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NAPLEX 2021 > Depression/Anxiety > Flashcards

Depression/Anxiety Flashcards

1
Q

Which neurotransmitters are believed to be inovled in depression?

A

serotonin, glutamate, ACh, dopamin, norepinephrine, and epinephrine

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2
Q

Drugs that can worsen depression

A 
Atomoxetine (ADHD) 
indomethacin (analgesic)
Efavirenz, Rilpivirine (NNRIS) 
propranolol 
contraceptives 
anabolic sgteroids 
varenicline
ethanol
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3
Q

DSM-5 Criteria

A 
M SIG E CAPS! 
mood
sleep
interest 
guilt/ feelings of worthlessness
energy - decreased
concentration - decreased
appetite - in or decreased
psychomotor agitation
suicidal ideation
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4
Q

What prompts a diagnosis of depression

A

experiencing 5 of the DSM-5 symptoms within the same two week period

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5
Q

What is rapid cycling and how can it occur

A

rapid switch between mania and depressive episodes in bipolar patients. Can occur if a bipolar patient is misdiagnosed and given an antidepressant

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6
Q

What is the role of BZDs in depression?

A

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

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7
Q

Natural products to treat depression

A

st. john’s wort
SAMe (s-adenosyl-L-methionine)
valerian

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8
Q

St. John’s Wort and SAMe increase risk of _____

A

serotonin syndrome

DO NOT USE WITH SEROTENERGIC AGENTS

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9
Q

What is a suitable trial period for depression tx

A

4-8 weeks at therapeutic dosing

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10
Q

What severity of depression requires medication treatment

A

moderate - severe

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11
Q

Main preferred first line agents

A

SSRI, SNRI, are main, but can consider mirtazapine, bupropion based on patient-specific symptoms and side effect profile

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12
Q

MAO inhibitor role

A

restricted to patients unresponsive to other treatments

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13
Q

list of MAOi

A

phenelzine
tranylcypromine
isocarboxazid

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14
Q

Risk of _____ is very high with MAOi use

A

serotonin syndrome

dose dependent

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15
Q

Symptoms of serotonin syndrome

A 
nausea
dizziness
headache
diarrhea
agitation 
tachycardia 
hallucinations
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16
Q

How to d/c an antidepressant

A

TAPER over several weeks

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17
Q

which antidepressants have highest risk of withdrawal

A

paroxetine

venlafaxine

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18
Q

Which antidepressant self tapers due to a long half-life?

A

fluoxetine

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19
Q

What drugs can be used to augment antidepressants for better response?

A

buspirone
low dose atypical antipyschotic (aripiprazole, olanzapine + fluoxetine, ER quetiapine)
lithium
T3 (thyroid hormone)

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20
Q

Initial choice of antidepressant in pregnancy

A

SSRI

*EXCEPT paroxetine

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21
Q

Why is paroxetine not an option in pregnancy

A

cardiac effects

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22
Q

Risk of _____ is warned about with SSRI use in pregnancy

A

persistent pulmonary hypertension of newborn (PPHN)

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23
Q

What antidepressants are preferred in breastfeeding

A

SSRI or tricyclics EXCEPT doxepin

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24
Q

What is required to be dispensed with all antidepressants

A

MEDGUIDE!

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25
Q

how long do physical symptoms take to improve when starting an antidepressant

A

1-2 weeks

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26
Q

how long do psychological symptoms take to improve when starting an antidepressant

A

month or longer

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27
Q

SSRI MOA

A

selective serotonin reuptake inhibitors maintain serotonin levels in the neuronal synapse

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28
Q

do SSRIs affect NE and DA?

A

weakly

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29
Q

list of SSRIs

A 
citalopram
escitalopram
fluoxetine
paroxetine 
sertraline
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30
Q

indication of Sarafem

A

Fluoxetine for premenstrual dysphoric disorder

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31
Q

Indication for Brisdelle

A

paroxetine for severe vasomotor symptoms in menopause

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32
Q

Which drugs should NOT be used in combo with SSRIs

A

MAOi
linezolid
methylene blue

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33
Q

Why should citalopram not be used at >20 mg/day yin elderly?

A

QT prolongation risk

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34
Q

Max dose of citalopram and escitalopram in elderly

A

citalopram: 20mg/day
escitalopram: 10mg/day

35
Q

Warnings of SSRIs

A

QT prolongation
hyponatremia
SIADH (too much ADH)
bleeding

36
Q

Side effects of SSRIs

A

sexual dysfunction

somnolence, insomnia,

37
Q

Which SSRI is the most activating and should be taken in the morning

A

Fluoxetine

38
Q

which SSRI is the most sedating and should be taken in the evening

A

paroxetine

39
Q

which SSRI is preferred in patients with cardiac risk?

A

sertraline

40
Q

CYP considerations with fluoxetine and paroxetine

A

CYP2D6 inhibitors

41
Q

Which antidepressant is preferred when pateint is taking tamoxifen

A

venlafaxine (SNRI) due to tamoxifen needed CYP2D6 metabolism to convert to its active form

42
Q

What are the two SSRI combo mechanistic drugs on market

A

Viibryd (SSRI and serotonin partial agonist)

Trintellix (SSRI, 5-HT3 receptor antagonist and 5-HT1A agonist)

43
Q

Benefits of Viibryd and Trintellex in terms of side effect profile

A

less sexual dysfunction compared to SSRIs and SNRIs

44
Q

SNRI MOA

A

serotonin and norepi reuptake inhibitors increase NE and 5-HT

45
Q

list of SNRIs

A

venlafaxine
duloxetine
desvenlafaxine

46
Q

Fatal risk of hypertensive crises occurs when these two drug classes are used together

A

SNRIs and MAOi

47
Q

Warnings with SNRIs

A

SIADH/hyponatermia
fall risk
bleeding risk

48
Q

Side effects with SNRIs due to increased NE

A

increased heart rate, dilated pupils, dry mouth, excessive sweating, constipation

49
Q

Which antidepressants would you not want to use as often in HTN patients

A

SNRIs especially venlafaxine

50
Q

A washout period of ____ is needed when changing between SNRIs and MAOis or MAOis and buproprion

A

14 days

51
Q

Due to risk of serotonin syndrome don’t initiate SNRIs in patients taking _____

A

linezolid or methylene blue

52
Q

SNRI with highest risk of QT prolongation

A

venlafaxine

53
Q

Tricyclics MOA

A

inhibit NE and serotonin reuptake while blocking ACh and histamine receptors

54
Q

which type of tricyclic is selective of NE

A

secondary amines

55
Q

which type of tricyclic is more effective but has worse side effects?

A

tertiary amines

56
Q

list of tertiary amines

A

amitriptyline

doxepin

57
Q

when should amitriptyline be taken

A

bedtime

58
Q

list of secondary amines

A

nortiptyline

59
Q

which tricyclic type has increased risk of anticholinergic effects, sedation, and weight gain

A

tertiary - why amitriptyline should be taken qhs

60
Q

Buproprion MOA

A

dopamine and NE reuptake inhibitor

61
Q

CIs of buproprion

A

seizure disorder

hx of eating disorder

62
Q

side effects of buproprion

A

dry mouth, insomnia, seizures, weight loss

63
Q

MAOi MOA

A

inhibit breakdown of catecholamines like serotonin, NE, Epi, and DA

64
Q

RIsk of _____ can occur with MAOi use

A

Fatal HTN crisis

65
Q

What is a food-drug interaction with MAOis

A

tyramine rich foods: aged cheese, yeast, air dried meats, fermented foods

66
Q

How long of wash out period is needed when switching from fluoxetine to MAOI

A

5 weeks! *remember, fluoxetine has a long half life

67
Q

mirtazapine MOA

A

central presynaptic alpha-2 adrenergic effects increasing NE and serotonin

68
Q

side effects of mirtazapine

A

sedation, weight gain

69
Q

why is nefazodone raraley used

A

hepatotoxicity

70
Q

Best choice antidepressant in a patient with cardiac risk

A

sertraline

71
Q

Best choice antidepressant in a patient who smokes

A

buproprion

72
Q

Best choice antidepressant in a patient with neuropathy

A

duloxetine

73
Q

Worst choice in a patient with seizure disorder

A

buproprion

74
Q

Best choice in pregnant patient

A

SSRIs other than paroxetine

75
Q

Lowest risk of sexual dysfunction with these antidepressants

A

buproprion

mirtazapine

76
Q

abilify side effects

A

anxiety, insomnia, akathisia

77
Q

olanzapine and quetiapine side effects

A

sedation, weight gain, metabolic didsorder

78
Q

Drugs that can cause anxiety

A 
albuterol 
antipsychotics
buproprion 
caffeine
pseudoephedrine 
illicit drugs 
steroids
stimulants
79
Q

buspirone side effects

A

dizziness
drowsiness
nausea

80
Q

BZD antidote

A

flumazenil

81
Q

BZDs preferred for anxiety use

A 
un-do anxiety with un-CLAD
clonazepam
lorazepam
alprazolam
diazapam
82
Q

BZDs preferred in elderly patients and those with liver impairment

A

use a safe LOT
lorazepam
oxazepam
temazepam

83
Q

Role of propranolol in anxiety

A

stage fright or performance anxiety

84
Q

Anxiety first-line agents

A 
escitalopram
fluoxetine
paroxetine
sertraline
duloxetine
venlafaxine

NAPLEX 2021 (28 decks)

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