Depression - Block 3 Flashcards
1
Q
Describe the mechanism of seratonin and melatonin?
A
2
Q
What does the monoamine hypothesis?
A
Serotonin: obsession and compulsions, ax
Dopamine: Attention, motivation, pleasure
NE: Ax, attention
3
Q
What are the medications used for depression?
A
Serotonergic: SSRIs: Citalopram, Escitalopram, Sertraline, Paroxetine, Fluoxetine
Noradrenergic: TCA
Dopaminergic: Bupropion
Dual mech: Venlafaxine, Duloxetine, desvenlafaxine -SNRIs
* SSRIs + Bupropion
* Mirtazapine, trazadone, vilazodone, vortioxetine
4
Q
What SSRI has the longest half-life?
A
Fluoxetine
5
Q
What is the SSRI MOA?
A
Selectively blocking the reuptake of serotonin to increase the amount of serotonin in the synapse
6
Q
What are causes of depression?
A
- Unknown
- ELevated stress levels (genetics)
- Decreased levels or activity of NE and/or serotnin/dopamine
7
Q
What are the main diagnosistic for depression?
A
DSM5 and ICD10
8
Q
How do you diagnose a patient with depression?
A
- Screen patient for hx and psychiattic history
- DSM5 for diagnosis
- Exclude other potential causes of symptoms
- Use clinician rating scale like PHQ-9/ HAM-D/ GDS to determine severity and to set baseline for monitoring purposes
9
Q
What is PHQ9?
A
Screening tool and aids the diagnosis of depression severity as well as track improvements of sx
10
Q
What are the common sx of depression?
A
Sleep disturbances
Interest or pleasure is decreased
Guilt or feeling worthless
Mood is low or depressed
ENergy loss or fatigue
Concnetration problems or problems with memory
Appetitie disturbance, weight loss or gain
Psychomotor agitation or retardation
Suicidal ideation, thoughd of death
11
Q
What is mDD?
A
sx must affect QOL-cause clinically significant disturbances of social, occupational, functioning
12
Q
Depression must have:
A
- Depressed mood a/o anhedonia
- Additional symptoms (must total at least 5 for > 2 weeks):
* Sleep disturbance
* Changes in appetite or weight
* Decreased energy
* Feelings of guilt or worthlessness
* Psychomotor agitation or retardation
* Decreased concentration
* +/- Suicidal ideation
13
Q
What disease states can be mistaken for depression?
A
- CNS disease
- Endocrine disorders
- Drug-related conditions
- SLeep-related disorders
- Bipoal
- Schizo
- Bereavement
14
Q
What are the drugs that worsen depression?
A
A: Alcohol, amphetamines, ADHD med (withdrawal-likemethylphenidate,amoxeine)
B: BDZ, Barbiturates, B-Blockers(lipid soluble- propranolol)
C: CNS depressants, cocaine
15
Q
How do you assess for deferential diagnosis?
A
- Patient hx ask about:
* Stressful events
* Consumption of illicit drugs, alcohol abuse
* Current medications
* Current medical conditions
* Family history of bipolar or schizophrenia
* Assess severity of symptoms
16
Q
What are patient assessment tools we can use?
A
PHQ9, HAM-D, MADRS
17
Q
What is the scoring of HAM-D?
A
Normal: 0-7
Mild: 8-13
Mod: 14-18
Severe: 19-22
Very severe: ≥23
18
Q
Whay do we look for when evaluating a patient?
A
Suicidal ideation: hosptial should be considered if risk is significant
19
Q
What are non-pharms for Tx?
A
CBT
Religion
Avoid stress
Excersise
Self-affirmation
Positivity
Motivational speakers
20
Q
Types of med intervention?
A
- Medications
- Psychotherapy
- ECT
- VNS
- Combo
21
Q
What complementary tx is good for depression but has a lot of DDIs?
A
St Johns wort: treatment of adults experiencing major depression of moderate severity
* Serotonergic, cause photosensitivity
22
Q
How do we select a AD?
A
- All AD are equal in effectiveness and safety (anticipated DDI, SE)
- Consider prior response
- Comorbidities
- Presenting symptoms vs target receptors
23
Q
What is the recommendations for administering an AD?
A
- Startlow gradual increase dose; 1-2 wks. to feel better 6-8 wks. For fulleffect
- Physical symptoms (energy levels, sleep disturbance) before mood improves- suicide risk
- Adequate trial of drug must be provided (4-8 wks) before considering (increase dose, switch, augment, combo)
24
Q
What is the goal of AD tx?
A
- Remission may take 12 wks (HAM-D score of ≤7)
- 50% reduction in sx
25
What is the first line for MDD?
SSRI: fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine
26
BBW of all AD?
Suicidality
27
Common ADR of AD?
1. N
2. D
3. COnstipation
4. Insomnia
5. Serotonin syndrome
6. Sexual SE
28
SSRI
| Counseling points
1. Don’t D/C abruptly must taper to prevent withdrawals
2. Start low gradual increase dose; 1-2 wks. to feel better 6-8 wks. For full effect
3. Physical sx before mood improves
29
How do we manage SSRI-induced sexual SE?
1. Will disappear spontaneously
2. Dose reduction
3. Add bupropion
4. Drug holiday for patients on short-acting SSRI
5. sildenafil or tadalafil for man, TD testosterone for women
30
How do we manage SSRI-induced GI SE?
N/V/C/D/Gi bleed
1. GI SE wanes after 2 or 3 weeks generally
2. Divide dose
3. Take with food
4. administering more of the dose at bedtime can help
5. Ginger
6. Antidiarrheal or switch to other agents
7. Constipation: physical activity, fluid and fiber intake, or laxatives
31
Fluoxetine
| MOA, Counseling
Prozac
**MOA:** SSRI
**Counseling:** can cause insomnia and anxiety
32
Sertraline
| MOA, Counseling
Zoloft
**MOA** SSRI
**Counseling:** Low concentration in breastmilk, causes insomnia and GI se
33
Paroxetine
| MOA, Counseling
Paxil
**MOA:** SSRI
**Counseling:** Causes constipation, sedation, weight gain
* Teratogenic
34
Fluvoxamine
| MOA, Counseling
Luvox
**MOA:** SSRI
**Counseling:** Sedation
35
What are important counseling points for fluoxetine?
Long half-life
* 5 week washout from fluoxetine to MAO
* 2 weeks for others
36
Special considerations of citalopram?
QTc prolongation risk if >40 mg
* Max: 40 mg or 20 mg in ≥60YO, hepatic impairment, poor CYP2C19 metabolizers, or meds that inhibit CYP2C19
37
Medication first line for post-partum depression?
Sertraline (Zoloft)
38
DDI of fluoxetine and paroxetine?
strong CYP 2D6 inhibitors so they increase serum concertation of:
* Metoprolol
* Haloperidol
* Risperidone
* Tamoxifen
Inhibits conversion of tramadol and hydrocodone to their active metabolite
39
DDI of fluvoxamine
CYP1A2 inhibitor -> increasce concentration of thioridazine, theophylline, olanzapine, clozapine, ramelteon and phenytoin
40
What is seratonin syndrome?
Fatal from use of multiple serotenergic drugs such
41
OTC products that can cause serotonin syndrome?
St. John's wort
42
Drugs that cause serotonin syndrome?
T- Triptans , TCA, Tramadol
L- Lithium, Linezolid
S- SNRI, Sympathomimetics
M- MAOI, Meperidine
D- Dextromethorphan
43
What is the tx for serotonin syndrome?
1. DC offending agent
2. Supportive: cooling blankets and respiratory assistance
3. Clonazepam for myoclonus
4. Anticonvulsants for sz
5. Nifedipine for HTN
44
What is activation syndrome?
early worsening of anxiety, agitation, and irritability that occurs in patients starting serotonergic or noradrenergic antidepressant
45
Tx for activation syndrome?
1. DC Tx
2. Patient ed
3. slower titration, especially in patients with anxiety symptoms, might prevent the syndrome
4. jitteriness is time-limited, waiting for tolerance to develop or temporarily combining the antidepressant with a **benzodiazepine or propranolol** may be helpful
46
What is DC syndrome?
Develops 1-7 days following dose reduction or DC of SNRI or SSRI
47
Tx for DC syndrome?
1. Tailor tapering to individual patient and specific antidepressants
2. Gradual reduction over 2-4 weeks
3. Prescribing and long-acting SSRI (fluoxetine) with DC current AD
48
What are the main sx of SC syndrome?
**F**lu like sx
**I**nsomnia
**N**ausea
**I**mbalance
**S**ensory distrubances
**H**yperarousal
49
SSRI used for GAD?
Escitalopram
49
What SSRI is used for OCD and not for really for depression?
Fluvoxamine
50
Types of SNRI?
venlafaxine, duloxetine, and desvenlafaxine
51
SNRI ADR?
1. Dry mouth
2. Sexual dysfunction
3. Sweating
4. COnstipation
5. Increased BP
6. Insomnia
52
What are the advantages of using duloxetine? CI?
Chronic pain, neuropathic pain, fibromyalgia, musculoskeletal pain
**CI:** narrow angle glaucome or liver or kidney dx, alcoholics
* **Liver Damage**
53
What SNRIs cause increased BP?
Venlafaxine and desvenlafaxine: Causes HTN
54
What are the other indications of duloxetine other than depression?
Diabetic peripheral neuropathy
Fibromyalgia
Chronic musculoskeletal pain
55
DDI of both SSRI and SNRI?
* Increased bleeding with anticoags, antiplatelet, NSAIDs, gingko
* HTN crisis when given with MAO-I (14 day wash out)
56
DDI of MAOI?
* Tyramine foods wih MAOI can lead to HTN crisis (aged, fermented, beans)
* OTC decongestants
57
What is the washout preriod between MAOS and starting other AD or CI drugs?
2 week break
58
ADR of MAOI?
* Orthostatic hypotension
* HTN crisis
* Drowsiness
* DZ
* Insomnia
* Sexual dysfunction
* Birth defects
59
What are the MAOIs?
phenelzine, isocarboxazid, tranylcypromine, and selegiline
60
What MAOI can be given with tyramine?
transdermal selegiline (Emsam)
61
What are the off-label uses for TCAs?
Migraine prophylaxisis
Pain and ax disorders
62
TCA used for migraine prophylaxis?
Nortriptyline, amitriptyline
63
TCA used for neuropathic pain?
Nortriptyline, amitriptyline
64
TCA used of insomnia?
DOxepin
65
What are limitations of using TCA?
1. Naroow TI
2. Slow onset
3. Significant ADR
4. Cardiotoxic and potentially fatal OD
* SZ and torsades risk
* Increased suicidicity
66
What are the prominent ADRs of TCAs?
**ANTI-HAM**
**Antihistamine**- sedation, weight gain
**Anti- alpha adrenergic** - orthostatic hypotension, cardiac abnormalities, sexual function
**Anti-muscarinic** – dry mouth, tachycardia, urinary retention , blurry vision, constipation
**Anticholinergic**
**Orthostatic**
**Withdrawal:** if DCd abruptly
67
What are the atypical AD?
1. Trazadone
2. Bupropion
3. Mirtazapine
4. Clomipramine
5. Vilazodone
Last line, for patients with resistant depression
68
Mirtazapine
| MOA, ADR, BBW
**MOA:** alpha 2 receptor antagonist, antagonist of 5-HT2, 5-HT3, and much histamine-1 (H1) receptors
**ADR:** sedation, increased appetite, weight gain
**BBW:** hepatotoxicity
69
Bupropion
| Advantages, ADR
**Advantages:** Less sexual dysfunction (or improve sexual function)
* 25% of patients experience initial weight loss
**ADR:** Insomnia (take in AM), ax, psychosis, seizure risk
70
Trazadone
| ADR
As effective as TCA and SSRI
**ADR:** priapism
71
72
How do we choose the righ AD?
1. All antidepressants are equally efficacious
2. Fit med to patient based on sx, hx, comorbid, cost, preference, ADR, meds
73
What are is the order of AD selection?
First SSRIs, then SNRIs can consider Bupropion, Mirtazapine
74
When should we assess the response to AD?
correct drug, dose, duration in 6 to 8 weeks
75
What are the types of augmentation tx?
Aripiprazole
Quetiapine ER
Olanzapine+fluoxetine(symbyax)
Buspirone
Lithium
76
What is resistant depression?
If patient fails to achieve remission after ≥2 antidepressants(same or different class), of adequate dosage and duration =Treatment resistance depression
77
What are the approaches for resistant depression?
1. treatment is considered failed with 6-8 week trial
2. First try dose increase
3. 2nd combine antidepressants with different MOA
4. Augmentation therapy
78
What medication is indicated for resistant depression?
Olanzapine in combination with fluoxetine
79
Overall counseling for AD?
1. Takes about 1-2wks to feel better 6 to 8 weeks to see full effect
1. continue to take their medications regularly as directed, even if their symptoms are less noticeable or have resolved
1. Must be used daily not prn, continue to take even if you feel well
1. Do not D/C abruptly- to prevent rebound depression esp. Paxil
1. Talk to pharmacist or MD before starting any medication including herbal or OTC
