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30 Cards in this Set

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What neurotransmitters are affected in depression? How are they affected?
Decrease in norepinephrine, serotonin, or both.
What do CSF studies of depressed patients often show?
Metabolites of NE and 5HT are often decreased.
Where is NE made in the CNS? Name the area and describe its location.
All NE for the neuraxis is made the locus ceruleus, located at the angle of the 4th ventricle from middle pons all the way up to the midbrain.
Where is 5HT made in the brain? Name the area and describe its location.
5HT is made in the dorsal raphe nucleus, located at the level of the inferior colliculus (mainly) and the most rostral pons.
What are the two types of major depression? Which type has a worse prognosis.
1. major depression without psychotic features
2. major depression with psychotic features--worse prognosis
What are the major features (S/S) of the two types of major depression (MD)?
Both have:
1. feeling sad/down
2. lack of energy
3. anhedonia
4. decreased (more common) or increased (less common)sleep
5. decreased (more common) or increased (less common) appetite
6. decreased libido
7. guilt/magnification of past transgressions

MD with psychotic features adds psychosis:
may be paranoid, delusional, have negative hallucinations about family members, etc.
Describe the time course for resolution of major depression; contrast young vs. old.
1. young: body usually automatically recovers within 1-1.5 yrs
2. old: may take about 5 yrs to recover
What percentage of patients admitted to hospital for major depression eventually commit suicide?
15%
Describe how stress directly affects the brain in terms of
1. hormones
2. specific areas of the brain affected
Stress activates the HPA axis. ACTH is released from hypothalamus, which increases release of CRH from pituitary, which increases cortisol release from adrenal glands. Prolonged elevated cortisol
1. can be caused by depression
2. can cause cell death in the hippocampus.
Describe the MOA of SSRIs.
Block reuptake of 5HT back into 5HTergic neurons. So 5HT stays at the postsynaptic site longer, increasing its effective concentration and prolonging its effects.
Fluoxetine:
1. Give trade name.
2. What class of drug?
3. Discuss its pharmacology (t1/2, etc.).
4. Significant side effects
1. Prozac
2. SSRI
3. Takes a long time to work, takes 5 weeks to wash out, has long t1/2, has significant sexual side effects including loss of erection men and loss of orgasm in women.
Citalopram
1. Give trade name.
2. What class of drug?
3. Discuss its pharmacology (t1/2, etc.).
4. Significant side effects
1. Celexa
2. SSRI
3. Quicker onset (~2 wks)
4. Least amount of sexual side effects
Escitalopram
1. Give trade name.
2. What class of drug?
3. Discuss its pharmacology (t1/2, etc.).
4. Significant side effects
*Similar to Celexa/citalopram
1. Lexapro
2. SSRI
3. "acts quickly"
4. few sexual side effects
Sertraline
1. Give trade name.
2. What class of drug?
3. Significant side effects
1. Zoloft
2. SSRI
3. Side effects:
a. Diarrhea
b. Same sexual side effects as Prozac: "has significant sexual side effects including loss of erection men and loss of orgasm in women."
Paroxetine
1. Give trade name.
2. What class of drug?
3. Significant side effects
1. Paxil
2. SSRI
3. Same sexual side effects as Prozac: "has significant sexual side effects including loss of erection men and loss of orgasm in women."
Bupropion
1. trade name?
2. mechanism of action?
3. side effects?
1. Wellbutrin
2. Increases both NE and DA
3. May counter many of the sexual side effects of SSRIs.
Mirtazepine
1. trade name?
2. class of drug?
3. indication?
1. Remeron
2. 5HT and NE reuptake blockers
3. Used for people who fail to respond to SSRIs
Venlafaxine
1. Trade name?
2. Class of drug?
3. Indication?
1. Effexor
2. 5HT and NE reuptake blockers
3. Used for people who fail to respond to SSRIs
Duloxetine
1. Trade name?
2. Class of drug?
3. Indication?
1. Cymbalta
2. 5HT and NE reuptake blockers
3. Used for people who fail to respond to SSRIs
What two drugs have been clinically proven to reduce the incidence of suicide among depressed patients?
1. Lithium
2. Clozaril (clozapine)
List the relative contraindications for ECT.
1. intracranial mass
2. recent CVA
3. recent MI
List and briefly explain the diagnostic tests necessary prior to ECT.
1. CT or MRI of the head to check for intracranial mass or recent bleed.
2. MRI and 2D cardiac echo to determine ejection fraction of left ventricle.
3. EKG
4. Radiographs of back to check for osteoporosis/spinal compression fractures
5. Neuropsychological testing to test cognition.
Severely depressed patients often exhibit decreased appetite/anorexia. Discuss the effects of protein malnutrition.
Depletion of serum protein secondary to anorexia causes diminished serum oncotic pressure. This leads to edema. Patients are particularly at risk when serum albumin falls to <3.
Why is an arm cuff used in ECT?
Prevents NM blocking agent from reaching the arm distal to the cuff. Since the arm is unparalyzed, it should exhibit seizure activity if ECT is successful. Allows the clinician to observe and confirm seizure activity when ECT is administered.
List the drugs used with ECT administration. Briefly explain what each drug's purpose is.
1. Sodium pentathol-general anesthetic
2. succinylcholine-blocks NMJ; causes fasciculations then paralysis
3. beta blocker-blocks the sympathetic discharge that commonly occurs
Discuss the acute effects of ECT on autonomic activity.
1. First causes parasympathetic discharge that transiently slows the pt.'s HR (sometimes to asystole).
2. Then a compensatory sympathetic discharge that increases HR and BP (often blocked by giving pt. beta blocker).
1. What is the risk of death with ECT?
2. What body system is usually primarily involved in ECT-related death?
3. What test(s) are recommended prior to ECT for this reason?
1. Same as risk of death D/T general anesthesia: about 1/50,000 to 1/10,000.
2. If death occurs, it's almost always cardiovascular event.
3. EKG and echocardiogram.
What are the predictors of ECT success?
1. Total seizure time of 226 seconds.
2. Improved score on Folstein Mini-mental Status Exam.
Describe the actual ECT procedure (very briefly).
Bilateral electrical stimulation with a low amount of current leading to a grand mal seizure.
1. What % of pts. improve immediately after ECT?
2. What % relapse in the 1st year?
1. 90%
2. 50%