Psych Case Wrap-Up (Jaynstein) (Midterm) Flashcards
When evaluating a Pt for depression what do you need to differentiate?
Differentiate between chronic depression and situational depression
When starting antidepressants how long does it typically take to see improvment?
Improvement may be experienced within the first week, but usually takes 4-6 weeks before the full effect is seen. Before trying a new med make sure to give a full 4-6 week trial.
How long after full remission of depression should the Pt continue to take their antidepressants?
4-9 months after full remission, then graded discontinuation. If recurrent depression may need to take meds indefinitely.
What percentage of Pts who receive treatment for depression will experience improvement?
80%
Are antidepressants habit forming?
No
What class of antidepressants are the most commonly prescribed?
SSRI
SSRI means what?
Selective Serotonin Reuptake Inhibitor
Name some common SSRIs
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
What is a SNRI?
Serotonin-norepinephrine Reuptake Inhibitor. Antidepressants that modulate two neurotransmitters.
Name some common SNRIs
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor)
Which classes of antidepressants are considered first line?
SSRIs and SNRIs
Amitriptyline (Elavil) and other TCAs are particularly good at treating which kind of depression?
Melancholic depression
What is one use, outside of depression, for Buproprion (Wellbutrin)?
Smoking cessation
Mirtazapine (Remeron) and Trazodone (Desyrel) are useful in Pts with?
Concurrent insomina/anxiety
When should Aripiprazole (Abilify) and Quetiapine (Seroquel) be considered?
In cases of resistant depression (failed trial of SSRI and/or SNRI)
If a Pt does not respond to one SSRI should you move to a different class of antidepressants?
No, failing one SSRI does not mean other SSRIs won’t work. Try a few different SSRIs before switching classes.
Common indications for antidepressant therapy?
- Depression
- Anxiety
- Chronic pain
- Premenstrual dysphoric disorder (PMDD)
- Smoking cessation
- Eating disorders
Is it okay to initiate antidepressant therapy on a Pts first presentation to the office for depression?
Yes!! It is likely if they are presenting with a concern for depression that they have been dealing with it for a while and have tried non-pharmacologic treatments like stress reduction.
What should you consider when choosing an antidepressant?
- Indication
- Cost (SSRIs tend to be very cheap)
- Availability
- Drug interactions
- Patient age and gender
Why are SSRIs and SNRIs first line?
- Inexpensive
- Easy to use
- Lower S/E compared to TCAs and MAOIs
- Safe
Which antidepressants are second and third line? Why?
TCAs and MAOIs
- Potential lethal overdose
- Need titration
- Serious drug interactions
- Many S/E
Common adverse effects of SSRIs
- Nausea
- GI upset
- Diarrhea
- Diminished sexual function
- Decreased interest
- Delayed orgasm
- Diminished arousal
- Headaches
- Weight gain
- Discontinuation syndrome:
- Sudden discontinuation can lead to dizziness and paresthesias
- Can make Pt feel shitty but is not lethal
- Recommended to do slow taper when discontinuing SSRI
SNRI and TCA adverse reactions
- Same as SSRIs
- Noradrenergic effects
- Increased BP
- Tachycardia
- CNS activation
- Insomnia
- Anxiety
- Agitation
- Anticholinergic (TCAs)
- Dry mouth
- Constipation
- Urinary retention
- Blurred vision
- Confusion
- Discontinuation syndrome
- Cholinergic rebound
- Flu-like symptoms
MAOI adverse effects
- Orthostatic hypotension
- Weight gain
- Highest rates of sexual dysfunction
Sadly suicide attempts are common in depressed Pts. When during the course of their treatment are they most common?
During initiation of antidepressants and during discontinuation of antidepressants
Which antidepressant class is the most common to OD on during a suicide attempt?
TCAs
A 1500 mg dose of amitriptyline (less than a week’s worth) is enough to be fatal.
Options to manage the following S/E of antidepressants
- GI distress:
- Sedation:
- Agitation and insomnia:
- Sexual dysfunction:
- Anxiety/Panic:
- Orthostatic hypotension:
- GI distress: Take after meals
- Sedation: Take at HS (most SSRIs such as Prozac are less sedating)
- Agitation and insomnia: Switch to a more sedating option (Remeron, Celexa, Effexor)
- Sexual dysfunction: Switch to medication with a low sexual S/E profile such as Wellbutrin or Remeron. Consider prescribing a PDE-5 in addition to the antidepressant
- Anxiety/Panic: Paxil, Remeron, Effexor, and TCAs are helpful in reducing anxiety. Try to avoid benzos!
- Orthostatic hypotension: Good hydration, education on getting up safely from rest
When tapering off antidepressants how long should you do it for?
Taper off over the course of 4 weeks, if Pt experiences withdrawal symptoms slow down the taper.
Which OTCs have been demonstrated to have some benefit in the treatment of depression?
St. John’s Wort and SAMe
St. John’s Wort and SAMe should not be used in which Pts?
Pts currently taking serotonergic agents. If planning to start an SSRI or SNRI ensure the patient is not taking St. John’s Wort or SAMe.
St. John’s Wort is a potent inducer of what?
CYP 450. Can lead to lots of interactions
When treating depression the best outcomes are found with?
Medication therapy + Psychotherapy
If a Pt shows some improvement on an SSRI but isn’t to the level they would like to be after 4-6 weeks what should you do?
Titrate up on the dose of the SSRI (up to max dose) before switching to a different med.
At what age does schizophrenia tend to appear?
- Can occur at any age
- Typically late teens to early 20’s for men
- Typically late 20’s to early 30’s for women
- Uncommon to be diagnosed in a person younger than 12 or older than 40
With aggressive treatment and medication compliance what percentage of schizophrenics can live fully independent lives?
About 50%
Antipsychotic agents reduce psychotic symptoms in which disorders?
- Schizophrenia
- Bipolar
- Psychotic depression
- Senile psychosis
- Drug-induced psychosis