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25 Cards in this Set

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What are the NON-pharmacologic tx options?
1. Psychotherapy.
2. Bright-light therapy (seasonal affective disorder):
Wellbutrin XL
3. Electroconvulsive therapy (ECT)
4. Vagal Nerve Stimulation (VNS)
What is the psychotherapy?
First line for mild-moderate depression.
- additive with antidepressants.
- NOT recommened for recurrent.
Electroconvulsive Therapy:
- safe and effective for SEVERE mental illness.
- typical course 6 to 12 tx two or three times wkly.

Adverse Effects:
1. Transient cognitive disturbance
2. C.V. dysfunction
3. Tx-emergent mania
4. HA, nausea, muscle aches.
Vagal Nerve Stimulation?
- FDA approved for adjunctive long-term tx of chronic or recurrent depression for adults 18 years and older with MDD and NO adequate response to four or more antidepressant tx.
Name of tricyclic Antidepressants:
- MOA: block both 5HT and NE reuptake.
- also blocks muscarinic, histamine, alpha 1 receptors.
What are the Pros and Cons OF TCAs:
PROS:
1. inexpensive
2. plasma conc. monitoring indications
3. multiple indications
4. QD

CONS:
1. Narrow therapeutic index.
2. Cardiac conductions abnormalities
3. OD = severe arrhythmias
4. Adverse Effects:
Antimuscarinic- antichol.
Antihistamic (weight gain, sedation)
Orthostasis, hypotension, dizziness (alpha)
sexual dysfunction
Decreased seizure threshold.
What are the tertiary amines and how what are there more specific side effects?
Tertiary amines:
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Doxepin (Sinequan)
Imipramine (Tofranil)
Trimipramine (Surmontil)

PRIMARILY BLOCK 5HT reuptake:
1. Also block histamine (more sedation and weight gain)
2. block anticholinergics:
- more potent
What are the secondary amines and wha are there more specific side effects:
1. Desipramine (Norpramin)
2. Nortriptyline (Pamelor)
3. Protriptyline (Vivactil)

PRIMARY BLOCKS NE reuptake soooo....less sedation, orthostasis, and less anticholinergics
Selective Serotonin Reuptake Inhibitors (SSRIs)
Citalopram
Excitaopram
Fluoxetine (only one used for children and adults)
Fluvoxamine
Sertraline
Paroxetine
First line:
Moa: selective and potent inhibitor of 5HT REUPTAKE.
PROS and CONS of SSRIs
1. No clinical sign. anticholingeric, histaminic, or alpha 1- blockage.
2. NO ORTHOSTASIS.
3. NO lethal OD, unlike TCA'S
4. All can be administered ONCE DAILY (AM)

CONS:
1. GI sx (TAKE WITH FOOD)
2. HA, insomnia, tremor.
3. Sexual dysfunction is HUGE (up to 70%)
4. Initial INCREASEs in anxiety (start low)
5. INCREASED risk of PPHN
6. INCREASED risk of fracture in older adults.
Short Acting Agents:
- Paroxetine
- Sertraline
- Fluvoxamine (not indicated for depression)
Do not abruptly d/c
Fluoxetine:
- Fairly activating
- Long half-life with active metabolite
- Monitor for QTc prolongation.
Paroxetine:

Sertraline : most GI distress

Escitalopram (is the S- enantiomer of citalopram)
Associated with constipation, dry mouth, drowsiness (may be evening)

Pregnancy Category D
Norepinephrine and DA reuptake inhibitors:

bupropion
blocks NE AND DA reuptake.

Adverse Effects:
1. Nausea, dizziness, tremor, insomnia, agitation, HA, Dry mouth.
2. > 450 mg/day = seizures.
3. NO RISK OF SEXUAL DYSFUNCTION.


Contraindication: Seizure disorder or history of bulimia or anorexia nervosa.
Dual SE and NE reuptake inhibitors: SSNRIs

Venlafaxine (Effexor, XR)
Duloxetine (cymbalta)
Blocks reuptake of NE and 5-HT and weakly inhibits DA reuptake.

Venlafasine:

- 5HT > NE > DA.
Adverse Effects:
1. N/V, agitation, sweating, sexual dysfunction and HA.
2. Dose-related increase in diastolic BP, so monitor!!!
3. Warning on Mydriasis.
4. Short half-life be careful of w/drawal sx.
Duloxetine:
inhibits 5HT AND NE EQUALLY.
- ALSO approved for diabetic peripheral neuropathic pain and generalized anxiety disorder.
Adverse Effects of Duloxetine:
1. dose dependent nausea (38%
2. Diarrhea
3. fatigue
4. slight increase in diastolic bp
4. sexual dysfunction
5. HEPATOXICITY:
- Do not use in pts with alcohol usage or evidence of chronic liver disease
- avoid use in patients with hepatic insufficiency.
Dual Serotonin and NE actions via alpha-2 antagonism:
- Mirtazapine (Remeron)
MOA: Enchances central noradrenergic and serotonergic activity through the antagonism of central presynaptic alpha 2 adrenergic auto and heteroreceptors
Adverse effects of Mirtazapine;
- Weight Gain, somnolence, increased appetite.
- Dry mouth, constipation, orthostasis.
- slight risk for increased LFTs and agranulocytosis --> routine lab work NOT recommended.
- NO SEXUAL DYSFUNCTION.
Dual Sertonin 2 Antagonists and Serotonin Reuptake inhibitors:
Trazodone (Desyrl) and Nefazodone (Serzone)
- MOA: 5HT2 antagonist and weak 5HT reuptake inhibitor.
Nefazodone --> life threatening hepatic failure (Black Box Warning) - no sexual dysfunction.
Trazodone as an AD agent and insominia may lead to priapism.
MAOIs:
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Transdermal Selegiline (Emsam) low dose (6mg dont have to worry about tyramine food)
MOA: Increase NE, 5HT, DA via inhibition of MAO A and B.
- RESERVED for pt who fial other AD AGENTS.
- use is LIMITED due to C.V. effects and dietary restrictions.
What are the DI for MAOIs: Hypertensive crisis.
1. Hypertensive Crisis:
- Rare but fatal
- intake of high tyramine foods:
(aged cheese, wine, canned, aged, or processed meat, tofu, soybeans, fava beans, meat extract, soy sauce, chocolate coffee, sauerkraut, pizza, bottled or canned beer)
Sx of Hypertensive Crisis:
Occipital HA, Stiff neck, n/v, heart palpitations, sweating, sharply elevated b.p.
- seek medical attention IMMEDIATELY
- tx with clonidine or nifedipine.
Sx of sertonin syndrome:
if switching to an MOAI from another AD:
2 WEEK drug-free period
AND 5 weeks for fluoxetinel.