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Watts Antidepressants Flashcards

1
Q

Types of depression

A

-Reactive (60%)
-Major depressive disorder (25%)
-Bipolar affective (15%)

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2
Q

Physiological symptoms of depression

A

-Decreased sleep
-Appetite changes
-Fatigue
-Psychomotor dysfunctions
-Menstrual irregularities
-Palpitations
-Constipation
-Headaches
-Nonspecific body aches

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3
Q

Psychological symptoms of depression

A

-Dysphoric mood
-Worthlessness
-Excessive guilt
-Loss of interest/pleasure in all or most activities

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4
Q

Cognitive symptoms of depression

A

-Decreased concentration
-suicidal ideation

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5
Q

What must be ruled out when diagnosing depression?

A

It is not caused by drugs, medical conditions, or bereavement

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6
Q

What drugs can cause drug-induced depression?

A

-Antihypertensive and Cardiovascular
-Sedative-hypnotics
-Anti-inflammatory and analgesics
-Steroids
-Anti-Parkinson
-Anti-neoplastic
-Neuroleptics

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7
Q

What is the biogenic amine hypothesis of depression?

A

-Reserpine causes depression by deleting NE and 5HT from vesicles
-Agents that increase 5HT and NE are effective for treating depression
-Genetic polymorphisms in SERT promoter
-Alteration in 5HT1A/2C and alpha2 receptors

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8
Q

What is the neuroendocrine hypothesis of depression?

A

-Changes in hypothalamic-pituitary-adrenal axis
-Stress causes hypothalamus to release CRF
-CRF promotes release of ACTH from pituitary
-ACTH promotes release of cortisol from adrenal
-Overactivity of HPA and elevated CRF found in almost all depressed patients
-Overactivity of HPA and elevated CRF found in almost all depressed patients
-Overactivity of HPA may desensitize feedback response in hypothalamus an pituitary
-Elevated CRF causes insomnia, anxiety, and decreased appetite and libido
-Antidepressants and ECT reduce CRF levels

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9
Q

What is the neurotrophic hypothesis of depression?

A

-Brain-derived neurotrophic factor is critical in neural plasticity, resilience, neurogenesis
-Stress and pain decrease BDNF levels in animals
-Decrease in volume of hippocampus
-BDNF has antidepressant activity in animals
-Depressed patients have reduced BDNF levels
-Antidepressants increase BDNF levels and may increase hippocampal volume

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10
Q

Which hypothesis of depression is correct?

A

All hypotheses can explain depression

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11
Q

What are the main classes of antidepressants?

A

-MAOIs
-TCAs
-SSRIs
-SNRIs
-5-HT2 antagonists
-Tetracyclic and unicyclic antidepressants

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12
Q

Why does antidepressant therapy take 2-3 weeks?

A

-Neuroadaptive responses?
-Activation of presynaptic receptors?
-Presynaptic adaptation?
-Postsynaptic adaptation?
-No one really knows

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13
Q

Mechanism of action of MAOIs

A

-Norepinephrine and serotonin are normally degraded by monoamine oxidase
-Blocking this degradation causes the vesicles to increase the amount of NE and 5HT that are packaged
-These vesicles then release more NE and 5HT into the synapse

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14
Q

What are the non-selective MAO inhibitors?

A

-Phenelzine
-Tranylcypromine

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15
Q

What are the MAO-B selective inhibitors?

A

-Selegiline

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16
Q

What are the MAO-A selective inhibitors?

A

-Moclobemide

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17
Q

What class of MAO inhibitors is irreversible?

A

Non-selective MAO inhibitors

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18
Q

What are common side effects associated with MAO inhibitors?

A

-Headache
-Drowsiness
-Dry mouth
-Weight gain
-Orthostatic hypotension
-Sexual dysfunction
-Hypertensive crisis

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19
Q

What are common interactions with MAOIs?

A

-Cold preparations and diet pills
-TCAs, SSRIs, L-DOPA
-Foods with tyramine
-St. Johns Wort

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20
Q

Indications for TCAs

A

-Depression
-Panic disorder
-Chronic pain
-Enuresis (bed wetting)

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21
Q

Overdose/toxic effects of TCAs

A

-Extremely dangerous, depressed patients are more likely to be suicidal
-Patients are more likely to commit self-harm or suicide 2 weeks into treatment

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22
Q

Tertiary amine mechanism of action

A

-Inhibits both NE and 5HT reuptake via NET and SERT
-Also acts as antagonists on H1 histamine receptors, muscarinic receptors, and alpha1 receptors

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23
Q

Major side effects associated with tertiary amines

A

-Sedation
-Autonomic side effects
-Weight gain
-Conduction disturbances of the heart (not major)

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24
Q

What are the tertiary amines used?

A

-Imipramine
-Amitriptyline
-Clomipramine (used for OCD)
-Doxepin

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25
What is imipramine metabolized to?
Desipramine
26
What is amitriptyline metabolized to?
Nortriptyline
27
What are the secondary amines used?
-Desipramine -Nortriptyline -Maprotiline (NET inhibitor)
28
Side effects of secondary amines
Less sedation, anticholinergic effects, autonomic effects, weight gain, and cardiovascular effects compared to tertiary amines
29
What are the SSRIs used?
-Fluoxetine (little autonomic SE, no sedation) -Fluvoxamine -Paroxetine -Sertraline -Citalopram -Escitalopram
30
What are SSRIs used for?
-Depression -Alcoholism -OCD -Enuresis -PTSD -Eating disorders -Social phobias -Panic anxiety -PMDD -GAD
31
Side effects of SSRIs
-Nausea/vomiting -Sexual dysfunction -Anxiety -Insomnia -Tremors
32
Side effects of abruptly discontinue SSRIs
-Brain zaps -Dizziness -Sweating -Nausea -Insomnia -Tremor -Confusion -Vertigo
33
What drugs can cause serotonin syndrome?
-MAOIs -TCAs -Metoclopramide -Tramadol -Triptans -St. Johns Wort
34
Symptoms of serotonin syndrome
-Hyperthermia -Muscle rigidity -Restlessness -Myoclonus -Hyperreflexia -Sweating -Shivering -Seizures -Coma
35
How to treat serotonin syndrome
-Discontinuation of medication and management of symptoms -Administration of serotonin antagonists (cyproheptadine or methysergide) -Benzodiazepines to control myoclonus
36
What are the SSRI+5HT1A partial agonists?
-Vilazodone -Vortioxetine
37
Differences between SSRI+5HT1A partial agonists and pure SSRIs
SSRI+5HT1A partial agonists have less sexual side effects vs pure SSRIs
38
What are the tetracyclic and unicyclic antidepressants used?
-Maprotiline -Mirtazipine -Bupropion
39
Maprotiline mechanism of action
NET inhibitor
40
Mirtazapine mechanism of action
-Alpha2 antagonist -5HT2 and 5HT3 antagonist -H1 antagonist
41
Bupropion mechanism of action
-DAT inhibitor -NET and SERT inhibitor -Also treats GAD -Zyban for smoking cessation
42
What are the 5-HT2 antagonists/SERT inhibitor?
Trazodone (Off-label hypnotic)
43
What are the SNRIs?
-Venlafaxine -Desvenlafaxine -Duloxetine -Milnacipran -Levomilnacipran
44
Venlafaxine clinical pearls
-NET and SERT inhibitor -Treats GAD and panic disorder -Diabetic neuropathy -Migraine prophylaxis
45
Desvenlafaxine clinical pearls
-NET and SERT inhibitor -Approved by FDA February 2008 -Treatment of vasomotor symptoms associated with menopause?
46
Duloxetine clinical pearls
-NET and SERT inhibitor -Treats GAD -Treats peripheral neuropathy
47
Milnacipran clinical pearls
-NET and SERT inhibitor -Approved for fibromyalgia
48
Levomilnacipran clinical pearls
-Active enantiomer of milnacipran -NET and SERT inhibitor -Approved in 2013
49
What are the norepinephrine selective reuptake inhibitors?
-Reboxetine -Atomoxetine
50
Reboxetine clinical pearls
-Possibly less side effects than Prozac -Licensed in over 50 countries by 2007 -The FDA declined the license for use in the USA for unknown reasons
51
Atomoxetine clinical pearls
-Originally intended to be an antidepressant drug (not approved!) -Used for ADHD
52
What are the serotonin-norepinephrine-dopamine reuptake inhibitors?
-Tesofensine -Brasofensine
53
What are triple blockers used for?
-Early research as Parkinson's therapies -Tesofensine is currently being researched as an appetite suppressants
54
What are the NMDA antagonists?
-Ketamine - subanesthetic doses -Scopolamine (muscarinic and NMDA antagonist) -Lanicemine
55
Esketamine side effects
-Depression -Drug interactions
56
How to treat postpartum depression
-SSRIs (fluoxetine and paroxetine) -Venlafaxine -CBT and counseling -Brexanolone
57
Brexanolone mechanism of action
-Allopregnanolone levels increase during pregnancy -GABAa receptors desensitize -Allopregnanolone levels return to normal postpartum -Brexanolone resensitizes GABAa receptors
58
New antidepressants in development
-Psychedelics: MDMA (ecstasy), psilocybin, and LSD (acid) -5HT2C receptor antagonists -Metabotropic glutamate receptor agonists -Reversible inhibitors of monoamine oxidase-A (RIMAS)
59
Non-pharmacologic considerations for treatment of depression
-Electroconvulsive therapy -Psychotherapy -Hospitalization
60
Pharmacotherapeutic considerations
-Severity of depression -Onset of drug action -Endogenous vs exogenous depression -Unipolar vs bipolar -Drug selection -Dosing -Duration of therapy -Compliance -Other factors
61
Pharmacology of Filbanserin
-Hypoactive sexual desire disorder -Developed as antidepressant -Polypharmacology - agonist at 5HT1A, antagonist at 5HT2A/C -Regional selectivity - prefontal cortex -Controversial approval
62
Types of bipolar
-Bipolar 1 disorder -Bipolar 2 disorder -Cyclothymia disorder -Unspecified bipolar and related disorder -Substance-induced mood disorder
63
Bipolar symptoms
-Mania -Hypomania -Depression -Mixed mania and depression
64
Symptoms of mania
-Euphoria/elation -Irritability/anger -Impulsive high risk behavior -Aggressive -Grandiose ideas -Decrease sleep and appetite -Difficulty concentrating -Delusions -Flight of ideas -Hallucinations
65
What is hypomania?
Less severe mania
66
Treatments of bipolar disorder
-Hospitalization -Psychotherapy -Pharmacotherapy
67
What drugs are used to treat bipolar disorder?
-Lithium -Anticonvulsants -Atypical antipsychotics -Calcium-channel blockers (verapamil, nimopidine) -Combo therapy (+BZD)
68
Lithium clinical pearls
-Mechanism not clearly understood -Deletion of PIP2 and associated signaling -Modulate GSK3 -Small therapeutic index -Acute vs chronic -Lag time for effectiveness -Loading dose
69
Anticonvulsants used for depression
-Sodium valproate -Carbamazepine -Lamotrigine -Topiramate
70
Anticonvulsant mechanism of action
-Increase GABAergic tone (increase GAD activity, inhibit GABA transaminase) -Block Na+ channels -Block T-type Ca2+ channels -Inhibits histone deacetylase (HADAC5)
71
Atypical antipsychotics used for depression
-Olanzapine -Olanzapine + fluoxetine -Quetiapine -Risperidone -Ziprasidone -Lurasidone -Aripiprazole

Therapeutics III (42 decks)

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