Behavioral Science (Block 6): Treatment For Depression/ect

Front 1

serotonin is synthesized from ________ and metabolized by _______. Once it's released into the synaptic cleft, serotonin is taken back up by ________.

Back 1

tryptophan; monoamine oxidase (MAO-A); serotonin transporter (SERT)

Front 2

which serotonin receptors are most relevant to medications for mood disorders? how does serotonin affect depression?

Back 2

5HT1A, 5HT2

decreased serotonin leads to some of the core symptoms of depression

Front 3

which adrenergic receptor is most significant in treating depression with norepi?

Back 3

alpha 2

Front 4

The dopamine system is organized in a fashion that suggests the primary function is modulation of neuronal activation in target projection areas:

Nigrostriatal is related to ____.
Mesolimbic is related to _____.
Mesocortical is related to _____.
Mesolimbic to nucleus accumbens is related to _____.

Back 4

motor fxn

reward and motivation

memory/attn

reinforcing properties of drug abuse and pleasurable activities

Front 5

medications that INC/DEC dopamine transmission are effecitve antidepressants.

Back 5

INC

Front 6

Depression is associated with atrophy of which part of the brain?

Back 6

hippocampus

- Atrophy correlates with the duration of depression
- Emerging data correlates remission of depression with restoration of normal hippocampal volume (if you treat depression, you see normalization of the size of the hippocampus – helps you say, this treatment works)

Front 7

in regards to the cytochrome P450 system, what's the main diff b/w 2D6 enzyme inhibition vs. 3A4 inhibition? which one's worse?

Back 7

If I give many SSRIs, it’ll block 2D6 enzyme. If there’s another medication that requires 2D6 to break it down, body won’t be able to break it down anymore. This can be toxic and cause side effects. Generally not as problematic bc there are other means of metabolism for the drugs that have issues with this enzymes. Or they’re not as toxic.

3A4 Inhibition –MORE SERIOUS problems caused by drugs that inhibit this enzyme. Highly toxic. this is the one you have to be most cautious about with drug interactions

3A4 GETS AN A+ FOR BEING BAD

Front 8

how do SSRIs work (in general)?

Back 8

inhibit presynaptic reuptake of 5HT and inc amt of neurotransmitter in the synapse --> alter genetic expression

Front 9

Name the major side effect of SSRIs. Name some other side effects....

Back 9

sexual dysfunction (men get delayed ejaculation and women get anorgasmia); loss of libido

other SE's: anxiety, restlessness, sleep disturbance, nausea, loose stools, headache, tremor, inc perspiration, dry mouth, YAWNING, vivid dreams

Front 10

All SSRIs except ______ have a half life shorter than ____.

Back 10

fluoxetine (prozac); 24 hrs.

Front 11

Fluoxetine (Prozac)

Back 11

mechanism: SSRI + some NE reuptake inhibition

uses: major depression, dysthymia, generalized anxiety disorder + other SSRI indications

SE: most safe SSRI to use to treat during pregnancy

misc: has longest half-life of the SSRIs, good bc it self-tapers off

Front 12

Sertraline (Zoloft)

Back 12

mechanism: SSRI + some DA activity (may be useful in brain injured pts)

short half life (24 hrs)

uses: anti-depressant

Front 13

which SSRI has the longest half life?

which anti-depressent would you use in a depressed pregnant mother?

Back 13

both FLUOXETINE (PROZAC)

Front 14

name the specific SSRIs (5)

Back 14

"For Sure People Can Fail"

fluoxetine
sertraline
paroxetine
citalopram
fluvoxamine

Front 15

Paroxetine (Paxil)

Back 15

mechanism: SSRI + some anticholinergic activity

short half life: 24 hrs

uses: anti-depressive, anxiety disorder (bc its somewhat sedating)

SE: anticholinergic SEs (dry mouth, constipation, blurred vision, gain weight/eat more)

SE: SIGNIFICANT 2D6 INHIBITION (SO DON'T CHOOSE THIS DRUG IF THERE'S CHANCE OF INTERACTION W/ OTHER DRUGS)

Front 16

Citalopram (Celexa)

Back 16

mechanism: SSRI

short half life: 24 hrs

uses: anti-depressant + other indicaitons for SSRIs

FEWER DRUG INTERACTIONS (USEFUL FOR SOMEONE ON LOTS OF DRUGS)

Front 17

Fluvoxamine (Luvox)

Back 17

mechanism: SSRI

uses: depression (not approved) + mainly OCD (approved)

Front 18

what is serotonin syndrome?

Back 18

rare problem when you use more than one SSRI that results in fever, delirium, hypertension (can result in DEATH)

THIS IS THE REASON WHY YOU DON'T WANT TO USE MORE THAN ONE SSRI AT ONCE

Front 19

Buproprion (Wellbutrin). WHAT'S THE MOST IMPORTANT THING ABOUT THIS DRUG?

Back 19

mechanism: inc DA and NE

uses: ANTIDEPRESSANT, smoking cessation, can dec sexual side effect when given with SSRI, usefull in treating ADHD

MOST IMPORTANT!! ==> DON'T GIVE THIS DRUG TO ANYONE WITH OR HAS HAD HISTORY OF SEIZURES OR EATING DISORDERS

"Just say Boo to Buproprion if the pt has had seizures of Boo-lemia."

Front 20

Nefazodone (Serzone)

Back 20

mechanism: serotonin presynaptic reuptake inhibitor (SSRI) + postsynaptic 5HT2 receptor antagonist

uses: antidepressant

SE: sedating, fewer sexual side effects, SIGNIFICANT 3A3/4 INHIBITION (RISK OF HEPATIC FAILURE==> NOT USED MUCH ANYMORE)

"NEFAZODONE IS FAST BECAUSE IT ACTS ON THE SYNAPSE BEFORE AND THEN AFTER!"

Front 21

Venlafaxine (Effexor)

Back 21

mechanism: NE and 5HT presynaptic reuptake inhibitor

uses: anti-depressant, generalized anxiety disorder

SE: similar to SSRIs, DOSE RELATED INCREASE IN BLOOD PRESSURE

misc: ONLY ANTI-DEPRESSANT WITH META-ANALYSIS THAT SHOWS BETTER RESULTS FOR RECURRENT DEPRESSION

Front 22

Desvenlafaxine (Pristiq)

Back 22

mechanism: Relatively greater norepinephrine reuptake inhibition than venlafaxine but still more serotonergic than noradrenergic

uses: anti-depressant, may be helpful in pain conditions (ie. fibromyalgia)

Front 23

Duloxetine (Cymbalta)

Back 23

mechanism: 5HT/NE reuptake inhibition

uses: anti-depressant for pt with pain conditions

SE: similar to SSRIs

Front 24

which anti-depressant(s) would you use in a pt with chronic pain conditions?

Back 24

duloxetine or desvenlafaxine

Front 25

Mertazapine (Remeron)

Back 25

mechanism: antagonist at PRESYNAPTIC alpha-2 adrenergic autoreceptor (so that NT's can't bind and put the brakes on, leading to more 5-HT & Epi)

uses:anti-depressant

SE: antihistaminc properties dramatically inc appetite --> serious weight gain; also sedation (can be helpful in pts with problems of loss of appetite or poor sleep)


DON'T GIVE MERTAZAPINE TO MERTA, SHE DOESN'T NEED THE EXTRA WEIGHT! SHE ALSO CAN'T STOP EATING BECAUSE SHE LOST THE AUTO-RECEPTOR FXN.

Front 26

What is the major concern for use of Trazodone?

Back 26

PRIAPISM (prolonged, painful erection) as a side effect - failiure to treat in timely manner could result in permanent ED

by the way, trazodone's mechanism is to inhibit serotonin reuptake

Front 27

Tricyclic antidepressants (TCAs)

Be sure to address other uses of TCAs

Back 27

mechanism: block reuptake of serotonin, & NE, block alpha-1 receptors, block histamine receptors, block muscarinic cholinergic receptors

uses: anti-depressant, pain management, OCD, enuresis (bed wetting)

SE: NOT USED ANYMORE DUE TO SO MANY SIDE EFFECTS RELATED TO THE THINGS IT ACTED ON; Anticholinergic (dry mouth, consitipation); alpha-adrenergic (orthostatic hypotension); antihistamine (sedation, inc appetite/weight gain); PROLONGED QT INTERVAL ==> TCAs ARE VERY LETHAL IN OVERDOSE

Front 28

Monoamine Oxidase Inhibitors (MAO inhibitors) - Selegiline (Emsam)

Back 28

mechanism: inhibit enzyme that metabolizes NE, 5-HT, DA, and tyramine ==> result in inc NTs in the synapse

uses: major depression, anxiety disorder, social phobia, treatment resistant depression

SE: HYPERTENSIVE CRISIS following consumptino of tyramine containing foods, drugs with DA, etc.

Front 29

Which anti-depressant is very dangerous with low doses and has lethal potential in an overdose?

Back 29

TCAs

Front 30

T or F. putting a pt on antidepressant medicationns puts them at higher risk for suicidal thinking/behavior.,

Back 30

T

Front 31

What disorder ECT is used for

Back 31

1) major depressive disorder (most common -- ECT is the FASTEST/MOST EFFECTIVE Tx for depression)

2) manic episodes

3) schizophrenia (only in those catatonic or mood symptoms - NOT effective for chronic schizo)

"ECT is useful for a Depressed Middle Schooler"

Front 32

What kind of workup would be done in preparing someone for ECT?

Back 32

physical exam
blood counts/chemistries
urinalysis
EKG
CXR
EEG

Front 33

Relative contraindications for ECT (which situations require inc monitoring)?

Back 33

pregnancy, space occupying lesions in CNS, inc intracranial pressure, risk of CNS bleeding, MI within 3 months, uncontrolled hypertension

Front 34

Generally, what is the scientific evidence for the efficacy of ECT?

Back 34

neurochemical studies show changes in every NT system after ECT (down reg of post synaptic beta-adrenergic receptors, changes in post synaptic serotnoin receptors, etc)

Front 35

SE's of ECT?

Back 35

headache
confusion
delirium shortly after seizure.

transient memory loss is also common ({only lose memory around time of Tx).

cardiac arrhythmias

Front 36

what type of therapy can be useful for SAD (seasonal affective therapy)?

Back 36

light therapy

Front 37

SE's of light therapy?

Back 37

headache, eyestrain, nausea, jumpiness/agitation

Front 38

transcranial magnetic stimulation is a newly approved Tx for depression. how does it work?are there side effects?

Back 38

rapid alternating current induces magnetic field in brain to pulse over the dorsolateral prefrontal cortex (DLPFC)

- daily stim for several weeks causes activation of various circuits that leads to an antidepressant effect

FEW SIDE EFFECTS (OTHER THAN HEADACHE)

Front 39

How is deep brain stimulation helpful for depression?

Back 39

- Highly experimental treatment for the most severe forms of depression
- Stimulation device is a battery powered pulse generator implanted in the chest
- One or two leads are tunneled under the scalp then guided into the brain often the subgenual area of the anterior cingulate cortex, part of the ventromedial prefrontal cortex
- This area has important connections to other areas including orbitofrontal cortex, DLPFC, and amygdala