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Pharmacology midterm 2 > pharmacotherapy of mood disorders > Flashcards

pharmacotherapy of mood disorders Flashcards

1
Q

affective disorders/mood disorders

A
  • Depression (unipolar depression, major depression)
  • Bipolar disorder
  • Anxiety disorder
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2
Q

Mood variations

A 
mania 
hypomania
euthymia
dysthymia
depression
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3
Q

Depression

A
  1. Major depression (MDD)
    - genetic?
    - MDD prevents a person from functioning normally, it
    interferes with a person’s ability to work, sleep, study,
    eat, enjoy once-pleasurable activities.
  2. Dysthymia
    - Characterized by long-term (2 years or
    longer) symptoms that may not be severe enough to disable a
    person but can prevent normal functioning or feeling well.
  3. Minor depression
    - symptoms for 2 weeks or longer
    that do not meet full criteria for MDD. Without treatment,
    people are at high risk for developing MDD.
  4. Psychotic depression
  5. postpartum depression
  6. seasonal affective disorder (SAD)
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4
Q

symptoms of depression

A
  • Low mood
  • Significant changes in the body weight
    (loosing or gaining weight)
  • Marked decrease in interest
  • Marked lack of feeling joy
  • Insomnia or sleepiness
  • Psychomotor agitation or retardation
  • Fatigue
  • Feeling of worthlessness or exaggerated
    consciousness of guilt
  • Decrease of ability to concentrate
  • Returning thoughts in relation to death and suicide
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5
Q

Symptoms of hypomania

A 
• Elevated mood
• Increased energy, motivation
• Optimism
• Decreased sleep
• Hypersexuality
• Increased creativity (not always, a
significant difference compared with mania)
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6
Q

Anxiety disorders

A
  1. Panic disorder - dyspnoe, palpitation, tremor,
    sweating, nausea - gastrointestinal discomfort,
    depersonalizations, feeling of hot/cold,
    substernal pain, fear of death, general fear
  2. OCD
  3. PTSD
  4. GAD
  5. premenstural dysmorphic disorder (PMDD)
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7
Q

Depression and anxiety together

A

• 30-60% of patients suffering from general anxiety
show depressive symptoms
• 60% of patients with depression may experience
anxiety symptoms
– In major depression the frequency of panic attacks is
about 15-30%

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8
Q

Depression, anxiety, suicide

A

• 1 million people commit „successful” suicide a year
• The risk of suicide is 20-fold higher in depression than in the average
population
• 8% of patients suffering from major depression try suicide during their lives
• Major depression can be diagnosed in 60 % of people who tried suicide
• Accompanied anxiety increases the suicide risk (panic disorder: 25% ; PTSD: 38%)

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9
Q

Monoamine hypothesis

A
  • monoamine depletors (reserpine) induce depression.
  • Genetic studies – functional polymorphism exists for SERT (5-HT transporter) gen.
  • Reduction of 5-HIIA (5-HT metabolite) in CSF is associated with violent and impulsive behavior (not specific for depression)
  • Nearly all the antidepressants enhance the availability of NE and/or 5-HT and/or DA in the synaptic cleft
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10
Q

timeframe for antidepressant effect

A

4-6 weeks

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11
Q

aim of antidepressant/antimanic drugs

A

 Relief of acute symptoms weeks
 Prevention of relapse (maintenance therapy) months
 Prevention of repeated episodes (prophylactic treatment) years

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12
Q

Drugs in the treatment of depression

A
  1. monoamine reuptake inhibitors
    - SSRI
    - SNRI
    - SSNRI
    - TCA
    - DA/NE reuptake inhibitors
  2. 5-HT re-uptake inhibitor + receptor inhibitor
  3. 5-HT re-uptake inhibitor + receptor inhibitor
  4. Melatonin MT1-2 agonist
  5. MAO inhibitors
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13
Q

SSRIs

A 
-  usually first choice - 
fluoxetine
fluvoxamine 
sertraline 
citalopram
escitalopram
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14
Q

SNRIs

A

reboxetine

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15
Q

SSNRIs

A

venlafaxine
duloxetine

  • venlafaxine is very popular, selectivity to serotonin transporter is lost over 200mg – drug switch is simply a dose escalation.
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16
Q

TCA - tricyclic antidepressants

A

imipramine
desipramine
clomipramine
amitryptiline

17
Q

DA/NE reuptake inhibitors

A

bupropion - MDD, not for panic disorders.

18
Q

5-HT re-uptake inhibitor + receptor inhibitor

A
  • 5-HT reuptake inhibitor and 5-HT2A antagonist E.g; trazodon, nefazodon, - (hepatotoxic)
  • 5-HT reuptake inhibitor and 5-HT1A partial agonist E.g.; vilazodon

• 5-HT reuptake inhibitor and 5-HT3A, 5-HT7 antagonist, 5-HT1B partial agonist and 5-HT1A agonist
E.g.; Vortioxetin

19
Q

NE re-uptake inhibitor + receptor inhibitor

A

NA reuptake inhibitor, 2 és 5-HT2,(3) antagonist (mirtazapin, mianserin)

20
Q

Melatonin MT1-2 agonist

A

agomelatin

21
Q

MAO inhibitors

A
  • MAO-A selective (moclobemid)

* MAO-B selective (selegiline)

22
Q

Cognitive triangle

A

thoughts –> behavior –> feelings

23
Q

treatment scheme of MDD

A 
SSRI, SSNRI, RIMA (moclobemid) --> if partial or no effect after 4-6 weeks --> Dose elevation or;
1. Adjuvant treatment:
SSRI+clonazepam
SSRI+reboxetine
SSRI+nefazodone
2. Medicine switch 
TCA
Reboxetine
Mirtazapine
3. augumentation:
Antidepressant+lithium
Antidepressant+quetiapine
Antidepressant+thyroxin
Antidepressan+light
24
Q

Treatment considerations of major depression

A

• Drug choice depends on the adverse effects, patients’
preference and economical considerations
• In 38% of the patients there is no response in the first
6-12 weeks of the treatment
• In more than 50% of the patients remission cannot be
achieved
• The risk of suicide is the highest in the first two
months (it is a black box warning!!!)
• Length of the treatment
– Usually for 4-9 months
– In patients with more than 2 episodes the treatment should be carried out for several years

25
Q

Risk of suicide

A

• The risk of suicide is the highest in the first two
months (it is a black box warning!!!)
• Reason: the motivations and activity improve
faster than the depressive symptoms disappear –
higher motivation with suicidal thoughts – the
patient may have the energy to commit it
• In young adults (18-25 years) the risk is the highest
• Very close observation!!!

26
Q

Treatment strategy of bipolar disorder

A

• VERY IMPORTANT!!! – MOOD STABILIZERS
– Lithium („gold standard”)
– Carbamazepine
– Valproate
– Lamotrigine
• Antipsychotics with antimanic and mood stabilizing
effets - e.g.; olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole
• In depressive episode: SSRI or TCA – risk of onset of
mania (4%, 10-60%, respectively) – always combined
with mood stabilizers
• Children and adolescents: aripiprazole, ziprasidone

27
Q

Anxiety disorders

A 
• Localized in space and time:
– Panic disorder
– Panic disorder with agoraphobia
– Agoraphobia
– Special phobias
– Social phobia
• Longer than 6 months – conditions connected with
events or activities in most of the days
– General anxiety disorder (GAD)
– Acute stress syndrome
– Obsessive-compulsive disorder
– Posttraumatic stress disorder
28
Q

Symptoms of panic disorder

A 
Monthly occuring panic attacks with sudden feel of fear and at least 4 autonomic/cognitive symptoms associated
-  Palpitation
– Sweating
– Shivering
– Dyspnea
– Choking sensation
– Chest pain
– Nausea, abdominal problems
– Dizziness, uncertainty
– Derealization,
depersonalization
– Loss of control, fear of madness
– Death fear
– Paraesthesias
– Burning sensation or heat waive (flushing)
29
Q

Drugs of choice in anxiety disorders

A
  1. Benzodiazepines (BZD)
    – Immediate action, high efficiency (high potential
    BZDs are chosen: clonazepam, alprazolam, lorazepam)
    – No sexual disturbance (selective anxiolytic doses are
    not sedative)
    – Risk of dependence, withdrawal symptoms – slow
    cessation, maximum length of use is few months
    – Impaired cognitive functions
  2. Antidepressants – especially in more severe cases
    – Primary choice: SSRIs
    – SSRIs may transiently increase anxiety – lower dose in the beginning, gradual increase
    – Can be combined with BZDs in the beginning of the treatment
    – Alternatives: TCAs, RIMA
  3. Buspirone (5HT1A partial agonist)
    – General anxiety disorder
    • In BZD naive patients
    • If cognitive impairment by the BZDs are severe
    • In agressive and irritated patients
    • The onset is slow, 2-4 weeks – can be combined with BZDs
    • If BZDs are inefficient buspirone will not act either
    - ineffective in panic disorder

Pharmacology midterm 2 (5 decks)

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