolizers at risk due to narrow therapeutic window and toxicity
lots of t1/2 variability from 8-80 days

46
Q

What are the adverse effects of TCAs?

A

cardiovascular (tachycardia, orthostatic hypotension)
muscarinic (dry mouth, urinary incontinence, confusion)
histaminergic (sedating)
insomnia
anxiety
reduced libido
GI (nausea, diarrhea)
weight gain
lowered seizure potential

47
Q

What is a very old drug that was used for depression? Why are they no longer used?

A

MAOIs
toxicity and many drug interactions
-sympathomimetics, TCAs, opioids, foods like cheese and red
wine
-toxicity correlates to MAO A affinity

48
Q

What is the MOA of MAOIs?

A

inhibit MAO A and B thus metabolism of all biogenic amines is reduced
-NE, DA, 5HT, tyramine
-hypertensive crisis can occur if NE builds up

49
Q

What are some pharmacokinetic properties of MAOIs?

A

many are irreverisible inhibitors, may take up to 2 weeks for MAO to recover
-significant when switching drugs (need wash-out period)
acetylation, slow metabolizers at risk

50
Q

What is the MOA of benzodiazepines?

A

bind to GABA receptors resulting in hyperpolarization and thus refractoriness to excitation
-highly sedating and addictive

51
Q

What are the uses of benzodiazepines?

A

epilepsy
low doses for short term insomnia or anxiety
prn use for panic attacks
due to abuse potential they are not used as much now for anxiety

52
Q

What is the MOA of buspirone?

A

partial agonist at presynaptic 5HT-1 receptors, resulting in increased serotonin release
central noradrenergic action
weak agonist at D2 receptors, but is not an anti-psychotic
non-sedating, not addictive

53
Q

What is the use of buspirone?

A

generalized anxiety disorder
takes 4-6wks for full effect

54
Q

What are the side effects of buspirone?

A

most common:
-nervousness
-overexcitement
-restlessness
also: nausea, headache, weird dreams, dizzy, lighthead, blurred vision

55
Q

What should be avoided while on buspirone?

A

alcohol

PHAR123 (15 decks)

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