Mood Rx

Front 1

What is the lifetime prevalence of depression in the US population?

Back 1

10 %.

Front 2

What is reactive depression and when should it be treated?

Back 2

Depression related/associated with grief &/or bereavement.

Treated when:
- Persistence >2 months
- Marked functional impairment
- satisfy criteria for Depression.

Front 3

Diagnostic Symptoms/Signs for Major Depressive Disorder

Back 3

5 of 9 nearly every day for 2+ weeks. Must have 1+ *.
*Depressed mood. (SIG E CAPS)
Sleep changes
*Interest loss (anhedonia)
Guilt or worthlessness, excessive.
Energy loss
Concentration difficulty
Appetite & Weight (>5% in 1 month) changes
Psychomotor retardation or aggitation.
Suicidal &/or Homicidal Ideation.

Front 4

Anhedonia

Back 4

Unable to experience interest or pleasure in previously enjoyed activities.

Front 5

What is Fluvoxamine, it's actions and what is it approved to treat?

Back 5

Fluvoxamine = SSRI.

Only approved to treat OCD

No sedative or anti-muscarinic action.

Front 6

Fluoxetine
- Action
- Kinetics
- Uses

Back 6

SSRI (may dec NE/DA reuptake too)

Sedative & Antimuscarinic actions.

Bulimia*, anorexia, obesity.
Depression, OCD, social anxiety, panic disorder

Front 7

What is the mechanism of action of SSRI's?

Back 7

Inhibition of pre-ynaptic neural reuptake of Serotonin

Increases Serotonin concentration and duration within the synapse.

Front 8

What is the mechanism of action of Tricyclic Antidepressants

Back 8

Inhibit neuronal reuptake of serotonin and norepinephrine.

Front 9

What is the mechanism of action of Second generation Heterocyclics?

Back 9

(Atypical antidepressants, 2nd: Bupropion)

Inhibits reuptake of serotonin, norepinephrine & dopamine.

Front 10

What is the mechanism of action of MAOIs?

Back 10

Monoamine oxidase inhibitors.

Inhibit/reduce degradation of DA, NE & 5-HT in presynaptic neurons

Front 11

Transference

Back 11

Patient projects feelings about another important person (formative) onto the physician/therapist.

Pt anger for Father is projected onto MD.

Front 12

Countertransference

Back 12

Physician/therapist projects feelings of a important person (formative) onto patient.

MD projects feeling towards child onto Pt (sybil)

Front 13

Name 5
Tertiary Amine Tricyclic Antidepressants.

Back 13

Amitryptelene, Clomipramine, Imipramine,
Doxepin, Trimipramine.

Front 14

Side Effect profile of:
Tertiary Amine Tricyclic Antidepressants

Back 14

Highly Anti-cholinergic:
Sedation!
dry mouth, blurring vision,
orthostatic hypotension,
constipation, urinary retention

Front 15

Uses of Tricyclic Antidepressants in general.

Back 15

Depression, Neuropathic pain, Panic disorder, PTSD,
Eating disorder, Migraines,
Enuresis, Irritable Bowel Synd,

Front 16

Side Effect profile of Tri-cyclic Antidepressants in general.

Back 16

Anticholinergic: sedation, dry-mouth, blur vision, orthostatic hypotension, constipation, urinary retention
Anti-a1 blocker: Tachycardia, QT interval prolongation
Anti-Histamine1: Weight gain

Front 17

Amoxapine

Back 17

Tetracyclic Antidepressant
Side Effects = Extrapyramidal Syndrome, Neuroleptic Malignant Syndrome.

Front 18

Tri-Cyclic Toxicity

Back 18

Tri-C's:
Convulsions,
(Atropine-like: dec sweating, inc muscle act/seizures --> hyperpyrexia)
Coma,
Cardiotoxicity (fatal arrhythmias - wide QRS)

Front 19

Secondary Amine Tricyclic antidepressants

Back 19

Nortriptyline
Desipramine
Protriptyline
(least side effects)

Front 20

Treatment for Tri-cyclic Toxicity

Back 20

IV NaHCO3

Front 21

Tri-cyclic antidepressant:
Drug interactions

Back 21

Alcohol, Barbituates, Benzodiazepines, MAOIs.

Front 22

Drugs that may cause Depression

Back 22

- Anti-HTN: Reserpine, Propranolol, Methyldopa, Guanethidine sulfate, Clonidine, Hydralazine
- Corticosteroids: Prednisone, Cortisone acetate
- Hormones/BCP: Estrogen, Progesterone
- AntiParkinson's: Levodopa, Carbidopa, Amantadine
- Anti-anxiety: SSRI, Benzodiazepine, Buspirone, Propranolol.
- Alcohol

Front 23

Vegetative Sx of Depression

Back 23

(reflect biochemical dysfunction)
Sleep disturbance, Appetite disturbance with Weight changes, Fatigue, Dec Sex drive, Restlessness, Agitation, Psychomotor retardation, Diurnal variation of mood, Impaired Concentration/ forgetfulness, Pronounced anhedonia.

Front 24

Common Side Effects of SSRIs & SNRIs

Back 24

**GI problems: distress, diarrhea
Sexual SE: delayed ejaculation, Nonorgasmia (f)
Agitation, Anxiety, Akanthisia (uncomfortable inner restlessness), Panic, Insomnia, HA
Increased suicide (mobilization phenomena)
Serotonin Syndrome

Front 25

Contraindications/Interactions with SSRIs/SNRIs

Back 25

MAOI within 4-6 weeks.

Electro-convulsant therapy.

Front 26

Clomipramine

Back 26

Tertiary Amine Tricyclic Anti-Depressant.
Most 5HT Reuptake Inhibitor specific.
Treats OCD &
depression, enuresis, IBS, Nerve pain, migraine, panic d/o, eating d/o, PTSD, induce sedation.

Front 27

29 common diseases that may cause depression

Back 27

Alzheimer's, Parkinson's, Multiple Sclerosis.
Addison's, Cushing's, DM, Hyper/HypoThyroidism.
CHF, Apnea, Asthma.
Infectious Hep, Malnutrition, Ulcerative Colitis.
Postpartum, Premenstrual, Menopause.
RA, SLE, AIDS, Influenza, Syphilis, Ch Infection.
Porphyria, Anemia, Uremia.
Ch Pain, Ch Fatigue Synd, Malignancy.

Front 28

Serotonin Syndrome

Back 28

*Tremor, Akathisia, Clonus (T>100)*
Hyperthermia, Hypertonicity, Rhabdomyolysis, Renal Failure, Convulsion, Coma --> Death.
Triad of Cognitive, Autonomic & Somatic Sx.

Front 29

Tx for Serotonin Syndrome

Back 29

Stop Rx.
Benzodiazepine &/or 5HT Antagonist (cyclopeptadine)

Front 30

SNRI vs SSRI

Back 30

SNRIs (and tricyclic's MoA)
- effective in depression refractory to SSRIs
- effective in relieving physical sx related to depression (neuropathic pain, etc)

Front 31

Venlafaxine
- Mechanism of Action

Back 31

(Effexor)
SNRI.
Potent 5HT RI,
NE-RI at higher doses.
mild Dopamine RI

Front 32

Venlafaxine
- Side Effects

Back 32

(SNRI, Effexor)
Nausea, Dizziness, Insomnia, Sedation & Constipation.
high dose: Inc BP

Front 33

Venlafaxine
- Uses

Back 33

MDD (refractory to SSRI &/or with physical sx (neuropathic pain)),
GAD, Social anxiety, Panic d/o

Front 34

Duloxetine
- Mechanism of Action

Back 34

SNRI (Cymbalta)
inhibits reuptake of 5HT & NEpi at all doses.

Front 35

Duloxetine
- Contraindications
- Side Effects

Back 35

(SNRI - Cymbalta)
C/I:
Hepatic insufficiency & end-stage renal dx
(liver metabolism & excreted)

SE:
GI: Nausea, drymouth, constipation > diarrhea, vomiting.
Insomnia, dizzy, somnolence, sweating, sexual dysfunction.

Front 36

SSRI
- Therapeutic Uses

Back 36

MDD
OCD
GAD
panic disorder
premenstrual dysphoric disorder
bulimia nervosa

Front 37

Uses of Fluvoxamine

Back 37

SSRI
only indicated for OCD

Front 38

Name SSRIs

Back 38

Fluoxetine (prozac)
Paroxetine (paxil)
Fluvoxamine (luvox)
Sertraline (zoloft)
Escitalopram (lexapro)
Citalopram (celexa)

Front 39

Citalopram
MoA & Uses.

Back 39

SSRI (Celexa)
Only indicated for Depression
useful in kids/teens.

Front 40

Bupropion
- mechanism of action

Back 40

(Wellbutrin)
NEpi/Dopamine Reuptake Inhibitor
Short T1/2 = multiple/day

Front 41

Bupropion
- uses

Back 41

Depression
Smoking Cessation (Dec nicotine craving)
Seasonal Affective D/o
(ADHD & neuropathic pain)

Front 42

Bupropion
- Side Effects

Back 42

No sexual side effects, sedation or anti-muscarinic

Dry mouth, sweating, tremor.
High doses: Seizures

Front 43

Mirtazapine
- Uses

Back 43

Refractory depression
esp in patients who need weight gain and have difficulty sleeping.

Front 44

Mirtazapine
- Mechanism of Action

Back 44

Block 5HT2 & alpha-2 receptors.

Potent anti-Histaminic = Sedation.

Front 45

Mirtazapine
- Side Effects

Back 45

No anti-muscarinic or sexual SE

Increased appetite & weight gain.
Markedly sedating (anti-H)
Dizziness, tremor, agranulocytosis.

Front 46

Nefazodone
- Mechanism of Action
- Side Effects

Back 46

5HT1 pre-synaptic autoreceptor blocker.
(weak SRI)
= increased 5HT release

Potent H1 blocker = SEDATING!!

Front 47

Trazadone
- Mechanism of Action
- Side Effects

Back 47

Block 5HT pre-synaptic auto-receptor.
(weak SRI)
= increased 5HT release

Potent H1 Blocker = SEDATING!!

Associated with Priapism.

Front 48

Nefazodone
- Uses

Back 48

refractory major depression
(with anxiety & insomnia)
sedation requires qhs

Front 49

Trazodone
- Uses

Back 49

refractory major depression
(with anxiety & insomnia)
sedation requires qhs.

Front 50

Name 5
Mono-Amine Oxidase Inhibitors

Back 50

Phenelzine
Tranylcypormine
Isocarboxazid
Selegiline (MAOI-B)
Clorgyline (MAOI-A)

Front 51

How do MAOI's work?

Back 51

Inhibition (often irreversible) of Mono-Amine Oxidase A &/or B.

Prevents the degradation of amines:
A: 5HT, Dopamine, Tyramine
B: NEpi, (Epi), Dopamine, Tyramine

Front 52

MAOI
- Uses

Back 52

Panic Disorder
Phobic States

Refractory Depression
- unresponsive or allergic to TCAs (or)
- w/ strong anxiety sx

Atypical Depression (labile mood, rejection sensitivity, appetite d/o)

Front 53

MAOI
- Cautions & C/Is

Back 53

- Reaches effect 2-4 wks post onset
- Enzyme regeneration = min 2 wks, recommended 4-6 wks post-termination.

- NO tyramine: aged cheese, poultry liver, beer, red wine.

Front 54

Actions of Tyramine

Back 54

Release of lg amt of stored catecholamines from nerve terminals
- HA, tachycardia, nausea, HTN, Cardiac arrhythmias, stroke

Normally inactivated by MAOI in gut.

Front 55

Management of tyramine ingestion with MAOIs?

Back 55

Phentolamine or Prazosin
help manage the induced HTN.

Front 56

MAOI side effects

Back 56

Drowsiness, Orthostatic Hypotension, Dry mouth, blurred vision, dysuria, constipation.

with tyramine ingestion:
HA, Tachycardia, Nausea, HTN, Cardiac Arrhythmia, Stroke.

Front 57

Lithium
- Uses

Back 57

Drug of Choice:
- Acute mania
- Prophylaxis for both manic & depressive episodes in bipolar disorder.

Front 58

Valproic Acid / Valproate
- Uses

Back 58

(Depakene)
Mixed Manic Episodes,
Rapid-Cycling Bipolar disorder

Front 59

Lithium
- Adverse Effects

Back 59

Fine tremor, Ataxia, Thirst, Metallic taste, Polyuria, Edema, Wt gain, GI problems, Leukocytosis, Thyroid enlargement, Hypothyroidism, Nephrogenic Diabetes Insipidus (tx = amiloride)

NOT sedative, euphoriant, depressant.

Front 60

Toxic & Lethal levels of Lithium

Back 60

Toxic >1.5
- AltMSt, Coarse tremor, Gait disturbance, Convulsions, Death (Tx=Dialysis)

Lethal >2.0

Front 61

Therapeutic Index of Lithium

Back 61

0.7 - 1.2

Front 62

Factors that decrease Lithium levels

Back 62

NSAIDs

Front 63

Factors that increase Lithium levels

Back 63

Dehydration
Salt deprivation
Impaired renal function
Diuretics
ACE-I
Metronidazole
Tetracycline
Aspirin

Front 64

Valproic Acid
- Adverse Effects

Back 64

Sedation, Wt gain, Alopecia, Hemorrhagic pancreatitis, Hepatotoxicity, Thrombocytopenia, Teratogenic (neural tube defects)

Front 65

Carbamazepine
- Mechanism of Action

Back 65

(teretol)
Blocks Na channel & Inhibits action potentials

Front 66

Carbamazepine
- uses

Back 66

Mixed manic episodes

Rapid-cycling bipolar disorder

Trigeminal Neuralgia mgmt

Front 67

Carbamazepine
- Adverse Effects

Back 67

Skin Rash, Drowsiness, Slurred speech, Ataxia,
Leukopenia, Aplastic anemia, Agranulocytosis,
Hyponatremia, Inc Liver enzymes,
Teratogenic (neural tube defects)

Front 68

Mood Stabilizer
- uses

Back 68

- Treat acute mania
- prevent manic relapses
- potentiate antidepressants in pt refractory to monotherapy
- potentiate antipsychotics in schizophrenia
- enhance abstinence in tx of alcholism
- Tx aggression & impulsivity (dementia, intoxication, MR, Personality d/o, Gen Med)

Front 69

Name 3
Long-acting Benzodiazepines

Back 69

1-3 Days
- Chlordiazepoxide (librium)
- Diazepam (valium)
- Flurazepam (dalmane)

Front 70

Name 4
Intermediate-acting Benzodiazepines

Back 70

10-20 Hours
- Alprazolam (xanax)
- Clonazepam (klonopin)
- Lorazepam (ativan)
- Temazepam (restoril)

Front 71

Name 2
Short acting Benzodiazepines

Back 71

3-8 Hours
- Oxazepam (serax)
- Triazolam (halcion)

Front 72

Benzodiazepine
- Mechanism of Action

Back 72

Potentiation of GABA

Front 73

Clonazepam
- Uses

Back 73

Intermediate acting Benzodiazepine (10-20 hrs)

Anxiolytic: Anxiety or Panic attack
Chronic Anti-epileptic activity
- suppress epileptogenic foci spread
- absence & myoclonic seizures
Tolerance develops.

Front 74

Drug(s) of Choice for status epilepticus

Back 74

Diazepam & Lorazepam
(Long & Intermediate Acting Benzodiazepines)

Front 75

Benzodiazepines
- Adverse Effects

Back 75

Sedation, Intellectual impairment, Reduced motor coordination/ Ataxia, Dizziness, Behavioral changes

Front 76

Benzodiazepines
- Toxicity

Back 76

Respiratory depression & Cardiac depression.

Combine with alcohol = lethal

Front 77

Chlordiazepoxide
- Uses

Back 77

(librium)
Long-act Benzodiazepine (1-3d)

- Alcohol Detoxification
- Presurgery anxiety

Front 78

Diazepam
- Uses

Back 78

(Valium)
Long-act Benzodiazepine (1-3d) with Rapid onset

- Anxiety
- Seizure control esp status epilepticus

Front 79

Flurazepam
- Uses

Back 79

(Dalmane)
Long-act Benzodiazepine (1-3d) with Rapid onset

- Insomnia

Front 80

Alprazolam
- Uses

Back 80

(Xanax)
Intermediate-act Benzodiazepine (10-20h)

- Panic Attacks

Front 81

Lorazepam
- Uses

Back 81

(ativan)
Intermediate-act Benzodiazepine (10-20h)

- panic attacks
- Alchohol withdrawal
- DOC Status epilepticus

Front 82

Temazepam
- Uses

Back 82

(restoril)
Intermediate-act Benzodiazepine (10-20h)

- insomnia

Front 83

Oxazepam

Back 83

(Serax)
Short-act Benzodiazepine (3-8h)

- anxiolytic

Front 84

Triazolam
- Uses

Back 84

(Halcion)
Short-act Benzodiazepine (3-8h) with rapid onset

- insomnia
- anxiolytic

Front 85

Zolpidem
- Use
- Mechanism

Back 85

Short term tx for insomnia

Selective binding at Benzodiazepine's site potentiating GABA effects.

Front 86

Zaleplon
- Use
- Mechanism

Back 86

(Sonata)
Short term treatment of insomnia with shorter T1/2.

Selective binding at Benzodiazepine's site potentiating GABA effects.

Front 87

Compare Triazolam / Temazepam to Zolpidem / Zaleplon

Back 87

Zolpidem / Zaleplon have:
- no withdrawl effects
- no anticonvulsant / muslce relaxant prop
- minimal reboutnd insomnia
- little-no tolerance/ dependence with prolonged use.

Front 88

Malingering

Back 88

grossly exaggerated physical or psychological complaints often accompanied by INTENTIONAL production of false physical or psychological complaints
to obtain a form of secondary GAIN.

Front 89

Signs of malingering

Back 89

Marked disparity between patient's disability and objective findings.

Often refusal of examination, previous history of dependence or substance abuse, etc.

Front 90

Factitious disorder

Back 90

INTENTIONAL production of false physical or psychological complaints
to assume a SICK ROLE, no secondary gain.

Front 91

Hypochondriasis

Back 91

Fear of disease
&
pre-occupation with body
Manifests as multiple somatic complaints.
Persists despite medical evaluations
Causes marked impairment
Lasts 6 months or longer.

Front 92

Conversion disorder

Back 92

Development of unexplained serious Neurological Symptoms
- preceded by an obvious emotional TRIGGER.
- Not ARTIFICIALly produced.
- unexplained by medical condition
- severe enough to cause social & functional IMPAIRMENT.

Front 93

Dependent Personality disorder

Back 93

Unable to make decisions without help.
Crave protection & guidance from others.
Devastated by separation and loss.
Go to great lengths to stay in dependent relationships.

Front 94

What is the best treatment for cachectic anorexic cancer patients?

Back 94

Progestins
(megestrol acetate, medroxyprogesterone acetate)
- as effective as corticosteroids for cachexia but better side-effect profile.
- Main adverse effect is slight inc risk of DVT