Drugs - depression - aa Flashcards
Indications for tricyclic antidepressants
- 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
Contraindications for tricyclic antidepressants
- Acutely suicidal since overdose can be fatal
- Bipolar disorder – can cause switch to manic behavior
- Preexisting arrhythmias
Indications for lithium
• Bipolar disorder – gold standard prophylaxis
Lithium is a great drug because it’s low-toxicity and has few side effects and interactions.
T/F
FALSE.
~Therapeutic index is EXTREMELY low
~Many drug interactions
~Renal monitoring
Indications for anticonvulsants (valproic acid, divalproex sodium, carbamazepine)
- Seizures
- Bipolar disorders
- Trigeminal neuralgia
Indications for SSRIs
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
What are the s/s of serotonin syndrome?
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
Indications for SNRIs
- 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
Indications for MAOIs
- 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
Contraindication for MAOIs
• Patient currently taking SSRI - discontinue at least 2 weeks before initiating the MAOI
Contraindication for SSRIs
Patient currently taking MAOI
Patient education for MAOIs
• Complicated diet restrictions required (avoid tyramine-containing foods)
Indications for bupropion
- Depression
- Smoking cessation
- Bipolar
Contraindication for bupropion
eating disorder e.g. bulimia
Indications and contraindications for mirtazapine
- Depression (esp. with difficulty sleeping- has potent antihistamine effects)
- Do not use if patient has used MAOI within 14 days
What is the firstline drug type for depression?
SSRIs
How long should SSRIs be tried in treating depression, and what is the next step if treatment is not effective?
If no response after 8-10 weeks:
~switch to another SSRI, bupropion, or venlafaxine
OR
~add bupropion to initial SSRI
What is the third line treatment step for depression if initial SSRI didn’t work and second line switching/augmenting also did not work?
~switch to mirtazapine or nortriptyline
If your patient wants to stop taking SSRIs, they should stop immediately.
T/F
FALSE.
SSRIs should be tapered off in order to avoid serotonin discontinuation syndrome.
What are the symptoms of serotonin discontinuation syndrome?
Dizziness, nausea, lethargy, headache, anxiety, paraesthesia, ‘shock-like’ sensations, balance problems, tremor, sweating, insomnia
What’s the FDA black box warning about on antidepressants?
Increased risk of suicidal thoughts or behavior (suicidality) in children, adolescents, and young adults up to age 25 treated with SSRI antidepressant medications.
Which SSRI is least likely to be associated with SSRI discontinuation syndrome when abruptly stopping?
fluoxetine
Which SSRIs are most likely to be associated with SSRI discontinuation syndrome?
venlafaxine
paroxetine
