Despressive disorders Flashcards
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symptoms for major depression
sleep psychomotor appetite concentration decreased energy decreased depressive mood interest decreased guilt/worthlessness suicide
criteria for major depression
presence of symptoms for >2weeks at least 5 symptoms present not due to a death cause significant distress occur nearly every day
additional symptoms of depression
cognitive - decreased concentration and memory
psychotic- hallucinations
physical - depression can cause physical symptoms, decreased libido and hygiene
some examples of secondary causes of depression
thyroid disorder stroke aids MS alcoholism anxiety ....
is what a family member is responsive to a sign of what another family member will respond to
no
non pharms
cognitive behavioural therapy
interpersonal
bright light therapy
exercise
explain the time course of major depression
lasts 6-24 months
often episodic recurrent episodes
acute treatment goals
shorten episode
decrease symptoms
restore function
chronic treatment goals
eliminate symptoms prevent relapse min AE of treatment min drug interaction promote adherence
what does the urgency of treatment depend on
severity of symptoms
severity in impairment of function
psychotic symptoms
suicidal risk factors
what are some suicidal risk factors
hopelessness substance abuse prior suicidal attempts male suicidal plans
symptom response to treatment
anxiety and insomnia - few days
energy - 2nd week
sleep patterns - several weeks
depressed mood, sexual dysfunction - 4th week
how long should we trial a depression med
6-12 weeks
what is the health canada advisory on SSRIs
severe agitation type adverse events coulped with self harm or harm to others
important to monitor for suicidal behaviour
because they get more energy but are still depressed
first step in treatment
start with SSRI and if failing make sure patient is adherant and at an optimal dose
what to do if no response to SSRI
switch to another SSRI or a non SSRI
can do up to 3 switches
if there was a partial response can consider augmentation (lithium, second antidepresant, thyroid hormone)
what to do if there is a response to an antidepressant
continue for 4-9 months
then 12-26 months maintanence if necessary
which combo therapy do you want to avoid
NEVER SSRI AND MAOI
TCA and MAOI - serotonin syndrome
examples of some combo therapies
venlafaxine and bupropion
SSRI and bupropion
SSRI and TCA
what are some augmentation treatments
T4 and T3- even if status normal thyroid tests dont predict response
VPA
atypical antipsychotics
lithium
diffeence between remission and recovery
symptoms go away
recovery is remission lasting 6-12 months
duration of treatment
4-9 months after remission
lifelong if <40 and 2+ episodes or anyone with 3+ episodes
what is poop out syndrome
antidepressant losses reponse overtime
who are candidates for ECT
need a rapid response - suicidal, psychotic
history of poor response to meds
pregnancy
how often is ECT
2-3 times a week
6-12 treatments
adverse effects of ECT
confusion
memory loss
CV dysfunction
examples of SSRIs
fluoxetine-kids
sertraline
paroxetine
citalopram
advantage of SSRIs
less side effects bc it doesnt block muscarinic, histamine and alpha sites
serotonin adverse effects
activatin - nervous insomnia - paroxetine GI initially weight gain kinda sexual dysfunction lots
SSRI tosic effects
tremor tachycardia seizure obtundation - full alertness bradycardia treat with charcoal
serotonin syndrom effects
cognitive - agitation, confusion
autonomic - diarrhea, fever, shiver, diaphoresis (sweating)
neuromuscular - incoordination, tremor, myoclonus(jerking)
causes of serotonin syndrome
MAOi - inhibit serotonin breakdown
drugs that block reuptake
drugs that enhance release - ectasy
serotonin precursors - lsd, lithium
treament of serotonin syndrome
neuromuscular - benzos
temp - tylenol
rigidity - dantrolene
severe - cypoheptadine
FINISH - SSRI withdrawal symptoms
flu like symptoms insomnia nausea imbalance - vertigo, dizzy sensory disturbance - paresthesia hyperarousal - anxiety, agitation
how long does it take for SSRI withdrawal symptoms to go away
calc how long drug would take to leave body based on half life
then add 7 days
ways to treat SSRI withdrawal
prevent by gradual tapering
increase dose and taper more slow
switch to fluoxetine if severe because of long half life and metabolites
which SSRI has long half life and active metabolite
fluoxetine
whats wrong with grapefruit
decrease cyp 3A4 in the intestine and separating wont prevent interaction
causes high level and toxicity
SNRI examples
venlafaxine - effexor
duloxetine - cymbalta
AE of SNRI
BP changes
GI
sexual dysfunction
dry mouth, constipation
NDRI norepinephrin dopamine reuptake inhibitor example
bupropion
good to switch to if lots of serotonin side effects
adverse effects of bupropion
activating
seizure at high doses **
dry mouth, constipation
advantages of bupropion
little weight gain and sexual dysfunction
good if not tolerant to serotonin effects
NaSSA
noradrenergic and specific serotonin example
mirtazapine
mirtazapine MOA
alpha 2 antagonist - enhances NE adn serotonin release
serotonin antagonist - min sex dysfunction, insomnia
histamin blocker - potent, weight gain
anticholinergic - dry mouth
advantages of mirtazapine
little sexual dysfunction
less serotonergic effects
what does TCA all block
serotonin and NE reuptake
histamine, muscarinic, alpha receptors
major warning in TCAs
cardiac effects
hypertension, tachycardia, antiarrhythmic….
high risk patients for cardiac effects with TCAs
elderly
CV disease
overdose
what are the preferred TCAs
tricyclic secondary amines
desipramine
nortriptyline
why might TCAs not be good for the elderly
anticholinergic effects - confusion, sedation, urinary retention
AE effects of TCAs
antihistaminic - sedation, weight gain
alpha adrenergic - orthostatic hypotension
most common cause of death in TCA overdose
refractory hypotension
toxic effect in TCA overdose
CV- QRS prolong, hypotension
CNS- seizure, coma
hyperthermia
TCA withdrawal syndrome
cholinergic and adrenergic rebound - diarrhea, anxiety
treat TCA withdrawal
taper over 2-4 weeks to prevent
restart at low dose
anticholinergic agent
MAOis MOA
irreversibly inhibit MAO A and B
takes 2 weeks before new enzyme is synthesized
wash out period for MOAs when switching to other antidepressants
antidepressant to MAOi - wash out 5 half lives of antidepressant
MAOI to antidepressant - wash out 10-14 days
DO NOT COMBINE WITH OTHER ANTIDEPRESSANTS
why do you want to avoid tyramine which is in chesse
its a dietary amine that is an agonist and increases NE peripherally which normally little is absorbed bc its metabolized by GI MAOA
with MOAi more will be absorbed
causes hypertensive crisis
what food to avoid when using MAOI
cheese alcohol fish aged meat over ripe fruit yeast extracts, vit supplements sauerkraut beans
when do you use MAOis
atypical depression
resistant depression
AE of MAOIs
orthostatic hypotension *
dry mouth constipation
sexual
insomnia
examples of MAOIs
phenlzine
tranylcypromine
what is moclobemide
reversible inhibitor of MAO-A
taken after meals to min tyramine response
indication for stjohns wort
mild-mod depression
AE and DI from st johns wort
serotonin syndrome, hypomania
cyp inhibitor
which are the drugs you need to have a washout before switching
RIMA
MAOI
drugs to avoid with seizure disorders
bupropion
TCA
drugs to avoid in sexual dysfunction
SSRI
venlafaxine
TCA
MAOI
drugs to avoid weight gain
TCA
MAOI
mirtazapine
SSRI - inital loss then regain
things you should watch for in the elderly
orthostatic hypotension - alpha block
cognition - anticholinergic
excessive sedation - histamine block
urinary retention - anticholinergic
why might you caution venlafaxine use in cardiac patients
increase in blood pressure
problem with anticholinergic effect in cardiac patients
increased heart rate
what drugs can cause arrythmias
TCAs
rare bradycardia with SSRI
venlafaxine OD
most evidence of safety in pregnancy
fluoxetine
then TCA - nortriptyline
are antidepressants safe in breast feeding
excreted in small amounts
try paroxetine, sertraline, fluoxetine, nortriptyline
what should you monitor with antidepressants and breast feeding
changes in sleep, feeding pattern, behaviour
drug options for children
fluoxetine and citalopram first line
best to combine with CBT
why arent TCAs recommended for children
lethal in overdose
rare cases of sudden death
children are at an increased risk for suicidal behavior - monitor!!
how long do you continue treatmetn in children
continue once effective for 6 months
gradually discontinue over 6 weeks
