Depression Tx Flashcards
Risk of Depression Recurrence
-1 episode: 50-60%
-2: 70%
-3: 90%
Pathologies related to depression
-stroke
-CHRONIC PAIN (fibromyalgia, low back/pelvic pain, bone/disease pain)
-mulitple sclerosis
-hypo/hyper thyroidism
-traumatic brain injury (TBI)
Recurrence
-risk becomes lower over time as duration of remission inc
-persistent mild sx during remission is a predictor of recurrence
-function deteriorates during episode and goes back to baseline upon remission
DSM-5 diagnosis
-at least one sx must be depressed mood or loss of interest/pleasure in doing things
DSM-5 diagnostic mnemonic (SIGE CAPS)
-Sleep (+/-)
-Interest dec
-Guilt/worthlessness
-Energy loss
-Concentration probs
-Appetite change (+/-)
-Psychomotor agitation/retardation
-Suicidal ideation
Self-admin rating scales
-Patient Health Questionnaire (PHQ-9): develped for primary care setting
-Mood Disorder Questionnare (MDQ): can rule out bipolar
Goals of depression tx
- reduce or eliminate sx
- restore functioning to baseline
- Reduce risk of relapse/recurrence
- Reduce suicide
How to choose drugs
-efficacy similar
-pt preference, response
-safety, cost, etc
Phase of depression tx
-acute: 6-12 weeks or remission of sx (induce remission)
-continuation: 4-9 months (recomended for all pt to prevent relapse)
-maintenance: pt specific duration, indefinite if >3 major, prevent recurrence
Risk of suicide
-boxed warning for suicide in ALL antidepressant meds for pt < 24 yeRA
Pharmacologic Classes
-SSRI
-SNRI
-TCA
-MAOis
-newer agents
-augmentation
SSRI drugs
-Citalopram
-Escitalopram
-Fluoxetine
-Fluvoxamine
-Paroxetine
-Sertraline
Citalopram
-dose-dependednt QTc prolongation
-substrate of 2C19 and 3A4
Fluoxetine
-long half-life (96-144h)
-activating potential
-2D6 and 3A4 inhibitor
-weight loss
Fluvoxamine
-1A2 and 2C19 inhbitor
Paroxetine
-MUST taper due to anticholinergic effects
-wt gain
-sedation
-septal wall defect risk to fetus
-2D6 and 2B6 inhibitor
Sertraline
-more GI upset than other antidepressants
SSRI adverse effects
-inc bleeding risk (platelet inhibition)
-weight gain (paroxetine)
-hyponatremia (esp in elderly)
-weight loss (fluoxetine)
-sexual dysfunction
SNRI drugs
-Desvenlafaxine
-Duloxetine
-Levomilnacipran
-Milnacipran
-Venlafaxine
Desvenlafaxine
-active metabolite of venlafaxine
-dose-limiting side effect: nausea
-no major CYP interactions
Duloxetine
-nausea
-FDA warning for hepatotoxicity
-2D6 inhibitor
-obtain LFTs at baseline and when sx or q6months
Levomilnacipran
-MUST adj renal impairment or strong 3A4 inhibitors
-3A4 substrate
Venlafaxine
-must be >150mg/day to have NE effects
-2D6 inhibitor at higher doses
SNRI adverse effects/key pearls
-BP elevation
-Nausea
-useful in pain syndrome, musculoskeletal pain, fibromyalgia, neuropathic pain
Tricyclic Antidepressants
-block DAT, SERT, NET
-amitriptyline (tertiary amine)
TCA adverse effects/key points
-more often used for neuropathic pain syndromes than depression
-CNS: sedation, sz, confusion
-anticholinergic: blurred vision, urinary retention, constipation
-CV: hypotension, tachycardia
-wt gain, sexual dysfunction
TCA NTI
-FATAL in overdose as low as 1000mg (4-10 tabs) due to arrhythmias or seizures
MAO inhibitors??
???
MAOi HTN crisis
-Tyramine diet is required w MAOis:
-smoked, aged, pickled meats/fish/cheese
-small amounts of beer, wine, avocados, caffeine, chocolate
Bupropion MOA
-DAT and NERT inhibitor
-stimulating = insomnia and appetite suppression
-XL dosing
Bupropion pearls
-2D6 inhibitor
-contraindicated in active seizure disorder and eating disorders
-can be used in combo w SSRI/SNRI
Mirtazapine pearls
-agranulocytosis
-inc cholesterol
-sedation and inc appetite in doses < 15mg??
-can be use in combo w SSRI/SNRIs
Trazodone pearls
-higher doses needed for depression
-orthostatic hypotension
-risk of priapism - med emergency
Vilazodone MOA
-primarily SSRI, maybe 5HT1a agonism (anxiolytic effects)
-do not combo w SSRI/SNRI
Vilazodone pearls
-take w food (nausea and inc bioavailability)
-3A4 substrate
-do not combo w SSRI/SNRI
Vortioxetine MOA
-SSRI + 5HT1A agonist + 5HT3 antagonist (dont combo w SSRI/SNRI)
Vortioxetine pearls
-possibly less sexual dysfunction
-2D6 substrate
-Nausea
-do not combo w SSRI/SNRI
Serotonin Syndrome
-med emergency
-OD or combo w serotonergic agents
Serotonergic Agents
-lithium
-serotonergic antidepressants
-buspirone
-linezolid
-amphetamines
-dextromethorphan
-serotonin agonists (triptans)
-St. Johns
-tramadol
-fentanyl
-cocaine
-LSD
Serotonin syndrom etx
-stop agent + supportive care
-potentially could use serotonin blockers
Antidepressant withdrawal syndrome
-common with ALL antidepressants EXCEPT fluoxetine
-Antidepressants w anticholinergic activity should be tapered no matter what
-not life threatening but uncomfy (depression sx)
Augmentation - Atypical Antipsychotics
-Aripiprazole
-Brexpiprazole
-Cariprazine
-Quetiapine
Overall antidepressant counseling points
-abrupt dc can lead to antidepressant withdrawal syndrome
-possible inc in suicidal thinking during first few weeks of therapy
Electroconvulsive therapy
-nonpharma treatment resistant depressino tx
-2-3 xweek
-usual course is 6-12 tx
-electrodes
