GAD, ADD, Depression Flashcards
Dx GAD
Excessive anxiety/worry more days than not x6 months + ≥3:
- Restlessness
- Easily fatigued
- Difficulty concentrating
- Difficulty falling/staying asleep
- Irritability
- Muscle tension
pathophys of GAD
Decreased GABA receptor density. Inc glutamate
Decreased 5-HT
CO2 serum concentration sensitivity (panic)
Increased amygdala activity
tx of acute phase anxiety
Start SSRIs, TCAs
+/-BZD if necessary
pphx anxiety tx
SSRIs, SNRIs
buspirone
pregabalin
name first and second line tx for anxiety
tx timelines
SSRIs for 12 weeks then switch to another for at least 6 mos.
- Fluoxetine may have best response and remission outcomes.
- Sertraline best tolerability outcomes.
Venlafaxine second line (dose 75mg or less)
- Venlafaxine and paroxetine may have worst comparative outcomes.
SSRIs for GAD w/
best response and remission outcomes.
best tolerability outcomes.
may have worst comparative outcomes.
Fluoxetine may have best response and remission outcomes.
Sertraline best tolerability outcomes.
Venlafaxine and paroxetine may have worst comparative outcomes.
Indication & MOI of Buspirone
advantages & disadvantages
indicated for GAD
5HT1A partial agonist
Advantages:
- Almost as effective as benzos for GAD
- No sedation, cognitive impairment, respiratory depression, dependence or withdrawal
- Lacks abuse potential
Disadvantages:
- Onset of effect ~2 weeks, but can take 6 weeks for full effect (similar to the antidepressants)
name an antiepiletic to consider w/ GAD
Pregabalin
Name the atypical antipsychotic you could use in GAD (unlikely)
Quetiapine –> monotherapy may be beneficial in non refractory GAD
greater discontinuations.
define panic attack
Period of intense fear in which 4 of the following symptoms develop abruptly and reached a peak within minutes.
- Palpitations
- Sweating
- Trembling
- Shortness of breath or smothering
- Feeling of choking
- Chest pain
- Nausea
- Dizzy or lightheadedness
- Chills or heat sensations
- Paresthesias
- Derealization or depersonalization
- Fear of losing control
- Fear of dying – peaks at 10-15mins and disappears in 30 mins
define panic disorder
YOU CHANGE YOUR LIFE
At least one of the attacks has been followed by 1 month of one of the following
- Persistent concern about having additional attacks
- Worry about the implication of the attack
- Significant change in behavior related to the attacks
first line for panic disorder
Antidepressants - high dose
how to dose SSRIs for pt with panic disorder
Need to start low and increase dose slowly – takes a while to get to therapeutic dose
- SSRIs can precipitate a panic attack if initially dosed too high.
- Goal dose is at high end of dosing range.
treat for at least 8 weeks (and probably 12).
name drugs to consider for a pt w/ panic attacks
SSRIs and SNRIs
TCAs
BZDs for the first 4-6 weeks of treatment only.
what type of benzos are indicated for panic attacks
Alprazolam
lorazepam
High potency, short acting
type of BZD indicated for GAD vs Panic disorders
GAD - low potency, low acting
Panic - High potency, short acting (Alprazolam, lorazepam.)
what is the most common comorbidity assoc w/ GAD & PD
MDD
At least half of GAD patients will develop MDD.
30-60% of Panic patients will develop MDD.
•Highest risk of admission due to OD in Medicaid patients when compared to other BZDs.
Alprazolam
name fast onset BZDs
- Triazolam
- Alprazolam
- Loprazolam
what drug would you give to a pt who is tapering off BZD and feeling withdrawl si/sx?
Pregabalin
describe how to taper BZDs
Empower patient.
- Most research has been done in median age > 60 yo
- offer to anyone >64 or to anyone prescribed for >4wks
_Slow reduction 3-6 month_s with decreases of 1/8 to 1/4 dose qweek/q2week/monthly dose
Along with initiation of an SSRI/SNRI for anxiety maintenance (if appropriate)
Melatonin for sleep*
Pregabalin with withdrawal/anxiety symptoms**
who should we offer BZD tapering to
over 64 or
anyone prescribed for >4wks
si/sx of protracted BZD withdrawl
May last for up to a year after drug cessation
- Anxiety
- Insomnia
- Depression
Weakness, muscle pain, tremor, irritable bowel
signs of rapid BZD withdrawl
Tremors
Anxiety
Perceptual disturbances
Dysphoria
Psychosis
Seizures
Insomnia
explain role of atypical antipsychotics in GAD and PD
For panic disorder:
- NO monotherapy –> adjunct to SSRIs.
For GAD: NOT RECOMMENDED
- atypicals shown to have more side effects with little benefit when added to SSRIs-
- Quetiapine monotherapy has positive efficacy data but poor tolerability
name other adjuct tx for anxiet & PD
Hydroxyzine
propranolol
clonidine
describe neurobiology of ADD
Blocking NE alpha2 receptors results in ADHD like behavior.
- Dysfunction in prefrontal-striatal neural circuits
- Reductions in synaptic DA, –> enhanced DA reuptake & i_ncreased catabolism_.
- Low prefrontal cortex NE.
P50 suppression deficiency.
- Deficiency in the ability to suppress reaction to an auditory stimuli.
Delayed brain maturation.
describe delayed brain maturation in ADD
Delayed Cortical thickness & surface area.
Approximately a 2-3 year delay in children.
- 18 yo the differences not significant.
list 2 office questionaires to help dx ADD
ADHD-RS
SNAP-IV
name notable findings on ADHD-RS
- Fidgets with hands or feet or squirms in seat.
- Does not seem to listen when spoken to directly.
- Is “on the go” or acts as if “driven by a motor.”
- Talks excessively.
name notable findings in the SNAP-IV
LETI
- Often does not seem to listen when spoken to directly
- Often loses temper
- Often is excitable, impulsive
- Often is irritable
MOI of stimulats used to tx ADD
methylphenidate: block the reuptake of dopamine and norepinephrine.
- dexmethylphenidate has less NE effects potentially resulting in better tolerability.
amphetamines: Also inhibits MAO and may have direct stimulatory effects on alpha and beta receptors.
INC DA
what ADD meds are you concerned as they are metabolized through 2D6 pathway
which is not?
dextroamphetamine/ mixed amphetamine salts/ lisdexamfetamine
Atomoxetine
methylphenidate is NOT!
what med should you never give to someone w/ ADD & a tic disorder
dextroamphetamine/ mixed amphetamine salts/ lisdexamfetamine
med of choice for ADD + anxiety sx
atomoxetine
med of choice ADD + SUD
atomoxetine
MOI of Atomoxetine
indication??
blocks the reuptake of NE.
- This results in benefits on both alpha 2 receptors and small increases in DA
Not as good as stimulant
ADD
Useful adjunct to stimulants.
Guanfacine
MOI of Guanfacine
Alpha 2 agonist –> This results in strengthening the relevant connections for attention.
- Compared to DA enhancement which weakens irrelevant connections.
- Lower NE –> reduce BP
adverse effects of Guanfacine
Decrease in BP and pulse
sedation/somnolence/fatigue
____, compared to guanfacine, is less specific and will stimulate alpha __, __ and __ receptors resulting
Clonidine, compared to guanfacine, is less specific and will stimulate alpha 2a, b and c receptors resulting
adverse effects of clonidine
in more sedation & greater decrease in BP.
shorter half life requiring increased frequency in dosing.
which stimulant is better to give someone w/ ADD + seizure
methylphenidate
define MDE
5 or more of the below symptoms for 2 weeks and which cause significant impairment in social, academic and occupational functioning.
- –*depressed mood
- –*lack of enjoyment in pleasurable activities
- –changes in weight
- –changes in sleep
- –psychomotor agitation or retardation
- –fatigue or lack of energy
- –feelings of worthlessness or excessive guilt
- –decreased concentration
- –thoughts of suicide
define persistent depressive disorder
Depressed mood for _more days than not for a_t least 2 years. _+ 2 o_r more of the following:
- -poor appetite or overeating
- -insomnia or hypersomnia
- -low energy or fatigue
- -low self-esteem
- -poor concentration or difficulty making decisions
- -feelings of hopelessness
what disorder is important to r/o when evaluating a depressed pt
what should tou ask them
bipolar
any mania??
define
beravement
adjustment disorder
- Bereavement - depressive symptoms which occur after the loss of a loved one.
- Adjustment disorder - development of emotional and/or behavioral symptoms within 3 months after an identifiable stressor.
T/F
in tx depression: All classes are equally efficacious
TRUE
in depression:
____the most useful when considering tolerability, efficacy and benefits.
_____ and____ had slightly better efficacy than the other reviewed antidepressants.1
- Sertraline the most useful when considering tolerability, efficacy and benefits.
- Escitalopram and mirtazapine had slightly better efficacy than the other reviewed antidepressants.1
what are the serotonin targets we want to agonize/antagonize in tx depresion
5-HT1a agonism
5-HT2 antagonism
- seems to lower anxiety and promote the 5-HT1a agonistic effect.
list steps to follow in regards to Nonresponse to initial antidepressant
- 4-8 weeks of treatment. <25% reduction in sx then inc dose
- If no response then switch to another antidepressant. (different type
- After 2 trials then consider the patient to be treatment resistant.
- Switching to a third antidepressant monotherapy. (SSRI –> SSRI –> SNRI)
- add adjuvant non antidepressive (esketamine, atypical, lithium)
- COMBO therapy –> (SSR+ Bup or SSRI/SNRI + mirtazapine)
name approriate combo therapy for depression
what pt would you use each combo w/??
SSRI along with bupropion. –> ↑ dopamine (NE)
- Drowsy all day / no energy
SSRI or SNRI with mirtazapine. –> ↑ serotonin & NE through alpha 2 blockade
- Can’t fall asleep – (hypnotic)
Combining an SSRI, SNRI or TCA with an___ is not recommended.
Combining an SSRI, SNRI or TCA with an MAOI is not recommended.
post partum depression
first line
second line
third line
First line: psychotherapy
Second line Pharm:
- Citalopram
- escitalopram
- sertraline
Third Line: Brexanolone IV
- Acts as allopregnanolone
- Neuroactive steroid that drops dramatically after childbirth
- Has positive GABAA modulatory effects (pass out)
name Non-Prescription Strategies for post partum dep
- SAMe
- Folic Acid
Non-Pharmacologic Therapies for dep
Electroconvulsive Therapy (ECT).
Repetitive Transcranial Magnetic Stimulation (rTMS). – noninvasive
Deep Brain Stimulation (DBS). - used for Parkinson’s Disease.
Vagus Nerve Stimulation (VNS). - used for seizure disorder.
tx follow up algorithm for starting pt on antidepresant s
Meet with pt after 10-14 days –> assess tolerability and safety/suicidal thoughts. –> Kids every week
Meet in 4 weeks to assess efficacy. –> Should be feeling better
Meet _2-4 weeks later to measure maximal respons_e
- (6-8 weeks of a therapeutic dose).
Meet e_very month for next 4-9 months_ during continuation phase. (up to 1 year)
- if more then 2 episodes take medication forever
Patient Education Message for antidep
- Take medication daily (as prescribed).
- Antidepressants need to be taken 2-4 weeks before noticeable effects will occur.
- Patients need to continue taking the antidepressant even if they start to feel better.
- Patients should not stop taking the antidepressant without talking to a clinician.
- Patients should be given specific instructions on how to resolve questions regarding their treatment (e.g. a contact person/case manager)
tx depression in kids
- Fluoxetine – >8 y/o (FIRST LINE)
- Escitalopram — >12 y/o (SECOND LINE)
- Venlafaxine after 2 failed attempts
tx dep in pregnancy & BF
PREGNANCY: No med preferred
- If need med – fluoxetine
- Bupropion – useful but does not help w/ anxiety
BREASFEEDING
- Sertraline & paroxetine negligible in milk
if prescribing atypical antipsychotic which would you choose bc of least side effects and least likely to cause movement disorder?
Aripiprazole
Aripiprazole is used in what case?
Adjunct/ add-on therapy for refractory depression (+SSRI or SNRI)
name adjuctive meds you can add on for depression
Selegiline transdermal patch
Esketamine – nasal inhalation
Brexanolone
Atypical antipsychotics:
- Aripiprazole – fewer side effects
- Olanzapine w/ fluoxetine
- Quetiapine
indication & adverse effects
Brexanolone
PPD
LOC/sedation/syncope (DEC O2)
indication / MOI / Adverse effects:
Esketamine
add-on for depression
MOI
- NMDA glutamate receptor antagonist
- Block reuptake of serotonin, NE, & DA
- 5-HT 1 agonist
- Opiate receptor agonist (mild)
Adverse Effects
- Dissociation - outer body experience (buzzed)
- INC HR/BP
indication / MOI / adverse effects
Selegiline transdermal patch
adjuct for depression
MOI: CNS (selective) monoaminoxidase inhibitors (MAOI)
- Works in the CNS but does not affect GI located monoamine oxidase (MO).
- Avoidance of GI located (MO) allows the GI tract to still break down dietary tyramine before it is allowed into the blood stream.
Adverse Effects:
- Hypertensive crisis at high doses 2° to GI tyramine absorption (dietary restrictions)
- Too much DA (bc too much tyramine)
- Skin irritation
- Xerostomia
- Diarrhea
what drug Mimics allopregnanolone (positive GABA effects)
Brexanolone
PPD
