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IC15: Depression Treatment Flashcards

1
Q

State at least 2 first line antidepressants for treating MDD

A
  1. Mirtazepine
  2. SSRI (fluoxetine, fluvoxamine, escitalopram)
  3. SNRI
  4. Bupropion
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2
Q

List 3 nonpharmacologic therapies for depression

A
  1. Improve sleep hygiene
  2. Psychotherapy (in combination with antidepressants)
  3. Neurostimulation- for very severe depression eg. catatonic states (ECT, rTMS)
    *Electroconvulsive treatment, repetitive Transcranial Magnetic Stimulation
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3
Q

True or False?

Antidepressants are indicated for mild, moderate, severe depression

A

False. Only moderate-severe depression

Also not given in adjustment disorder. Rule out mania as well

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4
Q

List the 2 phases of MDD treatment

A
  1. Acute phase treatment
  2. Continuation phase
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5
Q

Describe what is meant by Acute Phase Treatment in MDD

A

Treatment with adequate trial of antidepressants = adequate dose + 4-8weeks duration

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6
Q

Describe the meaning of Continuation Phase treatment in MDD

A

Continue MDD treatment for 4-9 months after acute-phase treatment (total 6-12mths)

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7
Q

State the time course following antidepressant treatment for improvements in physical and mood symptoms

A

Physical sx (sleep, appetite): 1-2 weeks
Mood sx: 4-8 weeks

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8
Q

Explain why antidepressants have a delayed onset of effectiveness

A
  1. Prolonged exposure to antidep activates presynaptic autoreceptors.
  2. This causes downregulation of autoreceptors (normally, will send negative feedback to stop 5HT secretion)
  3. This leads to steady, unopposed release of serotonin by the parent cell body.
  4. There is sufficient 5HT to interact with postsynaptic receptors
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9
Q

List 5 SSRIs used to treat depression and anxiety disorders

A

Fluoxetine, fluvoxamine, escitalopram, paroxetine, sertraline (FFEPS)

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10
Q

List the other medical indications of Duloxetine

A
  1. Diabetic neuropathy
  2. stress urinary incontinence ;
  3. fibromyalgia;
    4. chronic MSK pain
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11
Q

State a antidepressant belonging to the class of Noradrenergic and specific serotonergic reuptake inhibitors

A

Mirtazapine

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12
Q

State a medication belonging to the class of Serotonin Modulators & stimulators (SMS)

A

Vortioxetine

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13
Q

State at least 3 examples of TCAs

A
  1. Amitriptyline,
  2. Clomipramine,
  3. Dothiepin,
  4. Imipramine,
  5. Nortriptyline (ADC IN)
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14
Q

Which TCA can be used for the treatment of OCD?

A

Clomipramine

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15
Q

List 2 TCAs that can be used to treat neuropathic pain

A

Amitriptyline & nortriptyline

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16
Q

blank

A

blank

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17
Q

State a medication belonging to Reversible Inhibitor of monoamine oxidase A (RIMA)

A

Moclobemide

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18
Q

What is another psychiatric indication of moclobemide apart from depression?

A

Social anxiety disorder

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19
Q

State a medication belonging to the class of Norepinephrine dopamine reuptake inhibitor (NDRI)

A

Bupropion

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20
Q

Apart from depression, what is another indication of Bupropion

A

Smoking cessation

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21
Q

State a medication belonging to Serotonin antagonist and reuptake inhibitor (SARI)

A

Trazadone

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22
Q

Apart from depression, state another indication of trazadone

A

Insomnia (off label)

Strong H1 antihistamine effect

23
Q

Which drug class(es) prevent reuptake of NorA and 5HT?

A
  1. TCA (inhibit SERT & NERT in presynaptic nuerons)
  2. SNRI
  3. MAO-A inhibitors (phenelzine & trancypromine)

5HT mainly broken down by MAO-A (MAOA& B both breaks down NA & DA)

24
Q

Which drug class(es) prevent reuptake of 5HT only

A

SSRI (eg. fluoxetine), SMS (Vortioxetine)

25
Which drug class(es) prevent the reuptake of NorA and Dopamine?
Bupropion (NDRI)
26
Which drug class(es) do not inhibit the reuptake of 5HT
1. Bupropion(inhibits NorA & DA) 2. Mirtazapine (Direct A2, 5HT2&3 antagonism) 3. Agomelatine (MT1&2 agonist ; 5HT2C antagonism) 4. MAOi (inhibits MAO A/B, and not reuptake inhibition) eg. Moclobemide, Selegiline
27
State the off-target side effect(s) caused by TCAs, and their respective pharmacological mechanisms
1. Anticholinergic effects (dry mouth, constipation). MOA: muscarinic antagonism 2. Sedation. MOA: H1 antagonism 3. Orthostatic hypotension: a1 antagonism 4. Seizures. MOA: TCAs are proconvulsants that lower seizure threshold 5. Conduction abnormalities, leading to sudden cardiaac death
28
Which SSRI has the longest half life? State the half life & the implication on dosing
Fluoxetine, t1/2 = 4-6days Long t1/2 allows for abrupt discontinuation (dont need gradual taper)
29
# True or False? The absorption of sertaline is increased when taken with food.
True
30
State the class(es) of antidepressants associated with GI side effects and sexual dysfunction
1. TCAs 2. SSRI 3. SNRI 4. SMS (Vortioxetine, same MOA & SE as SSRI)
31
State 2 alternative anti-depressants that can be given to avoid sexual &/or GI side effects
1. Mirtazepine (GI & Sexual) 2. Bupropion (only sexual)
32
State the pharmacological mechanism for GI and Sexual side effects ## Footnote receptor involvement
GI: Postsynaptic 5HT3 agonism Sexual: Postsynaptic 5HT2 agonism
33
The use of Bupropion should be avoided in which population(s)?
1. Seizures 2. Insomnia 3. Psychosis 4. Eating disorer (bupropion will worsen these conditions) | Broken down to stimulating amphetamines (worsen psychosis) & lower seizu
34
State the limitations of using paroxetine for treating depression
1. Most anticholinergic SE 2. Sedating 3. Most weight gain 4. Short t1/2, leading to withdrawal
35
Describe the place in therapy of trazadone in MDD
Used more for insomnia rather than depression
36
State a rare SE of trazadone
Priaprism
37
State the side effects of the following SNRIs: - Venlafaxine - Duloxetine
Venla: Increase BP Dulox: urinary hesitation
38
State the adjunctive treatment options of depression
Adjunctive treatment 1) SGA: Aripiprazole, brexpiprazole, quetiapine XR 2) Esketamine 3) PRN hypnotics: i) Benzodiazepines (Lorazepam), ii) Z-hypnotics (zopiclone, zolpidem), iii)Antihistamines(hydroxyzine,promethazine)
39
List 3 management strategies if there is partial or no response to treatment
1. Switch anti-depressant 2. Augmentation (add 2nd antidepressant or adjunctive SGAs: Aripriprazole, quetiapine XR, brexpipirazole) 3. Treatment resistant depression: use symbyax (olanzapine + fluoxetine) or Spravato (esketamine) nasal spray adjunct to SSRI/SNRI
40
Define Treatment-Resistant Depression
No response to >/= 2 adequate trials of antidepressants
41
State the pharmacological treatments for treatment-resistant depression
1) Symbyax cap(olanzapine 6mg + fluoxetine 25mg) 2) Spravato (esketamine 28mg/vial) nasal spray adjunct to SSRI/SNRI
42
When should antidepressants be switched?
When ineffective or intolerable to adequate dose after 2-4 weeks
43
How should anti-depressants be switched?
**1) Cross-titration:** – watch for serotonin syndrome if combining serotonergic agents. **2) Direct switch:** – one SSRI can be stopped totally and the next serotonergic agent initiated. **3) If switching from a Serotonergic antidepressant **used daily for the past 2 months** to a Non- serotoninergic agen**t (e.g. switching from SSRI/SNRI → to Bupropion), gradual cross-tapering over several weeks can reduce risk of Antidepressant Discontinuation Syndrome **4) MAOIs:** wash out period is required
44
True or False? Hyponatremia induced by antidepressants in the elderly is associated only with SSRI class
FALSE. Hyponatremia is a/w in ALL antidepressant classes
45
Which class of antidepressant(s) should be avoided in elderly?
TCAs
46
State at least 2 alternative antidepressants that may have lower risk of causing hyponatremia in elderly
Mirtazapine or Bupropion, agomelatine
47
Management for hyponatremia in antidepressant induced hyponatremia
Monitor Serum Sodium at baseline, 2nd week, 4th week, then Q3mthly
48
Explain the concern and management of using anti-depresssants in patients 24 years and younger.
Increase risk of suicidability
49
State at least 3 pharmacodynamic DDIs with the use of antidepressants
1. Serotonin syndrome: use > 1 serotonergic agent (SNRI + SSRI + TCA + Triptans etc...) 2. Increase bleeding risk - esp in elderly on NSAIDs, warfarin, steroids 3. Additive CNS depression effects: eg. with alcohol 4. Increase Anticholinergic effects (eg. TCA + other anticholinergics)
50
State the symptoms of Antidepressant Withdrawal Syndrome
Rmb: FINISH **F**lu-like symptoms (lethargy, fatigue, headache, achiness, sweating), **I**nsomnia (with vivid dreams or nightmares), **N**ausea (sometimes vomiting), **I**mbalance (dizziness, vertigo, light-headedness), **S**ensory disturbances (“burning,” “tingling,” “electric-like” sensations) **H**yperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness). ## Footnote Worse after abruptly stoppping a regular treatment esp with paroxetine & venlafaxine
51
State the onset, duration & prognosis of antidepressant discontinuation syndrome
- Onset: 36-72hrs - Duration: 3 – 7 days; - typically resolves over 1-2 weeks without treatment. - Patient may feel some discomfort but this is unlikely life-threatening
52
Describe how the dose of antidepressants should be tapered to prevent antidepressant discontinuation syndrome
gradually tapering (by half tablet of lowest strength every 1-2 weeks) if patient had been on regular dosing for ≥6-8 weeks.
53
List 2 antidepressants that do not require gradual tapering for discontinuation
Fluoxetine & bupropion (long t1/2)

depression (5 decks)

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