Psychiatric Conditions: Depression Flashcards
DSM-5 Criteria
at least 2 of the following symptoms present during the same two week period
Mood = Depressed
Sleep = inc/dec
Interest/pleasure = diminished
Guilt or feelings of worthlessness
Energy = decreased
Concentration = decreased
Appetite = inc/dec
Psychomotor agitation or retardation
Suicidal ideation
M SIG E CAPS
Bipolar disorder should be ruled out before starting antidepressant therapy to….
avoid inducing mania or causing rapid-cycling
Natural products that maybe helpful for depression
St John’s Wort
SAMe
valerian
5-HTP
How long is suitable trial for depression
4-8 weeks, if drug doesn’t work then reassess
SSRI use in pregnant women warning
risk of persistent pulmonary hypertension of newborn
Symptoms of serotonin syndrome
severe nausea
dizziness
headache
diarrhea
agitation
tachycardia
hallucinations
muscle rigidity
How to discontinue antidepressant
taper over a few weeks to avoid withdrawal
boxed warnings for all antidepressants
possible increase in suicidal thoughts or actions in some children, teenagers, young adults in first few months of txm or when dose changed
SSRIs
Citalopram = Celexa
Escitalopram = Lexapro
Fluoxetine = Prozac
Paroxetine = Paxil
Sertraline = Zoloft
Citalopram (Celexa) dosing
20-40mg
Max: 40mg/day, 20mg in > 60yrs old
Escitalopram (Lexapro) dosing
Max 20mg/day, 10mg/day elderly
Fluoxetine (Prozac) dosing
Max 80mg/day
SSRI Contraindications
dont use with MAOi, Linezolid, IV methylene blue
SSRI warnings
QT prolongation: dont give more than 20mg citalopram elderly, 10mg escitalopram elderly
SIADH, hyponatremia, fall risk
Bleeding
SSRI side effects
Sexual side effects
Somnolence, insomnia, nausea, dry mouth, weakness, tremors, dizziness, headache
Most activating SSRI
Fluoxetine, take in AM
Most sedating SSRI
paroxetine, fluvoxamine, take in PM
SSRI preferred for patients with cardiac risk?
Sertraline
Washout period for SSRI and MAOi
2 weeks for most, 5 wks for Fluoxetine
Vilazodone (Viibryd) MOA
SSRI and 5-HT1A partial agonist
Vortioxetine (Trintellix) MOA
SSRI, 5-HT3 receptor antagonist, 5-HT1A agonist
Vilazodone (Viibryd) & Vortioxetine (Trintellix) CI, warnings, SE
CI: dont use within 14 days of MAOi
Warnings: seizures, avoid pts with seizure hx
Side effects: N/V/D, less sexual side effects
SNRI
Venlafaxine = Effexor
Duloxetine = Cymbalta
Desvenlafaxine = Pristiq
SNRI contraindications
Dont use SNRI/MAOi combo
SNRI warnings
fall risk, SIADH/hyponatremia, bleeding
SNRI side effects
similar to SSRI
inc HR, dilated pupils, dry mouth, excessive sweating and constipation due to inc NE
Which SNRI has greatest risk of inc BP?
venlafaxine when dosed > 150mg/day
Secondary vs Tertiary Amine TCA
Secondary = selective
Tertiary = can be more effective but worse side effects
Tertiary Amines TCAs
Amitriptyline
Doxepin
Clomipramine
Imipramine
Trimipramine
Secondary Amines TCAs
Nortriptyline = Pamelor
Amoxapine
Desipramine
Maprotiline
Protriptyline
TCA contraindications
Dont use with MAOi, linezolid, IV methylene blue
TCA side effects
Cardiotoxicity: QT prolongation with OD, orthostasis, tachycardia
Anticholinergic: Dry mouth, blurred vision, urinary retention, constipation, vivid dreams, weight gain, risk of calls
Dopamine and NE reuptake inhibitor
Bupropion = Wellbutrin
Bupropion max dose
450mg/day due to seizure risk
Bupropion Contraindications
seizure disorder
hx of anorexia/bulimia
dont use with MAOi, linezolid, methylene blue
Bupropion warnings
Neuropsychiatric adverse events when used for smoking cessation possible
Bupropion side effects
Dry mouth
CNS stimulation
weight loss
sexual dysfunction is rare
MAOi medications
Isocarboxazid = Marplan
Phenelzine = Nardil
Tranylcypromine = Parnate
Selegiline = Emsam = MAO-B selective
MAOi contraindications
hx of CVD, cerebrovascular defect, HA, hepatic disease
severe renal disease
MAOi warnings
hypertensive crisis or serotonin syndrome can occur with TCA, SSRI, SNRIs, tyramine rich foods
MAOi side effects
anticholinergic effects
Orthostasis
Sedation
sexual dysfunction
weight gain
Selegiline (Emsam) CI and side effects
CI: use with serotonergic drugs
Side effects: constipation, gas, dry mouth, loss of appetite, sexual dysfunction
Tyramine containing foods
aged cheese
pickled herring
yeast extract
air-dried meats
sauerkraut
soy sauce
fava beans
some red wines and beers
aged, fermented or smoked foods
Mirtazapine (Remeron) info
used often in one to help with sleep, inc appetite/ weight gain
Trazodone info
used mostly off label for sleep
SE: sexual dysfunction and priapism
Nefazodone info
rarely used due to hepatotoxicity, boxed warning
Aripiprazole (Abilify) side effects
anxiety
insomnia
akathisia
constipation
agitation
Olanzapine (Zyprexa) side effects
sedation, weight gain, inc lipids/glucose, EPS, QT prolongation - lower risk
Quetiapine (Seroquel) side effects
sedation, orthostasis, weight gain, inc lipids/glucose, EPS - lower risk
Brexpiprazole (Rexulti) side effects
weight gain, dyspepsia, diarrhea
Esketamine (Spravato) info
C3, comes as nasal spray
Given under supervision of HCP
REMS program
