Drugs - depression - aa

Question 1

Indications for tricyclic antidepressants

Answer 1

• Moderate to severe depression, panic disorder. Use SSRI or SNRI first
• Imipramine – bed-wetting in children over 6y/o
• Amitriptyline – migraines and chronic pain syndromes
• Low doses can be used to treat insomnia – especially doxepin

Question 2

Contraindications for tricyclic antidepressants

Answer 2

• Acutely suicidal since overdose can be fatal
• Bipolar disorder – can cause switch to manic behavior
• Preexisting arrhythmias

Question 3

Indications for lithium

Answer 3

• Bipolar disorder – gold standard prophylaxis

Question 4

Lithium is a great drug because it’s low-toxicity and has few side effects and interactions.
T/F

Answer 4

FALSE.
~Therapeutic index is EXTREMELY low
~Many drug interactions
~Renal monitoring

Question 5

Indications for anticonvulsants (valproic acid, divalproex sodium, carbamazepine)

Answer 5

• Seizures
• Bipolar disorders
• Trigeminal neuralgia

Question 6

Indications for SSRIs

Answer 6

First line for:
•	Depression 
•	Anxiety disorders: obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, PTSD, social anxiety disorder, 
•	Premenstrual dysphoric disorder 
•	Fluoxetine: bulimia nervosa 
•	Somatoform disorders

Question 7

What are the s/s of serotonin syndrome?

Answer 7

o Agitation or restlessness, confusion
o Rapid heart rate, high BP
o Dilated pupils, loss of muscle coordination or twitching muscles, muscle rigidity, heavy sweating
o Headache, shivering, goose bumps, diarrhea
o Severe: high fever, seizures, irregular heartbeat, unconsciousness

Question 8

Indications for SNRIs

Answer 8

• Depression in patients in whom SSRIs are ineffective
• The chronic painful symptoms associated with depression (ex. backache & muscle aches) which SSRIs are relatively ineffective in treating
• Neuropathic pain in conditions such as diabetic peripheral neuropathy

Question 9

Indications for MAOIs

Answer 9

• LAST LINE agents – due to risk of drug-drug interactions and food interactions
• Treatment-resistant depression
• Depression that is unresponsive or allergic to TCAs
• Phobic states
• Atypical depression

Question 10

Contraindication for MAOIs

Answer 10

• Patient currently taking SSRI - discontinue at least 2 weeks before initiating the MAOI

Question 11

Contraindication for SSRIs

Answer 11

Patient currently taking MAOI

Question 12

Patient education for MAOIs

Answer 12

• Complicated diet restrictions required (avoid tyramine-containing foods)

Question 13

Indications for bupropion

Answer 13

• Depression
• Smoking cessation
• Bipolar

Question 14

Contraindication for bupropion

Answer 14

eating disorder e.g. bulimia

Question 15

Indications and contraindications for mirtazapine

Answer 15

• Depression (esp. with difficulty sleeping- has potent antihistamine effects)
• Do not use if patient has used MAOI within 14 days

Question 16

What is the firstline drug type for depression?

Answer 16

SSRIs

Question 17

How long should SSRIs be tried in treating depression, and what is the next step if treatment is not effective?

Answer 17

If no response after 8-10 weeks:
~switch to another SSRI, bupropion, or venlafaxine
OR
~add bupropion to initial SSRI

Question 18

What is the third line treatment step for depression if initial SSRI didn’t work and second line switching/augmenting also did not work?

Answer 18

~switch to mirtazapine or nortriptyline

Question 19

If your patient wants to stop taking SSRIs, they should stop immediately.
T/F

Answer 19

FALSE.

SSRIs should be tapered off in order to avoid serotonin discontinuation syndrome.

Question 20

What are the symptoms of serotonin discontinuation syndrome?

Answer 20

Dizziness, nausea, lethargy, headache, anxiety, paraesthesia, ‘shock-like’ sensations, balance problems, tremor, sweating, insomnia

Question 21

What’s the FDA black box warning about on antidepressants?

Answer 21

Increased risk of suicidal thoughts or behavior (suicidality) in children, adolescents, and young adults up to age 25 treated with SSRI antidepressant medications.

Question 22

Which SSRI is least likely to be associated with SSRI discontinuation syndrome when abruptly stopping?

Answer 22

fluoxetine

Question 23

Which SSRIs are most likely to be associated with SSRI discontinuation syndrome?

Answer 23

venlafaxine

paroxetine