Mood disorders and antidepressants - Schneck

Question 1

With all this talk about medications, one shouldn’t forget what aspect of treatment?

Answer 1

Psychotherapy.

Question 2

In what order did the following drug categories arrive:

Heterocyclics, SSRI, SNRI, tricyclic antidepressants, MAOIs

Answer 2

Tricyclic–>MAOI–>Heterocyclic–>SSRI–>SNRI

**Differences exist in the sfx profile, but the efficacy and drug target really has not changed.

Question 3

How long should a patient “trial” an antidepressant before giving up on it?

Answer 3

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

Question 4

All current pharmacological antidepressants share what feature? (broad)

Answer 4

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

Question 5

What are the prototypical TCAs (2).

Answer 5

Amitryptiline*

Nortriptyline

Question 6

What are the prototypical MAOIs (2)?

Answer 6

Phenelzine*
Selegeline (available as transdermal).

**Rarely used due to sfx, safety

Question 7

What are the prototypical SNRIs (3)?

Answer 7

Venalfaxine*
Desvenlafaxine

Duloxetine

Question 8

What are the prototypical SSRIs (6)?

Answer 8

Fluoxetine (Prozac)*
Paroxetine*
Sertraline
Citalopram
Escitalopram*
Fluvoxamine

Question 9

Pros and cons of TCAs?

What type of drug is it (what does it treat)?

Answer 9

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.

Question 10

Pros and cons of MAOIs?

What type of drug is it (what does it treat)?

Answer 10

Mnemonic: “Last-ditch effort”

Pros: Efficacy in atypical depression

Cons: Hypotension, orthostasis, anticholinergic sfx, sexual sfx, weight gain

Antidepressant.

Question 11

Dangerous drug/drug interaction with an MAOI?

Answer 11

MAOI + meperidine* = tyramine reaction, hypertensive crisis, death

*aka Demerol. Patient Libby Zion was taking phenelzine, died. Also known as the “tyramine reaction”

Also SSRI,

Question 12

What are all the indications of SSRIs?

Answer 12

Depression, anxiety (GAD), bulemia, PTSD, OCD, panic, premenstrual dysphoric disorder (PMDD)

Question 13

What are the pros and cons of SSRIs?

What type of drug is it (what does it treat)?

Answer 13

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.

Question 14

What are the pros and cons of SNRIs?

What type of drug is it (what does it treat)?

Answer 14

Pros: maaybe a bit more effective? safe, well tolerated

Cons: INcreased diastolic BP, sweating, SEXUAL sfx, WITHDRAWAL syndrome “Electric shock sensation”

Antidepressant.

Question 15

What are the pros and cons of buproprion?

What type of drug is it (what does it treat)?

Answer 15

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.

Question 16

What are the pros and cons of mirtazapine?

What type of drug is it (what does it treat)?

Answer 16

Pros: helps insomnia, no sexual side effects, rapid relief of anxiety

Cons: WEIGHT GAIN, somnolence

Antidepressant.

Question 17

What is TMS? What’s up with it?

Answer 17

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.

Question 18

What is the difficulty in treating bipolar depression?

Answer 18

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”]

Question 19

What are the pros and cons of lithium?

What is it used to treat (what drug category)?

Answer 19

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)

Question 20

What are the pros and cons of Divalproex Sodium (Depacote)?

Answer 20

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.

Question 21

What are the pros/cons of 2nd gen (atypical) antipsychotics as a whole?

Answer 21

Pros: All are anti-manic, safe

Cons: risk of DIABETES, weight gain, hypercholesterolemia

Question 22

What drugs may work to prevent future episodes?

Answer 22

Lithium (+/- divalproex sodium), aripiprazole, Olanzapine

Question 23

What are the best treatments for bipolar depression?

Answer 23

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.