Depression/Anxiety Flashcards
Which neurotransmitters are believed to be inovled in depression?
serotonin, glutamate, ACh, dopamin, norepinephrine, and epinephrine
Drugs that can worsen depression
Atomoxetine (ADHD) indomethacin (analgesic) Efavirenz, Rilpivirine (NNRIS) propranolol contraceptives anabolic sgteroids varenicline ethanol
DSM-5 Criteria
M SIG E CAPS! mood sleep interest guilt/ feelings of worthlessness energy - decreased concentration - decreased appetite - in or decreased psychomotor agitation suicidal ideation
What prompts a diagnosis of depression
experiencing 5 of the DSM-5 symptoms within the same two week period
What is rapid cycling and how can it occur
rapid switch between mania and depressive episodes in bipolar patients. Can occur if a bipolar patient is misdiagnosed and given an antidepressant
What is the role of BZDs in depression?
can be used when anxiety is also present, but NOT first-line and not as monotherapy.
They can worsen/mask depression and can be problematic in patients with substance abuse disorder
Natural products to treat depression
st. john’s wort
SAMe (s-adenosyl-L-methionine)
valerian
St. John’s Wort and SAMe increase risk of _____
serotonin syndrome
DO NOT USE WITH SEROTENERGIC AGENTS
What is a suitable trial period for depression tx
4-8 weeks at therapeutic dosing
What severity of depression requires medication treatment
moderate - severe
Main preferred first line agents
SSRI, SNRI, are main, but can consider mirtazapine, bupropion based on patient-specific symptoms and side effect profile
MAO inhibitor role
restricted to patients unresponsive to other treatments
list of MAOi
phenelzine
tranylcypromine
isocarboxazid
Risk of _____ is very high with MAOi use
serotonin syndrome
dose dependent
Symptoms of serotonin syndrome
nausea dizziness headache diarrhea agitation tachycardia hallucinations
How to d/c an antidepressant
TAPER over several weeks
which antidepressants have highest risk of withdrawal
paroxetine
venlafaxine
Which antidepressant self tapers due to a long half-life?
fluoxetine
What drugs can be used to augment antidepressants for better response?
buspirone
low dose atypical antipyschotic (aripiprazole, olanzapine + fluoxetine, ER quetiapine)
lithium
T3 (thyroid hormone)
Initial choice of antidepressant in pregnancy
SSRI
*EXCEPT paroxetine
Why is paroxetine not an option in pregnancy
cardiac effects
Risk of _____ is warned about with SSRI use in pregnancy
persistent pulmonary hypertension of newborn (PPHN)
What antidepressants are preferred in breastfeeding
SSRI or tricyclics EXCEPT doxepin
What is required to be dispensed with all antidepressants
MEDGUIDE!
how long do physical symptoms take to improve when starting an antidepressant
1-2 weeks
how long do psychological symptoms take to improve when starting an antidepressant
month or longer
SSRI MOA
selective serotonin reuptake inhibitors maintain serotonin levels in the neuronal synapse
do SSRIs affect NE and DA?
weakly
list of SSRIs
citalopram escitalopram fluoxetine paroxetine sertraline
indication of Sarafem
Fluoxetine for premenstrual dysphoric disorder
Indication for Brisdelle
paroxetine for severe vasomotor symptoms in menopause
Which drugs should NOT be used in combo with SSRIs
MAOi
linezolid
methylene blue
Why should citalopram not be used at >20 mg/day yin elderly?
QT prolongation risk
Max dose of citalopram and escitalopram in elderly
citalopram: 20mg/day
escitalopram: 10mg/day
Warnings of SSRIs
QT prolongation
hyponatremia
SIADH (too much ADH)
bleeding
Side effects of SSRIs
sexual dysfunction
somnolence, insomnia,
Which SSRI is the most activating and should be taken in the morning
Fluoxetine
which SSRI is the most sedating and should be taken in the evening
paroxetine
which SSRI is preferred in patients with cardiac risk?
sertraline
CYP considerations with fluoxetine and paroxetine
CYP2D6 inhibitors
Which antidepressant is preferred when pateint is taking tamoxifen
venlafaxine (SNRI) due to tamoxifen needed CYP2D6 metabolism to convert to its active form
What are the two SSRI combo mechanistic drugs on market
Viibryd (SSRI and serotonin partial agonist)
Trintellix (SSRI, 5-HT3 receptor antagonist and 5-HT1A agonist)
Benefits of Viibryd and Trintellex in terms of side effect profile
less sexual dysfunction compared to SSRIs and SNRIs
SNRI MOA
serotonin and norepi reuptake inhibitors increase NE and 5-HT
list of SNRIs
venlafaxine
duloxetine
desvenlafaxine
Fatal risk of hypertensive crises occurs when these two drug classes are used together
SNRIs and MAOi
Warnings with SNRIs
SIADH/hyponatermia
fall risk
bleeding risk
Side effects with SNRIs due to increased NE
increased heart rate, dilated pupils, dry mouth, excessive sweating, constipation
Which antidepressants would you not want to use as often in HTN patients
SNRIs especially venlafaxine
A washout period of ____ is needed when changing between SNRIs and MAOis or MAOis and buproprion
14 days
Due to risk of serotonin syndrome don’t initiate SNRIs in patients taking _____
linezolid or methylene blue
SNRI with highest risk of QT prolongation
venlafaxine
Tricyclics MOA
inhibit NE and serotonin reuptake while blocking ACh and histamine receptors
which type of tricyclic is selective of NE
secondary amines
which type of tricyclic is more effective but has worse side effects?
tertiary amines
list of tertiary amines
amitriptyline
doxepin
when should amitriptyline be taken
bedtime
list of secondary amines
nortiptyline
which tricyclic type has increased risk of anticholinergic effects, sedation, and weight gain
tertiary - why amitriptyline should be taken qhs
Buproprion MOA
dopamine and NE reuptake inhibitor
CIs of buproprion
seizure disorder
hx of eating disorder
side effects of buproprion
dry mouth, insomnia, seizures, weight loss
MAOi MOA
inhibit breakdown of catecholamines like serotonin, NE, Epi, and DA
RIsk of _____ can occur with MAOi use
Fatal HTN crisis
What is a food-drug interaction with MAOis
tyramine rich foods: aged cheese, yeast, air dried meats, fermented foods
How long of wash out period is needed when switching from fluoxetine to MAOI
5 weeks! *remember, fluoxetine has a long half life
mirtazapine MOA
central presynaptic alpha-2 adrenergic effects increasing NE and serotonin
side effects of mirtazapine
sedation, weight gain
why is nefazodone raraley used
hepatotoxicity
Best choice antidepressant in a patient with cardiac risk
sertraline
Best choice antidepressant in a patient who smokes
buproprion
Best choice antidepressant in a patient with neuropathy
duloxetine
Worst choice in a patient with seizure disorder
buproprion
Best choice in pregnant patient
SSRIs other than paroxetine
Lowest risk of sexual dysfunction with these antidepressants
buproprion
mirtazapine
abilify side effects
anxiety, insomnia, akathisia
olanzapine and quetiapine side effects
sedation, weight gain, metabolic didsorder
Drugs that can cause anxiety
albuterol antipsychotics buproprion caffeine pseudoephedrine illicit drugs steroids stimulants
buspirone side effects
dizziness
drowsiness
nausea
BZD antidote
flumazenil
BZDs preferred for anxiety use
un-do anxiety with un-CLAD clonazepam lorazepam alprazolam diazapam
BZDs preferred in elderly patients and those with liver impairment
use a safe LOT
lorazepam
oxazepam
temazepam
Role of propranolol in anxiety
stage fright or performance anxiety
Anxiety first-line agents
escitalopram fluoxetine paroxetine sertraline duloxetine venlafaxine
