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Therapeutics 3 - Spring 2018 > Exam 4 - Depression/Bipolar (Watts/Butterfield/Ott) > Flashcards

Exam 4 - Depression/Bipolar (Watts/Butterfield/Ott) Flashcards

1
Q

3 major types of depression

A

reactive (60%)
MDD (major depressive disorder) (25%)
Bipolar Affective (15%)

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2
Q

Clinical Features of Depression:

Physiological Signs? (Main physiological signs)

A

Decreased sleep
Appetite Changes
Fatigue
Psychomotor dysfunctions

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3
Q

Clinical Features of Depression:

Physiological Signs? (“Other” physiological signs…)

A 
Menstrual irregularities
Palpitations
Constipation
Headaches
Nonspecific Body aches
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4
Q

Clinical Features of Depression:

Psychological Signs?

A

Dysphoric mood
Worthlessness
excessive guilt
loss of interest/pleasure in all or most activities

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5
Q

Clinical Features of Depression:

Cognitive Signs?

A

Decrease concentration

suicidal ideation

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6
Q

Drug Induced Depression:

4 main classes of drugs that can cause this?

A

Anti-HTN and Cardiovascular drugs
Sedative-hypnotics
Anti-inflammatory and analgesics
Steroids

(also Miscellaneous drugs…!!)

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7
Q

Drug Induced Depression:

what drugs in the Antihypertensive and cardiovascular classes can cause this

A 
reserpine
methyldopa
propranolol
metoprolol
prazosin
clonidine
digitalis
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8
Q

Drug Induced Depression:

what drugs in the sedative-hypnotics classes can cause this

A

alcohol
BZDs
barbituates
meprobamate

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9
Q

Drug Induced Depression:

what drugs in the Anti-inflammatory/Analgesic classes can cause this

A

indomethacin
phenylbutazone
opiates
pentazocine

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10
Q 
Drug Induced Depression:
what drugs in the steroid drug class can cause this
A

corticosteroids
oral contraceptives
estrogen withdrawal

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11
Q

Drug Induced Depression:

what Miscellaneous drug classes can cause this

A

anti-parkinsons
anti-neoplatics
neuroleptics

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12
Q

what are the 3 different hypothesises of depression

A

Biogenic amine
Neuroendocrine
Neurotrophic

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13
Q

Biogenic Amine Hypothesis of Depression:

overall idea behind it?

A

reserpine causes depression by depleting NE and 5HT from vesicles

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14
Q

Biogenic Amine Hypothesis of Depression:

________ causes depression by depleting ____ and _____

A

reserpine; NE; 5HT

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15
Q

Biogenic Amine Hypothesis of Depression:

Agents that increase _______ and ______ are effective for treating depression

A

5HT; NE

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16
Q

Biogenic Amine Hypothesis of Depression:

Genetic polymorphisms are seen in ________

A

SERT promoter

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17
Q

Biogenic Amine Hypothesis of Depression:

Alterations in that receptors are seen?

A

5HT1A or 5HT2C
and
alpha 2 receptors (aka NE receptors!)

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18
Q

Neuroendocrine Hypothesis of Depression:

overall idea of it?

A

changes in HPA Axis happen which leads to desensitized feedback response and leads to increased CRF

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19
Q

Neuroendocrine Hypothesis of Depression:

Changes are seen in the __________

A

HPA Axis

(hypothalamus-pituitary-adrenal) axis

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20
Q

Neuroendocrine Hypothesis of Depression:

stress causes hypothalamus to release _____

A

CRF

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21
Q

Neuroendocrine Hypothesis of Depression:

CRF will promote release of _____ from ____

A

ACTH; from pituitary

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22
Q

Neuroendocrine Hypothesis of Depression:

ACTH promotes release of ______ from _____

A

cortisol; from adrenal

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23
Q

Neuroendocrine Hypothesis of Depression:

Almost all patients with depression have overactivity of ______ and elevated ______

A

HPA; CRF

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24
Q

Neuroendocrine Hypothesis of Depression:

Overactivity of HPA may ___________ response in hypothalamus and pituitary

A

desensitize feedback

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25
Q

Neuroendocrine Hypothesis of Depression:

Overactivity of HPA may desensitize feedback response in ____________

A

hypothalamus and pituitary

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26
Q

Neuroendocrine Hypothesis of Depression:

Elevated CRF causes what things?

A

insomnia
anxiety
decrease appetite and libido

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27
Q

Neuroendocrine Hypothesis of Depression:

_______ CRF causes insomnia, anxiety, and decrease appetite and libido

A

elevated

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28
Q

Neuroendocrine Hypothesis of Depression:

antidepressants and ECT (electroconvulsive therapy) will (increase or decrease) CRF levels

A

decrease!!

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29
Q

Neurotrophic Hypothesis of Depression:

overall point?

A

BDNF can have antidepressant activity;

BDNF = brain derived neurotrophic activity

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30
Q

Neurotrophic Hypothesis of Depression:

BDNF stands for what?

A

brain derived neurotrohpic factor?

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31
Q

Neurotrophic Hypothesis of Depression:

BDNF is critical in what 3 things?

A

neural plasticity
resilience
neurogenesis

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32
Q

Neurotrophic Hypothesis of Depression:

Stress and pain (increase or decrease) BDNF in animals

A

decrease

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33
Q

Neurotrophic Hypothesis of Depression:

Depressed patients have reduced _____ levels

A

BDNF

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34
Q

Neurotrophic Hypothesis of Depression:

Antidepressants increase ______ levels and may increase _______

A

increase BDNF levels; increase hippocampal volume

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35
Q

Integrating Hypothesis of Depression:

______ and _______ regulate BDNF levels

A

HPA and steroid abnormalities

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36
Q

Integrating Hypothesis of Depression:

___________ receptors are activated by cortisol during stress (which ______ BDNF)

A

hippocampal gluccorticoid;

decrease BDNF

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37
Q

Integrating Hypothesis of Depression:

Chronic activation of monoamine receptors increase ________

A

BDNF signaling

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38
Q

Integrating Hypothesis of Depression:

chronic activation of of monoamine receptors leads to down regulation of _______

A

HPA axis

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39
Q

Main Classes of Antidepressants?

A 
MAOIs
TCAs
SSRIs
SNRIs
5-HT2 antagonists
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40
Q

why does antidepressant therapy take 2 - 3 weeks?

A

neuroadaptive responses

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41
Q

MOA of MAOIs?

A

inhibit break down of NE and 5HT = more NE and 5HT is released from vesicles into synapses

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42
Q

what drugs are are non-selective MAO inhibitors

A

Phenelzine

Tranylcypromine

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43
Q

what drug is MAO B selective

A

Selegiline

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44
Q

what drug is MAO A selective

A

Moclobemide

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45
Q

are MAOIs reversible or irreversible?

A

irreversible
(thus when switching agents must have some time from stopping MAOI and starting another drug because it may cause hella side effects)

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46
Q

Severe Side Effects of MAO Inhibitors

A 
HA
drowsiness
dry mouth 
weight gain
orthostatic hypotension
sexual dysfunction
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47
Q

MAO-I has interactions with what Rx drugs?

A

TCAs
SSRIs
L-DOPA

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48
Q

MAOIs should be avoided with that foods?

A 
tyramine rich
(aka cheeses, sour cream, sausage, red wine/beer/ale, miso soup, avocados, bananas and a million other foods...)
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49
Q

MAOIs have interactions with what OTC meds?

A

Cold preparations

Diet pills

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50
Q

MAOIs can lead to a _______ crisis

A

hypertensive

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51
Q

what are the two subgroups of TCAs

A

tertiary amine
and
secondary amine

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52
Q

indications for TCAs?

A

depression
panic disorder
chronic pain
enuresis

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53
Q

TCAs:

pts are more likely to commit self harm or suicide ________ into treatment

A

2 weeks

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54
Q

TCAs:

Toxicity risk — extremely _________ pts more likely to be suicidal

A

dangerous/depressed

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55
Q

Tertiary Amines - TCAs:

they inhibit both _____ and ____ reuptake via ___ and ____

A

NE and 5HT;

via NET and SERT

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56
Q

Tertiary Amines - TCAs:

major side effects?

A

sedation
autonomic side effects
weight gain

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57
Q

Tertiary Amines - TCAs:

also act as antagonists to what?

A

they are antihistamines
anitmuscarinic
antiadrenergic

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58
Q

what are the tertiary amine TCAs?

A 
Imipramine
Amitriptyline
Trimipramine
Clomipramine
Doxepin
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59
Q

Secondary Amines - TCAs:

inhibit _______ but not _____ like tertiary amine TCAs do

A

inhibit NET
not SERT

(*remember secondary has an N in it…)

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60
Q

what are the secondary amine TCAs?

A

desipramine
nortriptyline
protriptyline
maprolitine

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61
Q

TCAs:

secondary or tertiary amines have worst side effect profiles?

A

tertiary amines

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62
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

imipramine

A

tertiary

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63
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

Desipramine

A

secondary

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64
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

Amitriptyline

A

tertiary

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65
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

doxepin

A

tertiary

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66
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

nortriptyline

A

secondary

67
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

maprotiline

A

secondary

68
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

trimipramine

A

tertiary

69
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

clomipramine

A

tertiary

70
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

protriptyline

A

secondary

71
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

fluoxeine

A

SSRI

72
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

Fluvoxamine

A

SSRI

73
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

Venlafaxine

A

SNRI

74
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

Duloxetine

A

SNRI

75
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

desvenlafaxine

A

SNRI

76
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

paroxetine

A

SSRI

77
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

sertraline

A

SSRI

78
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

citalopram

A

SSRI

79
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

escitalopram

A

SSRI

80
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

Milnacipran

A

SNRI

81
Q

is it TCA (tertiary or secondary), SSRI, or SNRI?

Levomilnacipran

A

SNRI

82
Q

what drugs are SSRIs

A 
fluoxetine
fluvoxamine
paroxetine
sertraline
citalopram
escitalopram
83
Q

what drugs are SNRIs

A 
venlafaxine
desvenlafaxine
duloxetine
milnacipran
levomilnacipran
84
Q

what are the side effects of SSRIs

A 
N/V
HA
sexual dysfunction
anxiety!!
insomnia!!! (NOT sedation)
tremor
85
Q

SSRI discontinuation syndrome — symptoms?

A 
"brain zap"
dizziness 
sweating
nausea
insomnia
tremor
confusion
vertigo
86
Q

what drugs are NSRI

A

reboxetine

atomoxetine

87
Q

what drugs may be used as a rapidly acting antidepressants

A

NMDA receptor antagonists

like ketamine, scopolamine

88
Q

Non-Pharm options (per watts)

A

electroconvulsive therapy
psychotherapy
hospitalization

89
Q

MOA of Lithium?

A

depletes PIP2 and assoc. signaling (IP3 and PKC)

modules GSK3 (ultimately a;ters to gene transcription)

90
Q

MOA of Valproate

A

increase GABAergic tone
Block Na+ channels and Ca2+ channels
and inhibit histone deacetylase

91
Q

MOA of CBZ

A

inhibit Na+ channels

92
Q

MOA of lamotrigine

A

inhibit Na+ and Ca2+

93
Q

DSM - 5 Diagnostic Criteria for Depression:

____ or more of the symptoms listed are present during the same _____ week period and is a change from baseline

A

5 symptoms;

greater than 2 week period

94
Q

DSM - 5 Diagnostic Criteria for Depression:
need at least one of two symptoms (as part of the 5 total)
what are the 2 symptoms

A

depressed mood
or
loss of interest or pleasure

95
Q

DSM - 5 Diagnostic Criteria for Depression:

what are the other symptoms that can be part of the diagnosis

A 
SIGECAP!
S-suicidal ideation
I-insmonia/hypersomnia
G-guilt/worthlessness
E-Energy loss/fatigue
C-Concentration difficulties
A-Appetite changes
P-psychomotor agitation/retardation
96
Q 
Risk factors for MDD:
male or female?
age?
marital status?
race?
economic status?
employment?
co-morbid \_\_\_\_\_\_\_ and \_\_\_\_\_
Physical \_\_\_\_\_\_\_\_\_
lack of \_\_\_\_\_\_
\_\_\_\_\_\_\_\_ experiences
prior \_\_\_\_\_\_\_\_
A 
female
middle age
widowed/separated/divorced/single
white race
low econom. status
unemployed
co-morbid: medical disorder and substance use disorder
physical DISABILITY
lack of SOCIAL SUPPORT
stressful events/adverse childhood experiences
prior suicidal attemps
97
Q

Depression Recurrence Rates:
if 1 episode: _____ %
if 2 episodes: _____%
if 3 episodes: ____%

A

50 - 60
70
90

98
Q

what screening scales are self administered for depression

A

PHQ-9
QIDS-SR-16
MDQ

99
Q

what screening scales are clinician rated for depression

A

HAM-D
QIDS-C
CGI

100
Q

what screening scale is commonly used for clinical trial effiacy for antidepressants

A

HAM-D

101
Q

Boxed Warning for Antidepressants:

A

increase risk of suicidal thought behaviors in those aged < 24 y.o

No increase in suicides seen tho

102
Q

how to manage/”deal with” the boxed warning that comes with antidepressants

A

still give it to them (even pts under 24)
just closely monitor pts for clinical worsening/suicidal ideation, or unusual changes in behavior esp. for first 3 MONTHS of therapy or any dose changes

103
Q

Clinical Pearls for Citalopram:
ADE of _______ seen when dose > 40 mg/day
and
CYP_______?

A

QT prolongation

2C19 (substrate)

104
Q

Clinical Pearls for Escitalopram
CYP______?
and is the ______ of citalopram

A

2C19 and 3A4!

s isomer

105
Q

Clinical Pearls for fluoxetine:
long or short half life?
CYP?
ADEs?

A

long half life
2D6 and 3A4
ADEs: insomnia, initial weight loss, fatigue syndrome

106
Q

Clinical Pearls for Fluvoxamine:
FDA approved for _______
CYP____?

A

OCD tx

1A2

107
Q 
Clinical Pearls for Paroxetine:
Must \_\_\_\_\_\_\_\_ because of \_\_\_\_\_\_ effects
CYP\_\_\_\_\_?
ADEs:
Pregnancy Category \_\_\_\_: leads to?
A

must TAPER; b/c of ANTICHOLINERGIC effects
2D6
ADE: weight gain/sedation/anticholinergic
Category D; SEPTAL WALL DEFECTS

108
Q

Clinical Pearls for Sertraline
CYP_____?
More ____ at higher doses

A

2D6 (mainly but also all the usual thing)

GI upset

109
Q

which SSRI notably causes weight gain

A

paroxetine

110
Q

which SSRI notably causes weight loss

A

fluoxetine

111
Q

Overall SSRI ADEs?

A 
variable sedation
increased BLEEDING risk
GI upset
anxiety/agitation
sexual dysfunction
hyponatremia
decreased bone mineral density 
akathisia
(weight gain or weight loss)
112
Q

SSRIs:
take about _______ for onset of action
and
________ until full dose response is observed

A

1 - 2 weeks (onset)

4 - 6 weeks (full dose response)

113
Q 
Clinical Pearls for Desvenlafaxine:
\_\_\_\_\_\_\_\_\_ of venlafaxine
dose limiting side effect of \_\_\_\_\_\_\_\_
CYP\_\_\_\_\_\_?
\_\_\_\_\_ dosing adjustments
A

active metabolite of venlafaxine
nausea
no CYP!
renal dosing

114
Q

Clinical Pearls for Duloxetine:
CYP_______
how to help with nausea?
FDA warning for _______

A

2D6
slow titration or divided dosing to help w/ nausea
warning for HEPATOXICITY *gotta check LFTS at baseline and q 6 mos)

115
Q

Clinical Pearls for Levomilnacipran:
CYP_______
MUST adjust for what things?
Rare SEs?

A

3A4
renal dosing OR major CYP3A4 inhibitor
SE: seizures or glaucoma

116
Q

brand for Levomilnacipran

A

Fetzima

117
Q

brand for milnacipran

A

Savella

118
Q

brand for desvenlafaxine

A

pristiq

119
Q

Clinical Pearls for Milnacipran
indicated for _________
____ dosing adjustments

A

fibromyalgia

renal dosing

120
Q

Clinical Pearls for Venlafaxine:
CYP________
Dose must be > ______ mg/day to have _____ effect

A

2D6 and 3A4

150 mg; NE effects

121
Q

SNRIs can be helpful for what other things? (not depression…)

A

pain syndrome
musculoskeletal pain
fibromyalgia
neuropathic pain

122
Q

what is the one ADE that is different for SNRIs compared to SSRIs

A

blood pressure elevation seen in SNRI (bc NE effect!!)

123
Q

Clinical Pearls for Amitriptyline:

Used at _____ doses for ______ pain

A

lower; neuropathic

124
Q

Clinical Pearls for Desipramine:

just one pearl for this drug

A

not commonly used for depression..

125
Q

Clinical Pearls for Doxepin:
CYP_____
Commonly used for ______

A

2D6

insomnia

126
Q

Clinical Pearls for Imipramine:

most often used for children with ______ or ______ at ______ doses

A

ADHD; noctural enuresis

lower doses

127
Q

Clinical Pearls for Nortriptyline:

used in __________

A

smoking cessation

128
Q

what TCA is used for smoking cessation

A

notriptyline

129
Q

which TCA is used for ADHD

A

imipramine

130
Q

which TCA is used for neuropathic pain

A

amitriptyline (also nortriptyline)

131
Q

which TCA is the only one with a notable CYP interaction and what is the interaction

A

doxepin

CYP2D6

132
Q

which SNRIs need renal adjustmnet

A

desvenlafaxine
milnacipran
levomilnacipran

133
Q

which SNRI is indicated for fibromyalgia

A

milnacipran

134
Q

which SNRI has a FDA warning for hepatoxicity

A

duloxetine

135
Q

TCAs can be fatal in overdose due to ________

A

cardiac arrhythmias

136
Q

Clinical Pearls for all MAOIs?

A

must have 2 week washout period before switching antidepressants

all drugs need tyramine diet except selegiline (6mg/24 hr)

137
Q

Caution with MAOIs due to _______ and _______

A

hypertensive crisis
and
serotonin syndrome

138
Q

MAOIs contraindications? (8 in total)

A 
Pheochromocytoma
Hepatic or renal dysfunction
Excessive caffeine use
Cerebrovascular disease
Concomitant sympathomimetics (amphetamines and cocaine..)
Cardiovascular disease
Elective surgery
SSRI use (gotta d/c 2 -5 weeks before starting MAOI)

(PHECCCES)

139
Q

why is tyramine a note of concern with MAOIs

A

tyramine is degraded by MAO;

MAOIs wont break down tyramine, leads to hypertensive crisis

140
Q

Any drug that increases _________ in the brain are basically a drug interaction for MAOIs

A

increase NEUROTRANSMITTERS

141
Q

MAOI Patch has what drug in it?

A

Selegiline

142
Q

Selegine Patch:

monotherapy or adjunct therapy?

A

monotherapy!

143
Q

ADEs for selegiline patch?

A

hypotension
dry mouth insomina
headache
Gi effects

144
Q

what are the “novel agents” for depression

A 
bupropion
mirtazapine
trazodone
Vilazodone (Viibryd)
Vortioxetine (Trintellix)
145
Q

what is the brand for vilazodone

A

Viibyrd

146
Q

what is the brand for vortioxetine

A

Trintellix

147
Q

Bupropion:

____ and ___ reuptake inhibitor

A

DA and NE

148
Q

Bupropion:

it is stimulating and thus can cause ______ and _____

A

insomnia

appetite suppresion

149
Q

Bupropion:

CI with what 2 things?

A

seizures

eating disorders

150
Q

Bupropion:

if using SR formulation; do not give 2nd dose no later than ______

A

4pm

151
Q

Bupropion:

major CYP stuff?

A

2B6 Substrate

2D6 inhibitor

152
Q

Bupropion:

T or F: it can not be used with SSRIs or SNRIs

A

False!

it can be used with them

153
Q

Mirtazapine:

increased _____ and _____ occur with doses < ____ mg/day

A

sedation; appetite

15 mg/day

154
Q

Mirtazapine:

warnings for ______ and ______

A

agranulocytosis
and
increased cholesterol

155
Q

Mirtazapine:

T or F: it can not be used with SSRIs or SNRIs

A

False!

it can be used with them

156
Q

Trazodone:

risk of ______ - medical emergency

A

priapism

157
Q

Vilazodone:

should it be taken with or without food?

A

WITH FOOD!!

better absorption AND hella nausea is possible

158
Q

Vilazodone:

CYP interaction?

A

3A4

half the max dose if strong 3A4 inhibitor

159
Q

Vortioxetine:

CYP interaction?

A

2D6:

half the max dose if strong 2D6 inhibitor

160
Q

Antidepressant withdrawal syndrome:

occurs due to abrupt cessation of the antidepressant - and it is common in all depressants except _______

A

fluoxetine (bc it has a long half/can handle its own taper)

161
Q

Want to avoid cholinergic rebound - therefore HAVE to taper ______ and _____ (aka the anticholinergic antidepressants)

A

paroxetine; TCAs

162
Q

Symptoms of Antidepressant withdrawal syndrome?

A

agitation
irritability
GI disturbances
(similar to depression…)

163
Q

what drugs are Augmentation agents for depression

A

Lithium
T3
atypical antipsychotics
buspirone

Therapeutics 3 - Spring 2018 (20 decks)

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