treatment of depression Flashcards
Depression prevalence
- 8%
50. 6% also have chronic physical illness
Secondary causes for depression
Endocrine disorders Cardiovascular Deficiency states Infections Metabolic disorders Neurological Malignancy Withdrawal from alcohol, stimulants
Clinical presentation
At least 5 symptoms present for the same 2w period
- Interest: Decreased interest *
- Sleep: insomnia/hypersomnia
- Appetite: decreased appetite, weight loss
- Depressed mood*
- Concentration: impaired concentration
- Activity: psychomotor retardation/agitation
- Guilt
- Energy: decreased energy
- Suicidal thoughts/attempts
General Assessment
History of present illness Psychiatric hx Substances use hx Complete medical hx and medication hx Family, social, forensic, developmental, occupational hx Physical and neurological exam Mental State Exam (MSE) Labs and other investigations
Non-pharmacological therapy
Sleep hygiene
Psychotherapy
Neurostimulation (ECT)
First line
SSRI
SNRI
Mirtazapine
Bupropion
Phases of treatment
Acute phase – adequate trial (adequate dose+duration) 4-8w
Continuation phase, total at least 6-12m
Longer-term maintenance therapy if higher risk, ≥ 2 episodes, geriatric MDD
TCAs
Amitriptyline -> nortriptyline
Imipramine -> desipramine
Dothiepin
Clomipramine
TCAs MOA
Blocks reuptake of NE and 5HT
Anticholinergic
H1 and a-drenergic antagonism
TCAs SE
GI and sexual dysfunction Anticholinergic side effects Decrease in orthostatic BP Arrhythmias Seizures Fatal on overdose
SSRIs
Fluoxetine -> norfluoxetine
Fluvoxamine
Escitalopram/citalopram
Sertraline
SSRIs SE
GI and sexual dysfunction HA Transient nervousness during initiation Insomnia (fluoxetine) Hyponatremia/SIADH Bleeding risk EPSE
SSRIs characteristics
Long half life for fluoxetine, norfluoxetine
Paroxetine most anticholinergic, short half life
Escitalopram cause QTc prolongation if high dose in elderly
SNRIs
Venlafaxine
Duloxetine
SNRIs SE
GI and sexual dysfunction Transient nervousness during initiation Hyponatremia/SIADH Bleeding risk EPSE Increased BP Urinary hesitation (Duloxetine)
Duloxetine
Indicated for diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain
Mirtazapine MOA and Indication
a2-adrenoceptor antagonism
Increases 5HT and NE
5HT2 and 5HT3, H1 antagonism
Depression; can reverse GI and sexual SE of SSRI/SNRI
Mirtazapine SE
Somnolence
Increased appetite
Weight gain
Bupropion MOA and indications
Blocks reuptake of NE and DA
Depression
Decrease sexual SE of SSRI/SNRI
Smoking cessation aid
Bupropion SE
Seizure
Insomnia
Psychosis
Benzodiazepines MOA and indications
Potentiates GABA
Adjunctive therapy for depression; no more than 2w
Benzodiazepines SE
Sedation Drowsiness Muscle weakness Ataxia Amnesia
Z-hypnotics
Zolpidem
Zopiclone
Z-hypnotics MOA
Preferentially binds to benzodiazepine-binding sites with gamma and a1 subunits to cause sedation
Z-hypnotics SE
Taste disturbances (zopiclone) Complex sleep behaviours Half dose for Zolpidem in females
Antihistamines and MOA
Promethazine
Hydroxyzine
H1 antagonism
Antihistamine SE
Sedation
Anticholinergic symptoms
TCAs doses
Amitriptyline 30-300mg/day
Clomipramine 25-250mg/day, max 300mg/day
SSRI doses
Fluoxetine 20-60mg/day, max 80mg/day
SNRI doses
Desvenlafaxine 50mg/day, max 100mg/day
Mirtazapine doses
15-45mg/day max 45mg/day
Considerations in depression treatment
Pregnancy: Nortriptyline in late pregnancy
BF: sertraline/mirtazapine
Postpartum depression: brexanolone
Bipolar: lithium, SGA
Renal impairment: vortioxetine
Hepatic impairment: avoid agomelatine, consider vortioxetine
Fewer CYP Interactions
Mirtazapine Escitalopram Vortioxetine Sertraline Venlafaxine Desvenlafaxine
Antidepressant Discontinuation Syndrome
Flu like symptoms Insomnia Nausea Imbalance Sensory - electric shock senstations, parasthesia Hyperarousal
