Major Depressive Disorder - Antidepressant AEs, TRD, Serotonin Syndrome, D/C Syndrome Flashcards
What GI AEs result from antidepressants?
N/D, stomach upset, constipation
When are N and stomach upset usually experienced by the majority of pts on antidep tx?
Up to the 2nd week of tx
Which antidepressants are most assoc w/ nausea?
Venlafaxine > SSRI > buproprion > moclobemide > mirtazapine
How to manage N/upset stomach?
- divide doses
- reduce SSRI dose if pt is stable
- take some food w/ the medication
Antideps most assoc w/ constipation?
paroxetine, TCAs
How to manage antidep-induced constipation?
Activity, fibre
-Should resolve on its own (3 months)
How to manage antidep-induced diarrhea?
Should resolve on its own (3 months)
Antidiarrheal okay
What AE is possible within the first 2 months of antidepressant tx in pts under 24 yrs old?
Suicidal thoughts or behaviour
Which antidepressant showed best efficacy in preventing/reducing suicidality in adults?
sertaline
In <18 pts, which antidepressants showed the best efficacy for reducing suicidality?
fluoxetine and citalopram
Which antidep categories are most assoc w/ sexual dysfn?
SSRIs, SNRIs, and TCAs
Which antidepressants are assoc w/ the least amt of sexual dysfn?
- bupropion
- mirtazapine
- moclobemide
Best strategies for dealing w/ sexual dysfn due to antidepressants?
- add-on bupropion or mirtazapine
- PDE-5 inhibitor (sildenafil/tadalafil)
- switch to bupropion or mirtazapine (lowest rates of sexual dysfn)
When should follow-up take place to assess adherence, tolerability, response, and suicidality?
q1-2 weeks in the first 8 weeks
What should we do if the pt doesn’t improve following 8 weeks of adequate tx?
We can either
- switch, or
- augment w/ alternate mechanism antidep
- psychotx
When there has been a partial response to antidep tx, what should we do if there has been <50% improvement in sx’s after 8 weeks of tx?
Switch antidep
When there has been a partial response to antidep tx, what should we do if there has been ≥ 50% reduction in sx’s after 4 weeks of tx?
Increase dose and continue for 12 weeks > re-evaluate at 6, 8, and 12 wks
Define treatment resistant depression
Lack of improvement (< 20% reduction in depression scores) after adequate trials of ≥ 2 antidepressants) (CANMAT)
Approaches to dealing with treatment-resistant depression
- switch (again)
- augmentation tx
- combining antideps
When is switching antideps preferred?
When there’s little to no improvement in sx’s despite 4-8 wks of adequate tx/intolerable AEs
When is augmenting preferred?
If there has been partial response to tx within 4-8 wks
T or F: When switching, it’s best to switch to an antidep belonging to a diff class.
F
Comparable outcomes regardless of whether you switch within a class or b/w classes (though clinicians prefer to try diff classes)
How to switch to SSRI from another SSRI?
Direct switch or cross taper
How to switch b/w venlafaxine and duloxetine (both SNRIs)?
Direct switch or cross taper
How to switch from SSRI to MAOI?
Stop SSRI 2 weeks before starting MAOI (5 weeks for fluoxetine)
How to switch b/w drugs of different MOAs?
Cross taper
List the pharmacological augmentation agents that could be used in treatment-resistant depression
- bupropion
- lithium
- triiodothyronine (T3)
- 2nd gen antipsychotics (aripiprazole, brexpiprazole, quetiapine, olanzapine/fluoxetine)
Target lithium levels for treatment-resistant depression?
0.5-1.0 mEq/L
Recommended trial of Li augmentation tx for treatment-resistant depression?
3-4 weeks
T or F: Li is safe in overdose
F (it can cause death)
Why might triiodothyronine be preferred in treatment-resistant depression?
It’s better tolerated
T or F: Using T3 for treatment-resistant depression can result in significant side effects due to hyperthyroidism side effects.
F
The dose is so low in treatment-resistant depression tx, so it rarely results in hyperthyroidism-like side effects
T or F: Doses of atypical antipsychotics used in treatment-resistant depression are HIGHER than those used in schizophrenia or bipolar disorder.
F
Lower doses are used in treatment-resistant depression
What’s the advantage of combining antideps in treatment-resistant depression?
Not losing any benefit derived from the first antidepressant
When are SSRI/SNRI + bupropion combinations usually used?
Reducing the sexual dysfn induced by SSRIs/SNRIs
What combination of antideps is used in ppl who suffer from insomnia?
SSRI/SNRI + mirtazapine
When is serotonin syndrome likely?
When using multiple serotonergic agents
T or F: Serotonin syndrome is life threatening.
T
Describe serotonin syndrome.
Triad of…
- mental status changes
- autonomic hyperactivity
- neuromuscular abnormalities
Serotonin syndrome tx?
- supportive
- d/c serotonergic agents
- cyproheptadine (serotonin antagonist)
Who is discontinuation syndrome more likely to occur in?
Those who’ve been on antidep tx for >6-8 weeks
Which antidepressant will NOT cause d/c syndrome?
Bupropion
Why doesn’t bupropion not cause d/c syndrome?
It has no serotonergic activity
Sx’s of d/c syndrome?
FINISH
flu-like sx’s, insomnia, nausea, imbalance, sensory disturbances (pins and needles, electric shock sensations), hyperarousal (anxiety, agitation)
When do sx’s of d/c syndrome usually resolve?
within 1-2 weeks
How to avoid d/c syndrome?
TAPER dose down slowly
What can we do if slowly tapering doesn’t help with avoiding d/c syndrome?
Substitute current med for fluoxetine (it has a long half-life, hence less d/c sx’s)
When would you consider extending antidepressant tx for MDD pts (>2 yrs)?
- freq, recurrent episodes
- severe episodes (psychosis, severe impairment, suicidality)
- chronic episodes
- presence of comorbid psychiatric or other med conditions
- presence of residual sx’s
- difficult-to-tx episodes
