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PR3153 > IC12 Mood disorder I - Depression > Flashcards

IC12 Mood disorder I - Depression Flashcards

1
Q

What is SSRIs and what are they used for?

A

SSRIs - serotonin reuptake inhibitor

They inhibit the reuptake of serotonin.

SSRIs are used as 1st line agents for depression and anxiety.

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2
Q

List out common SSRIs that we know

A
  1. Escitalopram
  2. Fluoxetine
  3. Sertraline
  4. Citalopram
  5. Paroxetine
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3
Q

What common ADRs of using SSRIs?

A
  1. Drowsiness / insomnia, N&V
  2. Bleeding risk
  3. Hyponatremia
  4. Serotonin syndrome
  5. Sexual dysfunction
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4
Q

What are the 4 main challenges in the use of SSRIs?

A
  1. Drug response differs from every individual
  2. SSRIs have delayed onset - we can only determine the response after 4-8 weeks
  3. ADRs
  4. DDIs
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5
Q

Which are the 2 most common CYP enzymes involved in metabolism of SSRIs?

A
  1. CYP2D6
  2. CYP2C19

CYP2D6 & CYP2C19 help to metabolise SSRIs into inactive* metabolites.

Individuals with poor metabolizing gene for CYP2D6 and CYP2C19 will experience greater ADRs.

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6
Q

What kind of pharmacogenetics testing should we do for patients with inadequate response or have adverse reactions to SSRIs?

A
  1. We should consider CYP2D6 and CYP2C19 genotyping in patients with inadequate response or have adverse reactions.
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7
Q

How should we adjust dosing for drugs that are affected by CYP2D6 and CYP2C19 genotypic variation:

  1. Rapid metabolizers
  2. Intermediate metabolizers
  3. Poor metabolizers
A

Rapid metabolizers - increase dose of SSRI

Intermediate metabolizers - no change to dosing in SSRIs , except paroxetine which is to be decreased

Slow metabolizers - decrease dose of SSRI

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8
Q

Which SSRIs metabolism are affected by CYP2C19 genotypic variation?

A

Escitalopram, Sertraline, Fluvoxamine

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9
Q

Which SSRIs metabolism are affected by CYP2D6 genotypic variation?

A

Fluoxetine, paroxetine, bupropion

(six has an X in its spelling. SSRIs with X in its spelling are affected by CYP2D6)

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10
Q

What are general risk factors of depression?

A
  1. Poor
  2. Old
  3. Loneliness
  4. Male
  5. Other comorbidities
  6. History of attempted suicide
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11
Q

What are red flags for a patient with depression?

A
  1. Suicidal ideation
  2. Has a suicide plan
  3. Possess an intent to carry out the plan
  4. Exploring reasons to live and die

We should ask all patients w depression if they have any actual thoughts of killing themselves

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12
Q

What is the main theory that is speculated to cause Major Depressive Disorder (MDD)?

A

The Monoamine Hypothesis Theory

This theory talks about ↓ levels of:
(1) Norepinephrine (NE)
(2) Serotonin (5-HT)
(3) Dopamine (DA)

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13
Q

Apart from the Monoamine Hypothesis Theory, there are other contributing factors that can cause depression.

These factors are known as secondary causes.

What are some 3 examples of secondary causes?

A
  1. Medical
    - *Endocrine disorder: hypothyroidism
    - *CV: Coronary artery disease, CHF, MI
  2. Psychiatric disorders
    - Alcoholism
    - Schizophrenia
    - Anxiety disorder
    - Eating disorder
  3. Drug induced
    - Beta blockers
    - Withdrawal from alcohol, or other stimulants
    - Corticosteroids
    - CNS depressants: Benzodiazepine, barbiturates, opioids
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14
Q

The acronym for the clinical presentations of MDD is:

In. SAD. CAGES

What does In. SAD. CAGES stand for?

A

In - Interest

S - Sleep
A - Appetite
D - Depressed

C - Concentration
A - Activity
G - Guilt
E - Energy
S - Suicidal thoughts or attempts***

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15
Q

What is the guideline to diagnose a patient with MDD?

A
  1. Present at least 5 symptoms of IN.SAD.CAGES x 2 weeks
  2. Symptoms cause significant distress or impairment
  3. Symptoms are not caused by an underlying medical condition

In.SAD.CAGES:
In - Interest

S - Sleep
A - Appetite
D - Depressed

C - Concentration
A - Activity
G - Guilt
E - Energy
S - Suicidal thoughts or attempts***

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16
Q

Major Depressive Disorder (MDD), Adjustment disorder, Acute Stress disorder are 3 different disorders.

What are the differences between the 3 disorders?

A

MDD presents ≥ 5 out of 9 In.SAD.CAGES S&S for 2 weeks

Adjustment disorder is a temporary onset of depression sx within 3 months of a stressor. Once stressor is eliminated, sx of depression goes away.

Acute stress disorder is a temporary onset of depression within 1 month of a stressor.

Both Adjustment disorder and Acute stress disorders are very similar.
The difference between adjustment disorder and acute stress disorder is that:
- Adjustment disorder occur within 3 months
- Acute stress disorder occurs within 1 month

17
Q

What should we screen in patients before initiating antidepressants?

A

It is mandatory that we screen if a patient has mania, before we administer antidepressants.

Mania is a red flag that we must rule out.

Ask patient if they have any history of manic / hypomanic episode

18
Q

What are the 3 D’s?

A
  1. Delirium
  2. Dementia
  3. Depression
19
Q

The 3 D’s are often confused with one another.

What is the difference between the 3 D’s

  1. Delirium
  2. Dementia
  3. Depression

Based on (1)Onset, (2)Consciousness, (3)Memory

A

Onset:
> Delirium - acute
> Dementia - gradual
> Depression - cyclical

Consciousness:
> Delirium - impaired
> Dementia - clear until later stages
> Depression - generally unimpaired

Memory:
> Delirium - poor
> Dementia - poor short & long-term
> Depression - intact

20
Q

The Hamilton Rating scale for Depression (HAM-D) is the GOLD standard assessment for measuring severity of depression.

What score on the HAM-D scale would a patient achieve remission from depression?

A

A patient with a score of ≤7 will be able to achieve remission from depression.

21
Q

What is the main class of medication to use in MDD?

A

Antidepressants.

There are 4 types of anti-depressants:
1. *Mirtazapine (1st line)
2. *SSRI
3. SNRI
4. Bupropion

22
Q

There are 2 phases of treatment for MDD:

  1. Acute phase treatment
  2. Continuation phase treatment

What does these 2 phases of treatment mean?

A
  1. Acute phase treatment:
    - Treatment for 4-8 weeks
    - Adequate dose is used
  2. Continuation phase:
    - Treatment for 4-9 months after acute phase treatment
    - Total duration including acute phase treatment is between 6-12 months at least

Antidepressants do not work immediately. Physical symptoms may improve in 1-2 weeks, while mood symptoms take longer to improve (4 - 8 weeks).

23
Q

What are the antidepressant medications that we must know?

A
  1. SSRI - Fluoxetine, fluvoxamine, escitalopram
  2. SNRI - venlafaxine, duloxetine
    (Duloxetine can be used for chronic muscular pain as well)
  3. Mirtazapine

There are other classes of antidepressants - such as TCAs, MAOIs and Bupropion

24
Q

What are the SE of:
1. SSRIs
2. SNRI
3. Mirtazapine
4. TCA
5. MAOI
6. Bupropion

A
  1. SSRI - GI & sexual dysfunction
  2. SNRI - GI & sexual dysfunction
  3. Mirtazapine - sedation & weight gain (Reverses GI & Sexual SE of SSRI & SNRI)
  4. TCA - GI & sexual dysfunction, anticholinergic, fatal on overdose, sedation, weight gain, orthostatic hypotension
  5. MAOI - hypertensive crisis
  6. Bupropion - ↑ risk of seizures

Don’t use TCAs unless it is a last resort option.
All antidepressants are associated w causing hyponatremia.

25
Q

What are some non-pharmacological therapy for depression?

A
  1. Sleep hygiene
  2. Exercise
  3. Avoid use of St John’s Wort if on antidepressants
26
Q

What are some rules that we must follow if we need to swap antidepressants in patient?

  1. Switching SSRI w SNRI
  2. Switching SSRI w SSRI
  3. Switching from SSRI/SNRI to bupropion
  4. Switching from MAOI to SSRIs
A
  1. Switching SSRI w SNRI
    - Can switch directly and immediately
  2. Switching SSRI w SSRI
    - Can switch directly
  3. Switching from SSRI/SNRI to bupropion
    - Requires gradual cross-tapering over several weeks
  4. Switching from MAOI to SSRIs
    - Wash out period is necessary for MAOIs

If ≥2 adequate trials of antidepressants still have no effects, consider using combination therapy

27
Q

What are some DDIs involving antidepressants?

  1. SSRI/SNRI + SSRI/SNRI = ?
  2. SSRI & bleeding medications = ?
  3. Alcohol + CNS depressants = ?
  4. Anticholinergic agents + antidepressants = ?
A
  1. SSRI/SNRI + SSRI/SNRI = Serotonin syndrome
  2. SSRI & bleeding medications = High bleeding risk
    - SSRIs ↑ risk of bleeding
  3. Alcohol + CNS depressants = ↑ CNS depressant effects
  4. Anticholinergic agents + antidepressants = excessive anticholinergic effects
28
Q

What CYP enzymes do these drugs/drink inhibit?

  1. Fluvoxamine
  2. Fluoxetine
  3. Paroxetine
  4. Bupropion
  5. Grapefruit juice
  6. Mirtazapine
A
  1. Fluvoxamine - CYP1A2, CYP2C19
  2. Fluoxetine - CYP2D6
  3. Paroxetine - CYP2D6
  4. Bupropion - CYP2D6
  5. Grapefruit juice - CYP3A4
  6. Mirtazapine - little to no CYP enzyme interactions
29
Q

What is Antidepressant Discontinuation Syndrome (ADS)?

A

ADS is a sudden discontinuation of antidepressants, which leads to development of symptoms.

ADS is NOT withdrawal.

Some Sx of ADS:
1. Flu-like symptoms
2. Insomnia
3. N&V

ADS can be avoided by gradually tapering and reduce the dose.

30
Q

What are some counselling pointers when initiating pt on antidepressants?

A
  1. Antidepressants may take at least a couple of weeks to work
  2. Do not take w alcohol. Space 4-6 hours apart.
  3. If condition is worsening, you feel suicidal, or SE are intolerable, contact your doctor immediately

PR3153 (18 decks)

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