Psychiatric Cases-wrap up Flashcards
Case A: 41-yo F with depression
Important things to note
- MUST differentiate b/w chronic (chronic depressive episode) vs situational depression(i.e. Acute loss of a family member)
- 80% of ppl who receive tx for depression will improve
- Medication tx can take 4-6 weeks to become effective,
- BUT improvement is often seen within the first week
- Antidepressants are NON-habit forming
- Tx for 4-9 months after full remission and then graded discontinuation is possible
- Cont medication indefinitely for recurrent depression
SSRIs: list Ex’s
Selective serotonin reuptake inhibitors
–Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft)
SSRIs: MOA
selectively inhibits serotonin reuptake (i.e. increasing serotonergic activity).
SNRIs: list Exs
Serotonin-norepinephrine reuptake inhibitors
SNRIs- Desvenlafaxine (pristiq), Duloxetine (Cymbalta), Venlafaxine (Effexor)
SNRIs: MOA
Inhibits NE, Serotonin, and dopamine reuptake.
Tricyclics: list ex
-TCAs are particularly useful for _________ depression
Amitriptyline (Elavil)
**melancholic
Tetracyclic: list ex
Bupropion (wellbutrin)–CAN be first line
Wellbutrin MOA
Bupropion MOA: inhibits neuronal uptake of NE and dopamine. Exact mech of smoking cessation is unknown.
MAOIs- list Exs
Monoamine oxidase inhibitor
–Isocarbozid (Marplan), Penelzine (Nardil)
list other examples of antidepressants.
Mirtazapine (Remeron), Trazodone (Desyrel) –> GOOD for concurrent insomnia/anxiety
What drugs are good for tx resistant depression?
Aripiprazole (Abilify) and Quetiapine (Seroquel) –
list Indicators for an antidepressant
Depression Anxiety Pain Premenstrual dysphoric disorder Smoking cessation Eating disorders
How to chose an antidepressant?
Indication Cost Availability Drug interactions Patient age and gender
First line: SSRI or SNRI
-list reasons why?
inexpensive, ease of use, tolerability and safety
Although SSRIs are of one pharmacologic class, they are not of one chemical class. Therefore, failure to respond to one SSRI does not reliably predict failure to respond to others.
TCA and MAOI are now second or third line- because?
potential lethal overdose, need titration, serious drug interactions, adverse effects
Adverse Effects SSRI:
-serotonic activity=
nausea, GI upset, Diarrhea, diminished sexual function (decreased interest, delayed orgasm, diminished arousal), headaches, weight gain
Adverse Effects SSRI:
-discontinuation syndrome=
sudden discontinuation –> dizziness and paresthesia
SNRI and tricyclic adverse reactions
Serotonergic adverse effects
& Noradrenergic effects
CNS activation,
List ex’s of noradrenergic effects
increased BP, increased heart rate
Describe CNS activation
insomnia, anxiety, agitation
TCA- list ex’s of anticholinergic effects
dry mouth, constipation, urinary retention, blurred vision, confusion
Discontinuation syndrome for SNRI and TCAs: (list S/E)
cholinergic rebound and flulike symptoms
MAOIs: list adverse effects
**Orthostatic hypotension and weight gain, highest rates of sexual effects
What are some of the CAUTION points you need to be aware of when prescribing an antidepressant:
- Suicide attempts are common
- OD is most common method (especially with TCAs)
- A 1500 mg dose of amitriptyline (less than 7 days) is enough to be lethal
- Drug interaction
(have conversation with pt: in a small % of pts that start an antidepressant get suicidal, call the PCP asap and d/c med)
Managing SE’s:
GI distress: ?
Sedation?
GI Distress: Take after meals
Sedation: Take at HS, most SSRIs are less sedating (Prozac)
Managing SE’s:
Agitation and insomnia?
Sexual dysfunction?
Agitation and Insomnia: Switch to a more sedating options (Remeron, Celexa, Effexor)
Sexual Dysfunction: Less w/ Wellbutrin, Remeron, consider a PDE-5
Managing SE’s:
- anxiety?
- Ortho hypotension?
Anxiety/Panic: Options include Paxil, Remeron, Effexor, TCAs (try to avoid BDZs)
Orthostatic HYPOTN: hydration, education on mvt
Discontinuation of antidepressants:
- withdrawal is typically ___
- Reduce med over ___ weeks
- mild – but tapering off is recommended
- -Reduce over 4 weeks – slower if symptomatic
OTC’s: St. John’s Wort and SAMe
-benefit?
Both have demonstrated some benefit for treating depression
St. John’s Wort and SAMe:
BOTH should not be used in Pts also taking _____
a serotonergic agent (SSRI or SNRI)
St. John’s Wort is a potent inducer of ______
CYP 450 –> LOTS of interactions