Mood disorders and antidepressants - Schneck Flashcards
With all this talk about medications, one shouldn’t forget what aspect of treatment?
Psychotherapy.
In what order did the following drug categories arrive:
Heterocyclics, SSRI, SNRI, tricyclic antidepressants, MAOIs
Tricyclic–>MAOI–>Heterocyclic–>SSRI–>SNRI
**Differences exist in the sfx profile, but the efficacy and drug target really has not changed.
How long should a patient “trial” an antidepressant before giving up on it?
8-14 weeks. (3-6 weeks was “old school”, but almost half take a much longer time to see effect).
ALL current treatments have a 4-16 week delay before achieving antidepressant effect
Electroconvulsive Therapy (ECT) is the only approved treatment for depression that produces more rapid response
All current pharmacological antidepressants share what feature? (broad)
ALL target neurotransmitter systems (NE, 5-HT, DA) and boost synaptic action.
All are monoamine-based
All have modest efficacy
All have relatively slow onset
All have tolerability issues, especially in the long-term
What are the prototypical TCAs (2).
Amitryptiline*
Nortriptyline
What are the prototypical MAOIs (2)?
Phenelzine*
Selegeline (available as transdermal).
**Rarely used due to sfx, safety
What are the prototypical SNRIs (3)?
Venalfaxine*
Desvenlafaxine
Duloxetine
What are the prototypical SSRIs (6)?
Fluoxetine (Prozac)* Paroxetine* Sertraline Citalopram Escitalopram* Fluvoxamine
Pros and cons of TCAs?
What type of drug is it (what does it treat)?
Mnemonic: “Dirty Drugs” –> receptor cross-reactivity
Pros: Effective in severe depression, time-tested
Cons: 10 day dose is lethal, Hypotension, anticholinergic sfx, weight gain, sexual sfx
Antidepressant.
Pros and cons of MAOIs?
What type of drug is it (what does it treat)?
Mnemonic: “Last-ditch effort”
Pros: Efficacy in atypical depression
Cons: Hypotension, orthostasis, anticholinergic sfx, sexual sfx, weight gain
Antidepressant.
Dangerous drug/drug interaction with an MAOI?
MAOI + meperidine* = tyramine reaction, hypertensive crisis, death
*aka Demerol. Patient Libby Zion was taking phenelzine, died. Also known as the “tyramine reaction”
Also SSRI,
What are all the indications of SSRIs?
Depression, anxiety (GAD), bulemia, PTSD, OCD, panic, premenstrual dysphoric disorder (PMDD)
What are the pros and cons of SSRIs?
What type of drug is it (what does it treat)?
Mnemonic: “Give out like candy”
Pros: safe, effective, tx for many problems
Cons: Diarrhea, nausea, jitteriness, SEXUAL side effects (difficulty to orgasm, low libido), p450 inhibition (boards will love that shit)
Antidepressant.
What are the pros and cons of SNRIs?
What type of drug is it (what does it treat)?
Pros: maaybe a bit more effective? safe, well tolerated
Cons: INcreased diastolic BP, sweating, SEXUAL sfx, WITHDRAWAL syndrome “Electric shock sensation”
Antidepressant.
What are the pros and cons of buproprion?
What type of drug is it (what does it treat)?
Mnemonic: “Look sexy, feel sexy, quit smoking. Live well, with Wellbutrin.”
Pros: Weight neutral, no sexual sfx
Cons: Increased anxiety, insomnia, SEIZURE risk (active bulemia/anorexia - contraindicated)
Antidepressant.
What are the pros and cons of mirtazapine?
What type of drug is it (what does it treat)?
Pros: helps insomnia, no sexual side effects, rapid relief of anxiety
Cons: WEIGHT GAIN, somnolence
Antidepressant.
What is TMS? What’s up with it?
Transcranial Magnetic Stimulation. Reasonably effective, actually. However, it is a 1.5 hr procedure 5x per week. For 4-6 weeks. The biggest issue is cost: 6-12k out of pocket.
What is the difficulty in treating bipolar depression?
3 illnesses: mania, depression, prevention
Lithium is the only drug that really does this. That’s why patients end up on 3+ drugs (if not on lithium).
[“Mania is pretty easy to treat. BUT THE DEPRESSION IS REALLY HARD TO TREAT” Antidepressents don’t seem to work on Bipolar patients. “It is a different disease”]
What are the pros and cons of lithium?
What is it used to treat (what drug category)?
Pros: Best studied, best proven drug. ANTISUICIDAL. CHEAP. Neuroregenerative. Effective anti-manic, reasonable preventative agent, some antidepressant effect
Cons: Narrow therapeutic window, toxic in OD, diabetes insipidus, plus tremor, nausea, diarrhea, cognitive dulling
Best treatment for Bipolar disorders. 1st gen antipsychotic (typical)
What are the pros and cons of Divalproex Sodium (Depacote)?
Mnemonic: “You won’t die, but you might end up looking like chubby Justin Timberlake”
Pros: Safe, can load at high dose safely
Cons: not proven effective in bipolar depression. Not proven to prevent recurrence. Weight gain and curly hair.
1st gen antipsychotic (typical). This drug is basically an adjunct to lithium when treating bipolar. not proven to work as a stand-alone agent.
What are the pros/cons of 2nd gen (atypical) antipsychotics as a whole?
Pros: All are anti-manic, safe
Cons: risk of DIABETES, weight gain, hypercholesterolemia
What drugs may work to prevent future episodes?
Lithium (+/- divalproex sodium), aripiprazole, Olanzapine
What are the best treatments for bipolar depression?
very difficult to treat; quetiapine, lurasidone, lithium and possibly lamotrigine are best treatments thus far. Antidepressant use in bipolar disorder is controversial and not well proven.
