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PR3136 > treatment of depression > Flashcards

treatment of depression Flashcards

1
Q

Depression prevalence

A
  1. 8%

50. 6% also have chronic physical illness

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2
Q

Secondary causes for depression

A 
Endocrine disorders
Cardiovascular 
Deficiency states 
Infections 
Metabolic disorders 
Neurological 
Malignancy 
Withdrawal from alcohol, stimulants
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3
Q

Clinical presentation

A

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
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4
Q

General Assessment

A 
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
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5
Q

Non-pharmacological therapy

A

Sleep hygiene
Psychotherapy
Neurostimulation (ECT)

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6
Q

First line

A

SSRI
SNRI
Mirtazapine
Bupropion

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7
Q

Phases of treatment

A

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

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8
Q

TCAs

A

Amitriptyline -> nortriptyline
Imipramine -> desipramine
Dothiepin
Clomipramine

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9
Q

TCAs MOA

A

Blocks reuptake of NE and 5HT
Anticholinergic
H1 and a-drenergic antagonism

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10
Q

TCAs SE

A 
GI and sexual dysfunction 
Anticholinergic side effects
Decrease in orthostatic BP 
Arrhythmias 
Seizures 
Fatal on overdose
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11
Q

SSRIs

A

Fluoxetine -> norfluoxetine
Fluvoxamine
Escitalopram/citalopram
Sertraline

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12
Q

SSRIs SE

A 
GI and sexual dysfunction 
HA
Transient nervousness during initiation 
Insomnia (fluoxetine) 
Hyponatremia/SIADH 
Bleeding risk 
EPSE
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13
Q

SSRIs characteristics

A

Long half life for fluoxetine, norfluoxetine
Paroxetine most anticholinergic, short half life
Escitalopram cause QTc prolongation if high dose in elderly

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14
Q

SNRIs

A

Venlafaxine

Duloxetine

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15
Q

SNRIs SE

A 
GI and sexual dysfunction 
Transient nervousness during initiation 
Hyponatremia/SIADH 
Bleeding risk 
EPSE 
Increased BP 
Urinary hesitation (Duloxetine)
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16
Q

Duloxetine

A

Indicated for diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain

17
Q

Mirtazapine MOA and Indication

A

a2-adrenoceptor antagonism
Increases 5HT and NE
5HT2 and 5HT3, H1 antagonism
Depression; can reverse GI and sexual SE of SSRI/SNRI

18
Q

Mirtazapine SE

A

Somnolence
Increased appetite
Weight gain

19
Q

Bupropion MOA and indications

A

Blocks reuptake of NE and DA
Depression
Decrease sexual SE of SSRI/SNRI
Smoking cessation aid

20
Q

Bupropion SE

A

Seizure
Insomnia
Psychosis

21
Q

Benzodiazepines MOA and indications

A

Potentiates GABA

Adjunctive therapy for depression; no more than 2w

22
Q

Benzodiazepines SE

A 
Sedation
Drowsiness
Muscle weakness
Ataxia
Amnesia
23
Q

Z-hypnotics

A

Zolpidem

Zopiclone

24
Q

Z-hypnotics MOA

A

Preferentially binds to benzodiazepine-binding sites with gamma and a1 subunits to cause sedation

25
Q

Z-hypnotics SE

A 
Taste disturbances (zopiclone)
Complex sleep behaviours 
Half dose for Zolpidem in females
26
Q

Antihistamines and MOA

A

Promethazine
Hydroxyzine
H1 antagonism

27
Q

Antihistamine SE

A

Sedation

Anticholinergic symptoms

28
Q

TCAs doses

A

Amitriptyline 30-300mg/day

Clomipramine 25-250mg/day, max 300mg/day

29
Q

SSRI doses

A

Fluoxetine 20-60mg/day, max 80mg/day

30
Q

SNRI doses

A

Desvenlafaxine 50mg/day, max 100mg/day

31
Q

Mirtazapine doses

A

15-45mg/day max 45mg/day

32
Q

Considerations in depression treatment

A

Pregnancy: Nortriptyline in late pregnancy
BF: sertraline/mirtazapine
Postpartum depression: brexanolone
Bipolar: lithium, SGA
Renal impairment: vortioxetine
Hepatic impairment: avoid agomelatine, consider vortioxetine

33
Q

Fewer CYP Interactions

A 
Mirtazapine 
Escitalopram
Vortioxetine
Sertraline
Venlafaxine 
Desvenlafaxine
34
Q

Antidepressant Discontinuation Syndrome

A 
Flu like symptoms 
Insomnia
Nausea
Imbalance 
Sensory - electric shock senstations, parasthesia
Hyperarousal

PR3136 (5 decks)

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