Egleton: Mood disorders

Question 1

TCA vs SNRI

Answer 1

TCA= more off targets= more side effects, risk for overdose 
SNRI= less side effects, safer, less risk for overdose

Question 2

First line drug for depression and anxiety disorders

Answer 2

SSRI

Question 3

SSRI: common characteristics

Answer 3

Wide therapeutic window
Fewer autonomic side effects than TCAs
Less sedation than TCA
Increase alertness (take in morning)
Seldom cause cardiac arrhythmias

Question 4

SSRI: mechanism

Answer 4

Block presynaptic serotonin reuptake pump
(increase amount of serotonin available in synapse
(increase postsynaptic serotonin receptor occupancy
Inhibition rapid, but effect takes 3-6wks

Question 5

SSRI: naming convention

Answer 5

• xetine
• raline
• xamine
• talopram

Question 6

SSRI metabolism

Answer 6

Absorption at gut
Heptatic cytochrome P450 metabolism
Protein binding (80-90%)

Question 7

SSRI: ADR

Answer 7

Nausea, Diarrhea, Abdominal pain (improve by end of 1st wk)
Sexual dysfunction (pripiasm, male impotence)

Mostly by excess 5-HT (selective)
Minimal CV effect
Less side effects with Citalopram/ Escitalopram

Question 8

Serotonin syndrome

Answer 8

Don't mix SSRI with MAOI (not within 1-3 mon)
By Linezolid (antibiotics, MAOI like activity)

Agitation, Restlessness, Confusion, Insomnia, Seizure, Hypertension, GI symptoms, Diaphoresis, Rigidity, Hyperthermia, Tachycardia

Question 9

Fluoxetine

Answer 9

SSRI
No anticholinergic effects, orthostatic hypotension, weight gain
Inhibit cytochrome P450 isozyme
(less so for Citalopram/ Escitalopram)
Treat Bulimia nervosa

Question 10

SNRI: MoA

Answer 10

Inhibit reuptake of NE and 5HT

Question 11

Duloxetine

Answer 11

SNRI
For acute depressive disorder and GAD
Diabetic neuropathy
Don’t use for End stage renal disease

Question 12

Venlafaxine

Answer 12

SNRI

For Major depressive disorder, GAD, Social anxiety, Panic disorder

Question 13

Desvenlafaxine

Answer 13

For Major depressive disorder

rarely used

Question 14

SNRI: side effects

Answer 14

Nausea, Abdominal pain, Constipation (opposite of SSRI)
Sexual dysfunction (priapism/ impotence

More jitters

Question 15

TCA: MoA

Answer 15

Inhibit presynaptic neurotransmitter reuptake (NE and 5-HT)
Secondary amine: block NE reuptake> 5-HT reuptake
Tertiary amine: block 5-HT reuptake> NE reuptake

Question 16

TCA: use

Answer 16

Enuresis (impramine) {night time bed wetting for children}
Depression, Panic disorder, Phobic disorder, OCD
Not first line drug

Question 17

TCR: ADR

Answer 17

Weight gain!!!
Makes everything worse!!
Don’t give to suicidal (give just enough energy to kill themselves

Arrhythmia
Muscarinic blocking (cholinergic)
Sedation (5HT)
Orthostatic hypotension
Cardiac overstimulation (catecholamine)
Seizure (GABA A)

Question 18

Amoxapine

Answer 18

new heterocyclics
block NE > 5-HT
Sexual dysfunction 
Acute renal failure with overdose
Rarely used

Question 19

Maprotiline

Answer 19

newer heterocyclics
Highest seizure risk of all antidepressants
Sedating
Rarely used

Question 20

MAOI: MoA

Answer 20

Inhibit MAO
MAO-A: oxidize 5HT more than NE and DA
MAO-B: metabolize DA more than others
Not selective for A or B
Takes time to restore normal enzyme level

Question 21

Tranylcypromine

Answer 21

MAOI
Reversible
For depression

Question 22

Phenelzine

Answer 22

MAOI
Suicide inhibitor
For depression

Question 23

Isocarboxazid

Answer 23

MAOI
Suicide inhibitor
For Depression

Question 24

MAOI: ADR

Answer 24

Avoid Tyramine (chicken liver, beef, red wine, aged cheese)

Hypertension, Cardiac arrhthmia
Increased catecholamine release
(drowsiness, orthostatic hypotension, blurred vision, dry mouth, dysuria, constipation, hepatotoxicity)
Acute poisoning

Question 25

MAOI: interaction

Answer 25

Hypertensive crisis!
Oral hypoglycemics!!

Meriperidine= fever, delirium, hypertension, hypotension
L-dopa, TCA, Tyramine

Question 26

Bupropion (Zyban)*****

Answer 26

Weak DA, NE, 5-HT reuptake inhibitor
For Major depressive disorder and Smoking cessation
Few sexual dysfunction side effects (switch from SSRI)
ADR: agitation, insomnia, nausea, weight loss, seizure

Contra: epilepsy, seizure, anorexia nervosa

Question 27

Hypericum (St. John’s wort)

Answer 27

MAOI and 5-HT reuptake inhibitor
Improve mood and sleep, decrease anxiety
Self-medication?
Hypertensive crisis with SSRI

Question 28

Trazodone

Answer 28

Unknown MoA with serotonin
No anticholinergic side effects
Sedation (block H1)
Orthostatic hypotension with alpha 1 blockade
Sexual dysfunction (priapism, persistent clitoral erection)
Minimal effects on cardiac conduction
Higher therapeutic index than TCA

Question 29

Nefazodone

Answer 29

Block NE and 5-HT
(direct 5HT2 receptor antagonist and 5HT reuptake inhibitor)
Block alpha 1 receptor
Sedation
No sexual side effects (switch from SSRI)

Dry mouth constipation, nausea, dizziness
Hepatotoxicity
May increase REM sleep

Question 30

Mirtazapine

Answer 30

Tetracyclic antidepressant
Stimulate NE and 5HT release by blocking alpha2 and 5HT 1 receptors
Increase appetite (for anorexia)
Sedating
Few sexual side effects

Question 31

What to avoid for High suicide risk

Answer 31

Avoid TCA and MAOI

Question 32

Lithium

Answer 32

Treat mania and depressive symptoms
"mood stabilizer"
Reduce formation of IP3 by inhibition of myo-inositol-1-phosphatase
Interfere with cAMP formation
Reduce neuronal response to 5-HT NE
Increases glutamate reuptake

Need to monitor serum and urine level (renal excreation)

Question 33

Lithium: ADR and contra

Answer 33

Weight gain
Polyuria, Polydipsia (inhibition of ADH)
Hypothyroidism
Contra: Severe renal disease

Question 34

Carbamazepine

Answer 34

Treat mania
Block Na channel 
Fewer ADR compared to Lithium
Monitor serum Na and CBC
Hepatic function

Question 35

Valproate

Answer 35

Treat mania
Block Na channel/ Increase GABA
Very effective in "rapidly cycling" patients
Contra: hepatic disease
Monitor platelets/ hepatic function

Question 36

Lamotrigine

Answer 36

Treat mania
Block Na channels/ Inhibit Glutamate release
Titrate slowly due to risk of Steven-Johnson’s syndrome

Question 37

Omega-3 fatty acids

Answer 37

PUFA (poly unsaturated fatty acid)
Decrease activity of MAO-B (fish oil)

Walnuts, Canola, Fish
Neurological disorders
(For Alzheimer’s, ADHA, Autism, Schizophrenia, Anxiety, Depression, Bipolar disease)
Deficienty alters deliverry of AA and sugars into CNS
1g/day

Question 38

How does potency of antidepressants correlate with antidepressant effects?

Answer 38

Immediate action/ inhibition
Relief of depression takes weeks
{So, not so well}