Medications

Question 1

What impact on depressive symptoms can you expect after one week?

Answer 1

Week 1: improvements in terminal insomnia, appetite disturbances, and anxiety

Question 2

What improvements in depressive symptoms can you expect after 2 weeks of medication therapy?

Answer 2

Week2: improvements in fatigue, poor motivation, somatic complaints, agitation/retardation

Question 3

Upon initiating medication therapy what improvements in depressive symptoms can you expect after week 3?

Answer 3

Week3: improvements in dysphoric mood, subjective depressive feelings, and suicidal thoughts

Question 4

What is the first line antidepressant?

Answer 4

Fluoxetine (Prozac) : only antidepressant approved for 8 +
12 years 10-40 mg/daily
For MDD OCD or bulimia

Question 5

Sertraline (Zoloft)

Answer 5

FDA approved for OCD 6+ minimal data for efficacy in depression

Question 6

What is the usual dosing for sertraline (Zoloft)?

Answer 6

12 years 25-200 mg/day

For MDD, OCD, or PTSD, GAD

Question 7

Paroxetine ( Paxil )

Answer 7

One study showed increased suicide attempts. Do not use in children or older adults

Question 8

Citralopram (celexa)

Answer 8

Lower risk of drug reactions but not prove clearly effective
May use this or lexapro in older adults

Question 9

Fluvoxamine (Effexor)

Answer 9

fDA approved for 8+ with OCD Not studied in depression

Potent inhibitor of p450 1A2 and 3A4

Question 10

Venlafaxine (Luvox)

Answer 10

Few trial used in those who fail fluoxetine or sertraline

Question 11

Usual dosing for citalopram (celexa)?

Answer 11

12 yr 20-60 mg/ day

First line only if fluoxetine drug interactions must be avoided

Question 12

What is the usual dose for bupropion?

Answer 12

12yr 100-400 mg a day ER

Co morbid ADHD, substance abuse or smoking cessation

Question 13

When do patients initially starting medication need to be evaluated?

Answer 13

2-2 1/2 weeks to monitor for suicidal thoughts

Question 14

What are the side effects of SSRIs?

Answer 14

Nausea
Nervousness
Insomnia
Sexual dysfunction
HA
Weight gain

Question 15

What are the side effects of TCAs?

Answer 15

Dry mouth
Blurred vision     Dizziness
Constipation
Weight gain
Postural hypotension
Cardiac effects

Question 16

What are the FDA monitoring guidelines for acute therapy follow up the first 8 to 12 weeks?

Answer 16

Face-to-face contact weekly for four weeks contact every other week for the next four weeks another contact after 12 weeks then as clinically indicated beyond 12 weeks risk of suicide is greatest in the first two weeks with no increased risk after 12 weeks

Question 17

What is defined as acute therapy?

Answer 17

The first 8 to 12 weeks

Question 18

What is considered continuation therapy?

Answer 18

6 to 12 months following abatement of acute symptoms the goal is to prevent relapse therapies should continue for 6 to 12 months after symptom-free you made then taper down

Question 19

When would you consider maintenance therapy?

Answer 19

Maintenance therapy occurs over a long period of time to prevent relapse consider if three or more episodes of major depression or two episodes of major depression and one or more of the following positive family history of bipolar or depressive disorder, history of recurrence within 1 year of previous successful treatment, those episodes were severe life-threatening in the past three years, onset before age 20

Question 20

When would you consider referral?

Answer 20

Consider referral if the patient prefers it if there is concurrence psychoses incomplete response to therapy actively suicidal psychiatric hospitalization complex psychiatric diagnoses pregnancy occurs or is being planned

Question 21

How do you switch an SSRI to an SSRI?

Answer 21

Generally done by direct substitution but some experts recommend a cross taper. Give new dose based on whether the dose of the discontinued SSRI is low medium or high. Switching an be done without a washout period for most SSRIs. WHEN SWITCHING FROM PROZAC TO ANOTHER SSRI SOME EXPERTS RECOMMEND A 4 to 7 DAY WASHOUT AND BEGIN REPLACEMENT SSRI LOW DUE TO FLUOXETINES LONG HALF LIFE.

Question 22

Switching SSRI to/from Venalfaxine (Effexor)?

Answer 22

Usually a direct switch from SSRI to Venalfaxine does not cause discontinuation effects or adverse effects. SSRI THAT INHIBIT THE CYTOCHROME P-450 or 2D6 SUCH AS PAXIL AND PROZAC MIGHT DECREASE METABOLISM OF VENALFAXINE INCREASING RISK OF ADVERSE EFFECTS

Question 23

How do you taper paroxetine and Venalfaxine ?

Answer 23

Very slowly since they seem to have higher risk of discontinuation syndrome reduce the dose by one quarter every 4 to 6 weeks

Question 24

When would switch a patient from an SSRI to Wellbutrin?

Answer 24

They switch may help with sexual dysfunction and when an adequate response to SSRI. Patients with comorbid anxiety unresponsive to Bupropion trend may benefit from change to SSRI. To avoid discontinuation symptoms these two must be cross tapered

Question 25

How do you switch from an SSRI to nefazodone (serzone)?

Answer 25

Concurrent administration of SSRIs and the facet down have been associated with serotonin syndrome a direct switch may not prevent discontinuation symptoms since the drugs are mechanistically different. The best approach maybe to taper the first drug and allow a brief washout period Before beginning the new drug

Question 26

How do you switch and SSRI to mitazapine (remeron)?

Answer 26

Remeron and SSRIs work by different mechanisms drug interactions among these drugs are unlikely. Cross tapering will prevent discontinuation symptoms

Question 27

How do you switch from an SSRI to a TCA

Answer 27

The potential for drug interactions between SSRIs and TCAs is high so I direct switch is unwise. Crusty bring with lower doses the TCA when drug interactions are likely should reduce the risk of discontinuation of effects and adverse effects

Question 28

How do you switch Effexor to/from bupropion, nefazodone or mitazapine?

Answer 28

Because these drugs are mechanistically difference and drug interactions are not likely to be a concern, cross tapering is recommended.

Question 29

Bupropion to/from nefazodone or mirtazapine?

Answer 29

These drugs all at a different mechanisms. Drug interactions are unlikely cross tapering is a reasonable approach one making the switch

Question 30

How do you switch them in a MAOI to/from another antidepressant?

Answer 30

Although newer, safer in his presence have regulated MAOIs to the end of the treatment decision tree, they may be effective for atypical unipolar depression in anergic bipolar depression and other agents have failed. Switching that involves MAOIs require particular care. For patients taking in an MAOI and switching to another antidepressant including an MAOI allow at least a 14 day wash out. When switching from another in the present to him in a lie some clinicians follow 5/2 lives of this could discontinue drug including its active metabolites to pass before starting the new drug. HOWEVER WITH EXCEPTION OF PROZAC, SSRI PRODUCT LABELING AND THE AMERICAN PSYCHIATRIC ASSOCIATION DEPRESSION GUIDELINES RECOMMEND AT LEAST A TWO WEEK WASHOUT when switching from an antidepressant without a long half-life to an MAOI

Question 31

What meds for PTSD?

Answer 31

Sertraline, paroxetine, fluoxetine and possibly short term benzodiazepines lorazepam or diazepam all of these drugs are off label for PTSD they are used placed on known side effects

Question 32

What are the first line therapy is for OCD

Answer 32

First-line treatment is CBT clinical treatments include SSRIs for initial first treatment by Patsel is the most common flexor prefer panic GAD an SP Buspar ineffective.

Question 33

What are the treatment remission criteria for PTSD

Answer 33

No or minimal PTSD symptoms objective goal treatment outcome PTSD scale tops eight score less than or equal to five or six subjective goal no or minimal Anxiety HAM-a

Question 34

What is the first line drug class for major depression?

Answer 34

SSRIs are the mainstay due to side effect profile. They are cleaner than TCAs and do not have active metabolites and work faster. Expect results in 3-4 days