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87 Cards in this Set
- Front
- Back
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Sx's of Depression
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Depressed Mood
Decreased Interest and Pleasure Insomnia or Hypersomnia Psychomotor Retardation Feeling of Guilt Impaired Concentration Decreased Energy or Fatigue Suicidal Thoughts or Attempts Altered Appetite: Wt Loss/Gain |
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Which Sx's are the most common?
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Depressed Mood
Decreased Interest |
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What is Subsyndromal Depression?
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1. Doesn't have to have a depressed mood and/or decreased interest
2. At least two of the other Sx's for at least 2 weeks |
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Dx of a Major Depressive Disorder
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Depressed Mood
+ 4 more Sx's + At least 2 weeks |
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Dx for Dysthymic Disorder
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Depressed Mood
+ 2 more Sx's + NO Functional Impairment |
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Dx for Bipolar Disorder
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Major Depressive Episode
+ Mania/Hypomania |
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Dx for Cyclothymic Disorder
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Subsyndromal Depressive Episode
+ Hypomania |
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Mania Sx's
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Elevated Mood
Invol. Pleasurable Activities Decreased need for sleep Increased Activity Grandiosity Distractable Increased Talking Racing Thoughts |
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What is the difference between Mania and Hypomania?
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Hypomania does not lead to functional impairment and does not have psychotic Sx's
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Point Prevalence
vs Life-time Prevalence |
PP: 5%
LP: 10% |
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Depression and Gender
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Women 2-3 times more likely in females
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Depression and Genetics
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There is an increased risk w/ affected first-degree relatives and in twins
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Pathophysiology of Depression
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Triggered by stressful life events
Monoamine Hypothesis |
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How did the Monoamine Hypothesis come about?
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Reserpine for HTN and schizophrenia --> depression and a decrease in Monoamines
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Who are the 3 main monoamines?
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Serotonin
Norepinephrine Dopamine |
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What is the primary mechanism for NT clearance in synapses?
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Presynaptic Transporters
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After being transported back inside, what happens to the NT?
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Degraded by MAO
or Repackaged by VMAT |
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What is the fxn of the Presynaptic Receptors?
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NEGATIVE FEEDBACK
When they bind NT's, they decrease the Ca level in the presynaptic terminal -->decreased NT release |
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Based on the Monoamine Hypothesis, what are some options for Antidepressants?
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1. Transporter Inhibition
2. MAO Inhibition 3. Presynaptic Receptor Inhibition |
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Limitation of Monoamine Hypothesis
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It takes 3-4 weeks for the antidepressant effect to occur. You would think if it was just a lack of monoamines then the effect would be felt as soon as the monoamines were increased.
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Groups of Antidepressants
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Tricyclic Antidepressants
Heterocyclics Selective Serotonin Reuptake Inhibitors (SSRIs) Monoamine Oxidase Inhibitors (MAOIs) |
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Typical suffixes of TCA's?
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-pramine
-ptyline |
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What's bad about TCA's?
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They hit muscarinic, H1 Histaminergic, and Alpha1 adrenergic receptors --> MUCHO SIDE EFFECTS
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Which other types of drugs are better than TCA's?
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Heterocyclics have less side effects.
SSRIs are even better b/c they're more specific |
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What transporters do TCA's block?
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NET
SERT |
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Pharmacokinetics of TCA's
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1. Start at low dose and gradually increase (to monitor SE's)
2. 30-70% first pass metabolism-->low bioavailability 3. Binds to plasma proteins-->large volume of distribution |
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TCA's antimuscarinic SE's
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ANTI-MUSCARINIC
dry mouth constipation Pee retention blurred vision dizziness tachycardia |
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TCA Antiadrenergic SE's
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CARDIOVASCULAR
Orthostatic Hypotension Cardiac Conduction Defects Arrythmias |
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TCA Antihistamine SE's
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SEDATION!
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Other TCA SE's
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Aggravation of Psychosis
Insomnia Seizures Wt Gain |
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What happens when you take someone off of TCA's?
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Cholinergic Rebound:
dizzy Nausea Insomnia Restlessness |
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What is another thing to be wary of with TCA's?
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OVERDOSE
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What is one way to avoid Overdoses of TCA's?
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Limit Prescriptions to <1g
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Sx's of TCA OD?
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Agitation
Seizures Hypoventilation Hypotension Fatal Arrythmias |
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Rx for TCA OD?
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Gastric Levage
Endotracheal Intubation IV Fluids NO Dialysis b/c of large volume of distribution |
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TCA Drug Interactions
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1. Anticholinergics and Sedatives (additive effects)
2. Direct-Acting Sympathomimetics (increased vasopressor effect -->HTN) |
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General Mechanism of Heterocyclics
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Block monoamine transporters
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Which heterocyclic doesn't block monoamine transporters?
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Mirtazapine
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So what is mirtazapine's mechanism?
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block presynaptic, 2-adrenergic receptors
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What is special about Amoxapine's mechanism?
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It is also a D2-antagonist
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B/c of its D2 antagonism, what can Amoxapine be used for?
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Depression in psychotic patients
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What is special about Bupropion?
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DAT Inhibitor
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Heterocyclic Pharmacokinetics
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Nefazodone, Trazadone, and Venlafaxine have short half lives (~4hrs), so we divide the doses at initiation
Bupropion and Venlafaxine have extended release forms, so once a day |
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Adverse Effects of Amoxapine
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Parkinsonism
Tardive Dyskinesia (due to D2 antagonism) |
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Adverse Effects of Bupropion
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Aggravation of Psychosis
Seizures at high doses |
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Adverse Effects of Maprotiline
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Seizures
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Adverse Effects of Mirtazapine
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Sedation!
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Adverse Effects of Nefazodone and Trazadone
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Sedation
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Adverse Effects of Venlafaxine
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Sexual Dysfunction
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Which Heterocyclics are prone to overdoses?
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Amoxapine: neurotoxic and seizures
Maprotiline: cardiotoxic and seizures |
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Drug Interactions of Heterocyclics?
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Nefazodone increases circulating levels of alprazolam and triazolam
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Mechanism of SSRI's?
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The block SERT.
They don't touch muscarinic, histamine, or adrenergic receptors |
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Pharmacokinetics of SSRI's
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They all get N-demethylated-->a longer half life (days)
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Half Life of Fluoxetine?
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1-3 days, but after N-demethylation to Norfluoxetine = 10 days
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Plasma Half Life of Citalopram
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1-3 days
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Half Lives of Sertaline and paroxitine?
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1 day
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Typical administration of SSRI's
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Once a day
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Adverse Effects of SSRI's
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N&V&D
HA Insomnia Fatigue Sexual Dysfunction Mild and Short Lived |
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SSRI OD?
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Relatively harmless
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Drug Interactions of SSRI's?
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Inhibit Hepatic P450 enzymes-->increased levels of TCA's and warfarin
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Types of MAO Inhibitors
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MAO-A
MAO-B |
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Which MAOI's are non-selective?
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Phenelzine
Tranylcypromine |
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Phenelzine and Tranylcypromine Pharmacokinetics
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MAO Inhibition is IRREVERSIBLE, so during withdrawal the inhibition persists
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How long does it take to reproduce MAO after stopping Phenelzine or Tranylcypromine?
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2 weeks
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Adverse Effects of Phenelzine
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Hepatotoxicity
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Adverse Effects of Tranylcypromine
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Insomnia
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MAO Inhibitor OD?
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Not Life Threatening
Agitation Delirium Seizure Shock Hyperthermia |
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Drug Interactions of MAOI's?
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FOODS: cheese, fava beans, yeast products
TYRAMINE (a sympathomimetic metabolized by MAO) SSRI's TCA's |
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What happens w/ Tyramine/Foods and MAOI's?
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Elevated BP
Possible Stroke Occipital HA Stiff-neck N&V |
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MAOI's and SSRI interactions
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Serotonin Syndrome:
Muscle Rigidity Muscle Twitching Sweating Hyperthermia Possible Seizure, coma, death |
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How do we prevent Serotonin Syndrome?
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Ensure a 2 week withdrawal period when switching from one to the other
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TCA's and MAOI's interactions
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HTN reaction may occur
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Other Uses of Antidepressants
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Panic Disorder
OCD Bulimia Enuresis Chronic Pain ADHD Smoking Cessation |
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Which antidepressants are used for Panic Disorders?
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SSRI's
Imipramine MAOI's |
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Which antidepressants are used for OCD?
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SSRI's
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Which antidepressants are used for Bulimia?
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Fluoxetine
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Which antidepressants are used for Enuresis?
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TCA's
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Which antidepressants are used for Chronic Pain?
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TCA's
Venlafaxine |
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Which antidepressants are used for ADHD?
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Imipramine
Desipramine |
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Which antidepressants are used for smoking cessation?
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Bupropion
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When should you administer Antidepressants?
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DURING THE DAY:
MAOI's, SSRI's, and bupropion b/c of their CNS stimulation and insomnia AT BED TIME: other antidepressants b/c of their sedation |
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What happens with one third of patients?
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They don't respond to monotherapy.
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So if they don't respond what do you do?
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1. Ensure proper dose and duration
2. Antidepressants from a different class may be tried 3. If there is a Partial Response, try augmenting with a different class 4. remember 2 weeks off between MAOI's and SSRI's |
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What are some alternative therapies?
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Electroconvulsive Therapy (last resort)
Talk Therapy (cognitive therapy) |
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What must be considered when giving antidepressants to children?
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There is a higher risk of suicidal behavior
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How do we rate depression?
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The Hamilton Depression Rating Scale (HDRS)
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What is the take home message though about all Antidepressants vs Talk Therapy?
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None of the drugs really work that well. A placebo or talk therapy works almost as well.
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