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104 Cards in this Set
- Front
- Back
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What is depression?
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A disorder characterized by mood changes and somatic complaints.
The most common psychiatric disorder |
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Depression is under ______ and under ______
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1) recognized
2) treated |
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DSM criteria for depression states that depression or loss of interests must be accompanied with....
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4 other target symptoms (fat sad pigs)
*and not related to underlying medical condition |
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Assessing suicide risks (SAD PERSONS)
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S-Sex (male)
A-Age (elderly) D-Depressed Mood P-Previous Attempt E-ethanol abuse R-rational thinking loss S-social supports lacking O-organized plan N-no spouse S-sickness |
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Episodes of alternating mood swings, ranging from happy to depressed, to a combo of both
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Bipolar Depression
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What is Dysthymia?
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Persistent, chronic depression (at leat 2 yrs). Starts in childhood and is refractory to treatment.
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What is seasonal depression?
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Occurs during fall and winter. Full remission during spring and summer.
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What is psychotic depression?
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Pt has delusions/hallucinations.
It's recurring. Can manifest as psychotic episodes in the future. |
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Criteria for Depression, the Target Symptoms=(FAT SAD PIGS)
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F-fatigue
A-agitated T- trouble concentrating S-sleep problems A-appetite change D-decreased libido P-psychomotor changes I-interest loss G-guilt S-suicidal ideation |
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What is postpartum depression?
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Severe, persistent depression that occurs within one month following childbirth.
It can include psychotic features. And can be chronic and last at least 2 yrs. |
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What is mixed anxiety depression?
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significant symptoms of both anxiety and depression.
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What is premenstrual dysphoric disorder?
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Depressed with carb cravings. It is more severe than PMS. (heaven help us all!)
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What are the advantages of psychotherapy treatment of depression?
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benefits last longer than meds
helps prevent relapse |
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Who is at greater risk of depression?
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Women
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Rational Basis for med selection:
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STEPS
Safety (toxicity/drug reactions) Tolerability (ADRs, acute/chronic) Efficacy Price Simplicity (dosing, need for monitoring) |
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What other medical disorder should first be assessed if a person is depressed – before starting an antidepressant?
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Thyroid function. TSH.
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When talking about antidepressants, efficacy means ________ and effectiveness means ________
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Efficacy=6-8 wks effective in clinical setting
Effectiveness=long term |
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How often should you monitor pts on antidepressants? And what things are monitored?
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Weekly or biweekly for the first 8 weeks.
Monitor compliance, time course of response, safety, ADRs, and drug interactions |
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What is the expected time course for a response to antidepressants?
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At 6-8 wks the depressed mood subsides.
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How do you monitor a "response" to a drug?
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improvement by 50% in baseline symptoms
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How do you monitor "remission" of symptoms after taking a drug?
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No symptoms for 2 months
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What is discontinuation syndrome?
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The onset of a cluster of somatic and psychic symptoms after the discontinuation of an antidepressant drug, not attributable to other causes.
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What are the symptoms of discontinuation syndrome? (FINISH)
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Flu-like symptoms
Insomnia Nausea Imbalance Sensory disturbances Hyperarousal |
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How do you prevent discontinuation syndrome?
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Tapering rather than abruptly stopping the medication.
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Sudden TCA discontinuation results in:
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Cholinergic rebound: diaphoresis (excessive sweating), N/V, diarrhea
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How do you taper off antidepressants?
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Lower dose by 25% every 1-2 wks
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Whenever you see 5HT, you know its talking about...
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Serotonin Receptor Effects!
here are some common effects: anxiety, depression, migraine, sexual dysfunction, sleep arousal weight gain, nausea |
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Trazodone ADRs
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Sedation
Orthostasis Priapism (>4 hr erection.....how do function after an hour?) |
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Nefazodone ADRs
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Nef=Nephi=SO LDS
Seizures Orthostasis Liver toxicity Drug Interactions Sedation |
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Bupropion ADRs
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Nausea
Dizziness Tremor Insomnia Seizures Arrhythmias Blood Pressure increase |
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Venlafaxine/desvenlafaxine
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At lower doses: N/V
At higher doses: increase BP, cholesterol Withdrawal effects Can be fatal if OD |
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Duloxetine ADRs
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Nausea, Diarrhea, sedation
Dry mouth Liver toxicity Increased HR Increased BP Inhibits CYP2D6 |
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Mirtazapine ADRs
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Sedation
Weight gain |
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What are CYP 450 enzymes?
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The function of most CYP enzymes is to catalyze the oxidation of organic substances. CYPs are the major enzymes involved in drug metabolism and bioactivation
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Why are the effect of drugs on the CYP enzymes important?
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Many drugs may increase (induction) or decrease (inhibition) the activity of the CYP enzymes . This is a major source of ADRs, since changes in CYP enzyme activity may affect the metabolism and clearance of various drugs.
*For example, if one drug inhibits the CYP-mediated metabolism of another drug, the second drug may accumulate within the body to toxic levels. |
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If its a question about CYP inhibition, your best bet is choosing a drug name that starts with...
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F.
Seriuosly, fluoxetine blocks 3/5 and fluvoxamine blocks 4/5 of the options. And at least one of them blocks every CYP. Just in case you don't want to stress about remembering the CYP questions cause they're confusing. |
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What things should be considered when selecting an antidepressant for pts with comorbidities?
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--use one that may work in more than one disease state
--cost, ADRs, drug interactions --First line: try SSRIs --Second line: venlafaxine, bupropion, mirtazapine, nefazodone |
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If a pt has a HA comorbidity, which antidepressant should they use?
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TCAs
*avoid SSRIs |
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If a pt has comorbities of smoking and parkinson's which antidepressant is best?
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bupropion
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If a pt has an anxiety comorbidity which antidepressants are best?
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SSRIs, venlafaxine, nefazodone, TCA
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If a patient has atypical depression which antidepressants are best?
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SSRI, bupropion, MAOI
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Which antidepressant is used with comorbidities of wt gain, sedation, and when a antiemetic effect is desired?
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mirtazapine
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Which antidepressant is used with comorbidity of CV disease?
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SSRIs, bupropion
*avoid TCAs |
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Which antidepressant is used with comorbities of alzheimers?
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use SSRIs, bupropion, venlafaxine
*avoid TCAs |
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Which antidepressant is used with comorbidity of DM?
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TCA, SSRI, Duloxetine, Paroxetine
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Which antidepressant is used with comorbidity of insomnia?
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trazodone, mirtazapine, TCAs
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Psychotic depression is treated with:
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Antipsychotic + SSRI or TCA
MUST USE BOTH!!! (not sure what it means but its on pg 160 and in all caps, so I felt it was important) |
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Which antidepressants are approved for pregnancy by the FDA?
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Ha! None of them. It's too risky for the FDA to back. Trick question.
But sometimes the potential benefit to the mom outweighs the fetal risk |
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Pregnancy and SSRIs or SNRIs. What are the possible ADRs?
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withdrawal reactions, low birth weight, seizures, transient neurobehavioral problems, septal heart defects, pulmonary hypertension
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If pregnant mom is already on an antidepressant and it is working well....
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do not change!
*don't continue TCAs if she's suicidal |
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If mom becomes depressed during pregnancy, and needs to be put on antidepressant....
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use SSRIs and not TCAs
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Mom should taper off antidepressants before due date to avoid:
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-cholinergic rebound with TCAs
-discontinuation syndrome with SSRIs |
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The first line agents for postpartum depression are....
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SSRIs
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What are the breastfeeding guidelines for postpartum depression treatment w/ antidepressants?
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-stay on same drug as during pregnancy
-breastfeed when SDC (serum drug concentration) is lowest -Might need to withhold nursing for 4 hrs after taking meds |
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What are the 3 phases of Therapy?
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Acute:6-10 wks (achieve response)
Continuation: 4-9 mos (prevent relapse) Maintenance: after 12 mos (prevent recurrence) |
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What are refractory pts?
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Pts who don't achieve remission after 2 optimal treatment trials
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Which class of antidepressants are recommended for the elderly? Which should be avoided?
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SSRIs are first line
TCAs should be avoided |
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Which class of antidepressants are recommended for children and adolescents?
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Fluoxetine (SSRI)
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How does St. John's Wort interact with other drugs?
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It decreases the SDCs of many other drugs
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What does SDC mean?
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Serum Drug Concentratin
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Should you combine St. John's Wort with other antidepressants?
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Never!
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St. John's Wort is used for...
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mild depression
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If the pt's response at 6-8 wks is only somewhat better, continue the treatment and
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increase the dose! And reassess at 12 wk mark.
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If the pt's response at 6-8 wks is clearly better, continue for...
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8 more wks
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If after 6-8 wks the pt's response has shown no improvement....
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change to a different antidepressant
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What side effects should you try and minimize when prescribing TCAs?
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Anticholinergic, sedation, cardiovascular
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What side effects should you try and minimize when prescribing SSRIs?
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insomnia, GI (nausea, diarrhea, farts), sexual dysfunction
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What are the key roles for the clinician in treating with antidepressants?
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Identify/assess persons w/ depression
Inform pt about treatment Evaluate efficacy/ADRs Provide encouragement/ support |
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Antidepressants are not...
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addictive
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Initial anti-depressant therapy length is ....
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6-12 mos after Sx resolve
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Know the cases on page 173-177
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She said her test would have similar case studies
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What does titration mean?
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incremental increase in drug dosage to a level that provides the optimal therapeutic effect.
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TCAs have something in common...
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All TCAs generally have the same function (NE and 5HT reuptake inhibitors) and show all 5 ADRs, the only difference being Nortriptyline which is the lowest orthostasis (falls risk)
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What is orthostasis?
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Head rush or dizzy spell, can be a fall risk
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What are the 5 categories for the comparison side effects of antidepressants?
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1) Anticholinergic
2) Sedation 3) Seizures 4) Orthostasis 5) Arrhythmias |
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How do TCAs work?
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TCAs function to inhibit the reuptake of NE and serotonin (5HT), causing increased levels of both in the brain.
Low serotonin levels have been linked to depression and anxiety. Norepinephrine is believed to be associated with the fight or flight stress response. It contributes to feelings of alertness. |
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Bupropion is unique in that it is the only....
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DA reuptake inhibitor out of the anti-depressants.
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What do anticholinergic side effects include?
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dry mouth
dry eyes increased heart rate difficulty emptying our bladder constipation headaches confusion |
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What are the antidepressants of choice in pregnancy? Lactation?
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Use an SSRI, continue same if already on one that is working. Don’t continue TCAs if she’s suicidal. Same drug as pregnancy, SSRIs always good. No Doxepin.
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Worst Antidepressants for sedation.
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TCAs
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Worst Antidepressants for weight gain.
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Paroxetine
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Worst Antidepressants for HA
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Fluvoxamine and Sertraline
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Best antidepressants for help with insomnia.
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Trazodone, mirtazapine, or TCAs
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Worst Antidepressants for sexual dysfunction.
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Paroxetine (SSRI) and TCAs
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What is serotonin syndrome?
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When the body has too much serotonin, usually caused by taking two serotonergic agents. Don’t take two SSRIs, or SSRIs and SNRIs, or SSRIs and MAOIs.
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What two antidepressants cause the most discontinuation syndromes?
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Paroxetiine and venlafaxine
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What is the main serious side effect of bupropion?
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seizures although rare
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What is the main serious side effect of Nefazodone?
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Liver toxicity
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Two main side effects of trazodone?
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sedation and orthostatsis.
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What are the two main side effects of venlafaxine and at what doses?
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Lower doses they inhibit serotonin reuptake so you see GI side effects; at higher doses you see inhibition of NE reuptake so you see increased BP.
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What is the best antidepressant for Parkinson's?
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bupropion
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What is the best antidepressant for Alzheimer's?
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SSRIs, bupropion, venlafaxine (no TCAs)
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What is the best antidepressant for pain syndromes?
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TCAs
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What is the best antidepressant chemo pts?
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mirtazapine
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What is the best antidepressant for atypical depression?
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SSRI
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What is the best antidepressant for insomnia?
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trazodone, mirtazapine
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What is the best antidepressant when in doubt?
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SSRI
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Why is the first 1-3 wks of antidepressant therapy the most dangerous?
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1-3 most dangerous because energy increases but the depression has not (suicide danger).
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What make up the work up for treating someone for depression?
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--Medical/medication Hx and possible causes of depression associated
--physical/neuro exam --Lab work:TSH, electrolytes, blood count --ECG if considering TCAs |
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With Refractory pts what is the bottom line?
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-dose increase
-switch antidepressants -combine antidepressants -augmentation w/ non-antidepressant |
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Consider lifetime treatment if:
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-Elderly
-3rd episode -after 2nd episode if >50 y/o -after 1st episode if > 60 y/o - 2 episodes in 5 yrs |
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When switching from one anti-depressant to another always:
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cross taper medications
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The SSRIs:
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--are all 5HT uptake inhibitors.
--and pretty much the only side effects are sedation and seizures. --paroxetine does have anticholinergic effects and is the worst for WT Gain out of all the antidepressants |
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Things to remember SSRIs
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-if it starts with an F or an E it's an SSRI
-if it doesn't cause arrythmias its like 90% sure to be a SSRI -If it doesn't inhibit NE reuptake, it's most likely SSRI -SSRIs have the least amount of ADRs, and the ADRs they have are moderate |
