exam 5 ott depression and bipolar Flashcards
What is the risk of recurrence for depression?
1 episode = 50-60%
2 episodes = 70%
3 episodes = 90%
recurrence becomes lower overtime as duration of remission increases
What are the DSM 5 criteria for depression?
atleast one of the symptoms must be depressed mood or loss of interest or pleasure in doing things
what are symptoms of depression?
SIGE CAPS
sleep
interest
guilt
energy loss
concentration difficulties
appetite changes
psychomotor agitation
suicidal ideation
what are the self-administered rating scales?
PHQ-9
MDQ
QIDS-SR-16
what are the goals of treatment?
reduce signs/symptoms
restore ocupation and psychosocial functioning
reduce risk of relapse and recurrence
reduce risk of harmful consequences
what is a boxed warning for all antidepressant medications?
risk of suicidality
What is important about citalopram?
dose dependent QT prolongation
substrate for CYP 2C19 and 3A4
what is important about flouxetine?
long half life –> do not have to taper
activating potential due to being an inhbitor for 2D6 and 3A4(norfluoxetine)
weight loss
What is important about fluvoxamine?
inhibitor for 1A2 and 2C19
what is important about paroxetine?
must taper due to anticholinergics
weight gain, sedation
teratogenic –> septal wall defect in fetus
inhibitor of 2D6, 2B6
what is important for sertraline?
more GI upset than other antidepressants
what are the class effects for SSRIs?
hyponatremia
increase bleeding (platelet inhibition)
sexual dysfunction
what is important about desvenlafaxine?
active metabolite for venlafaxine
dose-limiting side effect: nausea
no major CYP interactions
what is important about duloxetine?
Ott’s go to drug
FDA warning for hepatotoxicity –> monitor LFTs
inhibitor of 2D6
nausea
what is important about levomilnacipran?
must adjust in renal impairment or strong 3A4
substrate for 3A4
what is important about venlafaxine?
must be >150mg for NE effects
2D6 inhbitor at higher doses
what are the ADRs for SNRIs?
SSRI ADRs and hypertension and nausea
what is TCA MOA?
DAT, NET, SERT inhibitor
what is important about TCA?
amitriptyline - tertiary amine
used for neuropathic pain syndromes
Sides:
CNS: sedation, reduced seizure threshold
anticholinergics:
CV: orthostatic hypotension, tachycardia
NTI –> fatal overdose as low was 1000mg
what is important about MAOi?
must have 2 weeks washout before switching to antidepressant
needs 5 weeks for fluoxetine
all require tyramine diet except for selegiline patch
caution due to HTN crisis and serotonin syndrome
what is MOA for buproprion?
DAT and NET inihibitor
what is important about buproprion?
stimulating - insomnia and appetite suppression
2D6 inhibitor
CI in seizure disorder and eating disorder
can be combined with SSRI/SNRI
what is important about mirtazepine?
sedation and increased appetite with <15mg/day
agranulocytosis, increased cholesterol
can be used in combination with SSRIs/SNRIs
what is important about trazodone?
MOA: 5HT1, 5HT2, H1, A1 antagonist inhibitor
higher doses for depression
sides:
orthostatic hypotension
risk for priapism
what is important about vilazodone?
primarily SSRI with some 5HT1a agonism for anxiolytic effect
do not use with SSRI/SNRI
take with food: increase bioavailability and significant N
substrate 3A4
what is important about vortioxetine?
SSRI, 5HT1a agonist, 5HT3 antagonist
do not use in combination with SSRI/SNRI
possibly less sexual dysfunction
substrate 2D6
nausea
what is serotonin syndrome?
medical emergency with excessive amounts of serotonin in CNS
what is antidepressant withdrawal syndrome?
common with all antidepressants except fluoxetine
antidepressants with anticholinergic activity should be tapered
what is used for augmentation?
atypical antipsychotics:
aripiprazole, brexpiprazole, cariprazine, quetiapine
what are overall counseling points of antidepressants?
abrupt discontinuation can lead to antidepressant withdrawal syndrome
possible increase in suicidal thinking during the first few weeks of therapy
What are clinical factors of bipolar?
depression is a mood pole that is experienced most often in bipolar –> so can lead to misdiagnosis
alcohol and substance use is common
anxiety is common comorbiity that can impact remission of mood episodes
what is bipolar 1 disorder?
1 or more manic episodes
manic episodes last for greater than 1 week
what is bipolar 2 disorder?
major depressive and hypomanic epsiodes
usually last >4 days
what is the treatment arm of bipolar?
mood stabilizers:
1st line: lithium or valproic acid
2nd line: carbamazepine, oxcarbazepine, lamotriginr, topiramate
antipsychotics
what is important about lithium?
associated with decrease in suicidality
NTI drug –> 1.2-1.5 mEq has toxicity
dose: normally use 1:1 conversion
what are the ADRs of lithium?
toxicity: ataxia, GI, coarse hand tremor, altered mental status, seizure
sides: fine hand tremor, hypothyroidism, polyuria, polydipsia, acne, weight gain, ECG changes
teratogenic: avoid in first trimester
what should be monitored when using lithium?
Scr, BUN, electrolytes
CBC
thyroid functions
what are drug interactions with lithium?
increase Li levels when taking ACE/ARB, thiazide, NSAIDS, dehydration
what are adverse effects of valproic acid?
unsafe in any trimester – needs a pregnancy test
PCOS occurs in 50% of women
GI: anorexia, N/V/D, dyspepsia, ulceration
thrombocytopenia, platelet inhbition
teratogenic – neural tube defect
hypermmonemia
increased appetite
what are monitoring parameters of valproate?
baseline: pregnancy test, LFTs, CBC
routine: serum concentrations
serum ammonia if suspected for hyperammonia
what are drug interactions with valproate?
significant concern with lamotrigine
increased lamotrigine concentration and can lead to stevens johnson syndrome
what is important about carbamazepine?
thrombocytopenia
hematological effects
what is important about oxcarbazepine?
CYP450 3A4 inducer
hyponatremia
what is important about lamotrigine?
1st line treatment for depressive symptoms in bipolar
not useful for acute treatment or for manic episodes
what is important about topiramate?
may cause weight loss
heat intolerance/hypohidrosis
metabolic acidossi and kidney stones
possible teratogen
how are antipsychotics used in bipolar?
can be used in bipolar as monotherapy or in combination with other mood stabilizers, but not two together
what are treatment considerations for bipolar?
mood stabilizer treatment is long-term and considered to be maintenance treatment to reduce time to subsequent mood episodes
suicide attempt risk is high in both poles –> monitor lithium carefully
what should be used in bipolar during pregnancy?
lithium is good in first trimester
lithium, valproic acid, carbamazepine, topiramate are all known possible teratogens
what are the antidepressant uses in bipolar?
needs to have a mood stabilizer on board
serotonergic antidepressant used to treat anxiety
prefer mood stabilizers that target the depressive pole:
lithium, lamotrigine, lurasidone, quetiapine
