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124 Cards in this Set

  • Front
  • Back
How do clinicians diagnose depressive disorders?
according to the DSM-IV-TR
what are the 4 categories of depressive disorders?
major, dysthymic, double, depression NOS
what might occur if depression is not diagnosed and treated?
What is the prevelance of depression?
around 16%
What trends are emerging?
increased rates and decreased age
More common in what gender?
females (prolly cuz men suck)
Typical age of onset?
What usually precipitates first episode of depression?
stressful life event
What is the significance of family history?
1.5 to 3xs more likely to develop if 1st degree relative suffers from depression
describe the relationship between co-morbidity and depression?
very common, usually will see anxiety, substance abuse, PTSD, social phobia,or EtOH dependence with depression
discuss the risk of reocurrence of depression
very high, relapses increase as # of episodes increase. risk factors: 1st degree relative, 1st episode <20 yo, >2 prior episodes, h/o reoccurence w/in 1 year of d/c meds
What are some possible etiologies?
genetic, deficiencies in NTs, dyregulation hypoth, excess secretion of glucocorticoids, NK theory, structural abnormalities
what are some medical disorders associated w/ depression?
endrocrine - hypothyroid
deficiency - anemia, wernicke's
infections - flu, Tb, AIDS
metabolic - hypokalemia/natremia
cv - post MI/CVA, CHF
neuro - alzheimer's, parkinson's, post CVA, MS
psych - anxiety, eating disorder, schizo, substance dependence
what are some meds associated w/ depression?
EtOH, propranolol, diuretics, baclofen, fluorouracil, metaclopramide, ondansetron, reserpine, hydralazine, OCP, brompheniramine,interferon-a*, metronidazole, theophylline, methyldopa, clonidine, steroids, dig, isotretinoin, NSAIDS
Discuss the clinical presentation of depression
sx develop over days/weeks
r/o all medical causes
various assessment scales may be used (beck, hamilton)
S:sleep disturbance
I:interest (loss of)
E:energy (loss of)
C:concentration (poor)
A:appetite changes
P:psychomotor changes
S:suicidal ideation
What are some risk factors associated w/ suicide?
elderly, h/o prior attempts, feelings of hopelessness, living alone, substance abuse, anniversary of a loss, unemployment, family hx, lack of support system, presence of plan and ability to carry it out; women attempt more often, men succeed more often
What are the treatment goals for depression?
reduce depressive sx
return pt to optimal level of fx
what are some non-pharm options for the treatment of depression?
ECT (last resort)
light therapy
Discuss the general concepts of pharmacotherapy.
antidepressent effects usually seen in 2-4 weeks (ADRs show up sooner); require minimum of 4 week trial; sleep, app, energy improve before mood; FDA warning: increase risk of suicidal thinking/behav in child/adolescents. most meds require slow titration and tapering
What are some factors to consider when choosing therapy?
current sx, h/o drug response, ADRs relative to pt's med/psych conditions, drug inx, safety, pt preference, cost
What are the ADRs associated with a1 adrenergic blockade?
orthostatic hypotension
What are the ADRs associated w/ cholinergic blockade?
dry mouth, constipation, blurred vision, urinary retention
what are the ADRs associated w/ histaminergic blockade?
sedation, wt gain (can be good or bad depending on pt)
what are the ADRs associated w/ DA reuptake inhibition?
psychotic features, activation
What are the ADRs associated w/ 5-HT reuptake inhibition?
N/V/D, anxiety, sex dysfx, insomnia
What are the ADRs associated with NE reuptake inhibition?
sex dysfx, insomnia, tachycardia, tremor
What causes serotonin syndrome and what are its sx?
concurrent use of meds that increase serotonin;
confusion, seizures, tachycardia, agitation, hyperthermia, tremor, coma, HTN, ataxia
Which agents are TCAs?
tertiary amines:
secondary amines:
What is the MOA of TCAs?
block the reuptake of 5-HT, NE, and DA?
Are TCAs 1st line for depression?
What other disorders are TCAs effective in treating?
trigeminal/post herp neuralg
diabetic neuropathy
migraine prophylaxis
panic disorder
Why are the secondary amine TCAs preferred over tertiary?
less anticholinergic side effects (desipramine, nortriptyline, protriptyline)
What are the ADRs associated with TCAs?
anticholinergic- dry mouth, constipation, urinary retention
antihist-sedation, wt gain
alpha adrenergic block - orthostasis
sweating, sexual dysfx, seizures, cardiac conduction delays (heart block in pts w/ pre-exist abnorms)
What receptors do TCAs block? (results in most of their side effects)
alpha-1 adrenergic, cholinergic, and histaminergic
TCAs are metabolized by which enzymes?
1A2, 2D6, 3A4
How does food affect absorption of TCAs?
it doesn't
What is 1/2 life of TCAs and what is normal dosing schedule?
24hr t1/2, qd dosing
Significant drug inx of TCAs?
alcohol and bupropion increase the risk of seizure
What are the advantages of TCAs?
well estab efficacy
generic formulations
qd dosing
sedation (good/bad)
effective for non-mood disorders
What are the disadvantages of TCAs?
high rates of d/c
dose titration req'd
differences in metab among individuals
fatal in OD situations
wt gain (good/bad)
sexual dysfx
What class to TCAs fall under
mixed 5HT/NE reuptake inhibitors
What class does venlafaxine fall under?
serotonin/noradrenergic reuptake inhibitor (SNRI)
what are the FDA indications and off label uses of venlafaxine?
depression, GAD, SAD, PD
off label: OCD
What is the MOA of venlafaxine?
potent inhibitor of 5HT/NE reuptake, weak inhib of DA reuptake
What line of therapy is venlafaxine considered?
possible first line
what are the ADRs associated with venlafaxine?
nausea, constipation, dry mouth, dizziness, sweating, sexual dysfx, agitation, HA, insomnia, may cause dose related increase in BP w/ high doses (at low dose = SSRI, at high dose, more NE effects)
which antidepressant has the highest rate of sexual dysfx
what effect does food have on absorbtion of venlafaxine?
no effect
what enzyme metabolizes venlafaxine
what is the normal dosing schedule for venlafaxine?
qd for ER form
bid for IR form
which agents, when combined w/ venlafaxine may result in serotonin syndrome?
MAO-Is, TCAs, other serotonergic meds
What are the advantages of venlafaxine?
ER form available
relatively safe in OD
minimal drug inx
what are the disadvantages of venlafaxine?
high rate of sex dysfx
potential for increased BP
dose titration usually req'd
Is venlafaxine activating or sedating?
What class does duloxetine fall under?
what are the FDA indications of duloxetine?
depression, diabetic neuropathic pain
what is the MOA of duloxetine?
inhib of 5HT/NE reuptake, weak inhib of DA reuptake
What are the ADRs associated with duloxetine?
insomnia, nausea (dose limiting), fatigue, diarrhea, dry mouth, constipation, MAY INCREASE LFTS!
How does food affect the absorption of duloxetine?
delays rate/extent of absorption
What enzymes metabolize duloxetine?
2D6, 1A2
what drug inx are associated w/ duloxetine?
cimetidine, cipro, thioridazine, MAO-Is and other serotonergic drugs, warfarin (increase in INR)
Name the SSRIs
which SSRI is not indicated for depression?
which 2 SSRIs are associated with the least amount of drug inx?
citalopram, escitalopram (good for elderly)
which drugs are the most prescribed as 1st line for depression? (which class)
what is the MOA of SSRIs?
inhibit the reuptake of 5HT
SSRIs appreas to be effective in treating which disorders?
depression, GAD, PD, OCD, PTSD, SAD, PMDD, eating disorders
what ADRs are associated with ALL SSRIs?
nausea, HA, sleep disturbances, anxiety, sexual dysfx, tremor
which two SSRIs are sedating?
paroxetine, fluvoxamine
which SSRI is associated with the most agitation?
which SSRI causes wt gain?
which SSRI causes the most diarrhea?
Which two SSRIs inhibit CYP 2D6?
fluoxetine and paroxetine
Which SSRI has a long half life, allowing for once weekly dosing?
for which agents is the starting dose potentially the therapeutic dose?
What are the advantages of SSRIs?
qd dosing for most
minimal dose titration
relatively safe in OD
effective for other psych disorders
long t1/2 of fluoxetine
what are the disadvantages of SSRIs?
high rates of sex dysfx
cost of some
long t1/2 of fluoxetine
possible wt gain (paroxetine)
what is the MOA of trazadone?
inhibits 5HT reuptake
blocks 5HT type 2 receptor
what is the primary use of trazadone?
sleep aid
what is the significance of the MOA of trazadone?
less anxiety, insomnia, sex dysfx
what are the ADRs associated w/ trazadone?
sedation, orhtostasis, dizziness, priapism
what are some significant drug inx of trazadone?
CNS depressants, EtOH, other seroton. meds
what are the advantages of trazadone?
minimal wt gain
sedative effects
relatively safe in OD
what are the disadvantages of trazadone?
potential for over-sedation
what is the MOA of nefazodone
inhibits the reuptake of NE and 5HT
5HT type 2 receptor antag
blocks alpha 1 recept
what are the ADRs associated w/ nefazodone?
sedation, dry mouth, constipation, nausea, dizziness, black box warning for hepatotoxicity
how does food affect the abs/bioavail of nefazodone?
what enzyme does nefazodone inhibit?
what are the advantages of nefazodone?
decreased anxiety, insom, sex dysfx
minimal wt gain
relatively safe in OD
what are the disadvantages of nefazodone?
divided daily dosing
dosing titration usually req'd
drug inx
LFT monitoring
potential for hepatotox
what is the MOA of bupropion?
inhib the reuptake of DA and NE
what are the FDA indications for bupropion?
depression, seasonal affective dis, smoking cessation
what is bupropions place in therapy?
possible first line
what ADRs are associated w/ bupropion?
dry mouth, insomnia, HA, N/V, agitation, anxiety, dizziness, tremor, constipation
what is a contraindication to the use of bupropion?
seizure disorder
what inx are significant for bupropion?
TCA and EtOH, may cause seizure
what are the advantages to using bupropion?
low risk of wt gain and sex side effects
long acting form available
indicated for smoking cess
what are the disadvantages of bupropion?
what is the MOA of mirtazapine?
increases NE and 5HT through blockade of the presynaptic alpha 2 receptor
5HT type 2 and 3 receptor antag (decreased nausea)
blocks hist/chol receptors as well
what is mirtazapine's place in therapy?
possible first line agent
what happens w/ low dose mirtazapine?
antihist side effects - sedation, wt gain
what are some side effects of mirtazepine?
sedation, increased app, wt gain, constipation, dry mouth, increase in cholesterol, increase in LFTs, angranulocytosis, neutropenia
what are some drug inx w/ mirtazapine?
clonidine, CNS depressants, EtOH, other seroton. drugs
what happens w/ high dose mirtazapine?
activation rather than sedation
what are the advantages of mirtazapine?
decreased anxiety, insom, sex dysfx, nausea
relatively safe in OD
minimal drug inx
qd dosing
sedation (low dose)
what are some disadavantages of mirtazapine?
wt gain
dose titration
possible insomnia (high dose)
what is the MOA of MAO-Is?
increase 5HT, NE and DA through inhib of MAO enzyme
why are MAO-Is not first line?
potential dietary and drug inx
what are some MAO-Is?
What foods should not be combined w/ MAO-Is?
tyramine containing foods
absolute C/I:aged cheese/meats, improperly stored meat, saurkraut, soy sauce/soybean cond, tap bear
moderate restrictions:red/white wine, bottled/canned beer
What type of MAO-I is selegiline?
type B
which antidepressant is available in a transdermal system?
what are the ADRs associated w/ selegiline?
HA, insomnia, dizziness, nausea, app site rxn
what is the MOA of St John's Wort?
believed to inhibit reuptake of 5HT
what are the ADRs associated w/ st johns wort?
insomnia, vivid dreams, retlessness, anxiety, agitation, irritability, GI upset, dry mouth, dizziness, HA, photo dermatitis
What are some common drug inx w/ st johns wort?
OCPs, seroton. meds, warfarin (st johns wort is a 3A4 inducer)
what are the lenghts of treatment and indications for the acute, continuation and maintenance phases for the tx of depression?
acute: 6-12 weeks, all pts w/ acute major depressive episode
continuation: 6-12 months, all pts responsive to acute tx of major depressive episode
maintenance: variable (2-5 yrs, indefinitely), pts w/ three or more prior depressive episodes or high risk factors for recurrences
which ADs are associated w/ insomnia?
SNRIs (venlafaxine, duloxetine)
SSRIs (except parox,fluvox)
high dose mirtazapine
st johns wort
which ADs are associated w/ sedation?
low dose mirtazapine
Which ADs are associated w/ wt gain?
low dose mirtazapine
which ADs are associated w/ sex dysfx?
Which ADs are associated w/ HTN
high dose venlafaxine
which ADs are hepatotoxic?
which ADs are associated w/ risk of seizure?
All ADs decrease seizure threshold
escpecially bupropion and TCAs