Depression

Front 1

What are the NON-pharmacologic tx options?

Back 1

1. Psychotherapy.
2. Bright-light therapy (seasonal affective disorder):
Wellbutrin XL
3. Electroconvulsive therapy (ECT)
4. Vagal Nerve Stimulation (VNS)

Front 2

What is the psychotherapy?

Back 2

First line for mild-moderate depression.
- additive with antidepressants.
- NOT recommened for recurrent.

Front 3

Electroconvulsive Therapy:

Back 3

- 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.

Front 4

Vagal Nerve Stimulation?

Back 4

- 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.

Front 5

Name of tricyclic Antidepressants:

Back 5

- MOA: block both 5HT and NE reuptake.
- also blocks muscarinic, histamine, alpha 1 receptors.

Front 6

What are the Pros and Cons OF TCAs:

Back 6

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.

Front 7

What are the tertiary amines and how what are there more specific side effects?

Back 7

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

Front 8

What are the secondary amines and wha are there more specific side effects:

Back 8

1. Desipramine (Norpramin)
2. Nortriptyline (Pamelor)
3. Protriptyline (Vivactil)

PRIMARY BLOCKS NE reuptake soooo....less sedation, orthostasis, and less anticholinergics

Front 9

Selective Serotonin Reuptake Inhibitors (SSRIs)
Citalopram
Excitaopram
Fluoxetine (only one used for children and adults)
Fluvoxamine
Sertraline
Paroxetine

Back 9

First line:
Moa: selective and potent inhibitor of 5HT REUPTAKE.

Front 10

PROS and CONS of SSRIs

Back 10

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.

Front 11

Short Acting Agents:
- Paroxetine
- Sertraline
- Fluvoxamine (not indicated for depression)

Back 11

Do not abruptly d/c

Front 12

Fluoxetine:

Back 12

- Fairly activating
- Long half-life with active metabolite
- Monitor for QTc prolongation.

Front 13

Paroxetine:

Sertraline : most GI distress

Escitalopram (is the S- enantiomer of citalopram)

Back 13

Associated with constipation, dry mouth, drowsiness (may be evening)

Pregnancy Category D

Front 14

Norepinephrine and DA reuptake inhibitors:

bupropion

Back 14

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.

Front 15

Dual SE and NE reuptake inhibitors: SSNRIs

Venlafaxine (Effexor, XR)
Duloxetine (cymbalta)

Back 15

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.

Front 16

Duloxetine:

Back 16

inhibits 5HT AND NE EQUALLY.
- ALSO approved for diabetic peripheral neuropathic pain and generalized anxiety disorder.

Front 17

Adverse Effects of Duloxetine:

Back 17

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.

Front 18

Dual Serotonin and NE actions via alpha-2 antagonism:
- Mirtazapine (Remeron)

Back 18

MOA: Enchances central noradrenergic and serotonergic activity through the antagonism of central presynaptic alpha 2 adrenergic auto and heteroreceptors

Front 19

Adverse effects of Mirtazapine;

Back 19

- Weight Gain, somnolence, increased appetite.
- Dry mouth, constipation, orthostasis.
- slight risk for increased LFTs and agranulocytosis --> routine lab work NOT recommended.
- NO SEXUAL DYSFUNCTION.

Front 20

Dual Sertonin 2 Antagonists and Serotonin Reuptake inhibitors:

Back 20

Trazodone (Desyrl) and Nefazodone (Serzone)
- MOA: 5HT2 antagonist and weak 5HT reuptake inhibitor.

Front 21

Nefazodone --> life threatening hepatic failure (Black Box Warning) - no sexual dysfunction.

Back 21

Trazodone as an AD agent and insominia may lead to priapism.

Front 22

MAOIs:
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Transdermal Selegiline (Emsam) low dose (6mg dont have to worry about tyramine food)

Back 22

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.

Front 23

What are the DI for MAOIs: Hypertensive crisis.

Back 23

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)

Front 24

Sx of Hypertensive Crisis:

Back 24

Occipital HA, Stiff neck, n/v, heart palpitations, sweating, sharply elevated b.p.
- seek medical attention IMMEDIATELY
- tx with clonidine or nifedipine.

Front 25

Sx of sertonin syndrome:

Back 25

if switching to an MOAI from another AD:
2 WEEK drug-free period
AND 5 weeks for fluoxetinel.