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Psychopharmacotherapy > Depressive disorders > Flashcards

Depressive disorders Flashcards

1
Q

After 2nd episode of MDD what is the likely hood of a 3rd?

A

70%

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2
Q

After 3rd episode of MDD what is the likely hood of a 4th?

A

90%

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3
Q

How are the SNRIs divided?

A

Older non-selective

  • TCAs
  • MAOIs

Newer selective

  • Venlafaxine
  • Duloxetine
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4
Q

What drug is a NDRI?

A

Bupropion

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5
Q

What drug is a serotonin modulator?

A

Nefazodone

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6
Q

What drug is a serotonin and norepinephrine modulator?

A

Mirtazapine

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7
Q

Is there clinical evidence to support a significant difference in the benefits of different antidepressant drugs?

A

No, but the drugs do vary on adverse effects

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8
Q

What is the acute phase of treatment?

A

6 to 12 weeks

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9
Q

What is the continuation phase of treatment?

A

4 to 9 months

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10
Q

What is the maintenance phase of treatment?

A

1+ year

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11
Q

When is the worsening of a condition considered a relapse?

A

When it occurs in the acute or continuation phase

- 6 weeks up to 9 months

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12
Q

When is the worsening of a condition considered a recurrence?

A

When it happens in the maintenance phase

- 1+ year

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13
Q

What are the TCAs?

A

Imipramine
Desipramine
Trimipramine

Amitriptyline
Nortriptyline
Protriptyline

Amoxapine
Doxepin

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14
Q

What 3 broad catagories of receptors do TCAs block that lead to the know side effects?

A
  1. Muscarinic
  2. Alpha-adrenergic
    - Ortho-static hypertension
  3. Histaminergic
    - Sedation
    - Weight gain
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15
Q

Why can TCA medications be leathal?

A

3 Cs

  • Coma
  • Cardiac arrhythmia- Slows cardiac condution
  • Convulsions
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16
Q

When are TCAs contraindicated?

A

First 6 weeks after MI

- Ventricular arrhythmia

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17
Q

When would you want to monitor blood levels of TCAs as well as use ECG monitoring?

A

Patient has a pre-existing first degree AV block

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18
Q

Which TCAs have a theraputic window for plasma levels?

A

Nortriptyline
Desipramine
Imipramine

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19
Q

Which TCA has the lowest risk of orthostatic hypotension? Which population is this medication the safer choice for?

A

Nortriptyline

Geriatrics

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20
Q

What are the MAOIs?

A

Phenelzine
Tranylcypromine
Isocarboxazid

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21
Q

Which MAO subtype needs to be inhibited inorder to see a theraputic effect on depression?

A

MAO-A

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22
Q

What are the potential adverse effects of MAOIs?

A

Orthostatic hypotension- Alpha block
Weight gain- Antihistamine
Sexual dysfunction- 5-HT2a
Insomnia- 5-HT2a

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23
Q

What types of food should be avoided while taking MAOIs?

A 
Aged or fermented foods
- Cheese
- Meats
- Tap beer
- Yeast extracts
Others
- Fava beans 
- Broad bean pods
- Sauerkraut
- Soy sauce
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24
Q

What types of medications are not safe to use with MAOIs?

A

Sympathomimetics
Stimulants
Carbamazepine
Oxcarbazepine

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25
Q

What cold medications are safe to take with MAOIs?

A

Plain alka-seltzer
Chlor-Trimeton Allergy
Plain Robitussion
Plain Tylenol

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26
Q

What other medications are generally considered safe to take with MAOIs?

A 
Antibiotics
Codeine
Laxatives and stool softeners
Local anesthetics without epinephrine or cocaine
Morphine
NSAIDs
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27
Q

When are MAOIs indicated?

A

Second line agets:

  • Atypical depression
  • Comorbid panic
  • Comorbid socail anxiety disorder
  • Refractory cases
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28
Q

Which MAOI is available in a transdermal patch? What is the benefit?

A

Selegiline

Less dietary restrictions

29
Q

What are the SSRIs?

A 
Fluoxetine
Sertraline
Paroxetine
Citalopram
Fluvoxamine- Luvox
Escitalopram- Lexapro
30
Q

Which 5-HT receptor is responsible for the antidepressant effects?

A

5-HT1a

- Causes disinhibition of serotonin in the prefrontal cortex

31
Q

Which 5-HT receptors are responsible for agitation, akathisia, anxiety, panic attacks, insomnia, and sexual dysfunction?

A

5-HT2a

32
Q

Which 5-HT receptor is responsible for nausea, GI distress, and diarrhea?

A

5-HT3a

33
Q

What are the indications for SSRI usage?

A
  1. Depression comorbid with:
    - OCD
    - Panic disorder
    - Social phobia
    - Bulimia
  2. Atypical depression
34
Q

When should SSRIs be avoided?

A

Depression associated with:

  • Sexual dysfunction
  • Secondary refractoriness
  • Nocturnal myoclonus is present
  • Consistent insomnia and agitation
35
Q

What are the newer class of SNRIs?

A

Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran

36
Q

What is the benefit of using newer SNRIs over older SNRIs?

A
  1. Less side effects
    - No anticholinergic action
    - No blockade of Alpha-adrenergics
    - No antihistamine
  2. Wide theraputic index
37
Q

What are the side effects of SNRIs?

A

Same as SSRI

  • 5-HT2a effects
  • 5-HT3a effects

Potential to elevate BP

38
Q

Which SNRI has been show to have the most effect on BP, especially at high doses?

A

Venlafaxine

39
Q

What is duloxetine indicated for?

A

Depression
GAD
Diabetic neuropathy
Fibromyalgia

40
Q

What are the serotonin modulators used to treat depression?

A

Nefazodone

Vilazodone

41
Q

What is the main action of nefazodone?

A

Blocks 5-HT2a- less “activating” symptoms

Partial SNRI

42
Q

What are the clinically important effects of 5-HT2a blockade?

A

Reduced anxiety
Enhanced slow wave sleep
Blockade of SSRI-induced sexual dysfunction

43
Q

What are the potential adverse effects of nefazodone?

A 
Sedation
Dizziness
GI side effects
Blurred vision
Headaches
44
Q

When is the use of Nafazodone indicated?

A

Depression associated with:

  • Anxiety
  • Agitation
  • Sleep distrubance/Insomnia
  • Prior SSRI-induced sexual dysfunction
  • Inability to tolerate SSRIs
45
Q

When should nefazodone be avoided?

A 
Patient has a block of CYP2D6
Hypersomnia/Psychomotor retardation 
Complicated patients
- Won't BID
- Won't follow-up for titration
46
Q

What action does vilazodone have?

A

SSRI

Partial agonist at 5-HT1a

47
Q

What other medications have the novel effect as a partial agonist for 5-HT1a?

A

Trazodone
Buspirone
Aripiprazole

48
Q

What are the potential adverse effects of Vilazodone?

A

GI distrubances

Insomnia

49
Q

What is one potential benefit of using vilazodone?

A

Low incidence of sexual side effects

50
Q

What is the MOA of vortioxetine?

A 
SSRI
5-HT1a agonist
Partial agonist 5-HT1b
Antagonist:
- 5-HT3
- 5-HT1D
- 5-HT7
51
Q

What is the only medication in the NDRI class?

A

Bupropion

52
Q

What aspect of bupropion is most effective?

A

The metabolite

53
Q

What are the adverse effects of bupropion?

A 
Narrow-theraputic index- Seziures
Agitation
Insomnia
Dizziness
Confusion
GI upset
54
Q

What is the major benefit of bupropion?

A

Very low incidence of sexual dysfunction

55
Q

What population is bupropion very safe in?

A

Cardiac patients

56
Q

What type of condtion is bupropion effective at treating?

A

Apathy

57
Q

What behavior related habit can bupropion be used to help stop?

A

Smoking

58
Q

Who should not take bupropion?

A

Seizure disorders
Bulimia
Anorexia

59
Q

When is bupropion a good treatment option for depression?

A

Depression associated with:

  • Psychomotor retardation
  • Hypersomnia
  • Serotonergic agents aren’t an option
  • Sexual dysfunction
  • Cognitive slowing/pseudodementia
60
Q

When should bupropion be avoided?

A

Seizure disorder
Seizure prone/head injury
Agitated, insomnic patients
Bulimic patients

61
Q

What is the only drug that modulates Norepinephrine and Serotonin?

A

Mirtazepine

62
Q

What receptors does mirtazepine act on?

A

Blocks alpha-2 receprors- Increase NE and 5-HT

Blocks 5-HT2 and 5-HT3

63
Q

What are the adverse effects of mirtazepine?

A 
Sedation
Dizziness
Weight gain/Increased appetite
Dry mouth
Flu-like symptoms
Constipation
64
Q

When is mirtazapine a good option for treating depression?

A

Depression associated with:

  • Anxiety
  • Agitation
  • Insomnia
  • Panice
  • Weight loss

SSRI-induced

  • Sexual dysfunction
  • Nausea
  • GI distrubance
65
Q

When should mirtazapine be avoided?

A

Hypersomnia
Motor retardation
Cognitive slowing
Weight gain

66
Q

What are the preferred treatments for MDD with psychotic features?

A

Antipsychotic and antidepressant

ECT

67
Q

What are some alternative treatments for depression?

A

St. John’s Wort
SAM
Omega-3s
Folate

68
Q

When is it appropiate to use psychotimulants in depression?

A

Patients with prominent apathy

- Very effective for post-stroke patients failing rehab

69
Q

After 1st episode of MDD what is the likely hood of a 2nd?

A

50 to 60%

Psychopharmacotherapy (8 decks)

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