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62 Cards in this Set

  • Front
  • Back
three major categories of depressive disorders
major depressive disorder
dysthymic disorder
cyclothymic disorder
what are the 5 "R's" of major depressive disorder
response ("better" 50% reduction in symptoms)
remission ("well" - this is where we want to patient to be)
recovery (remission for 6-12 months)
relapse (symptoms occur before remission)
recurrence (symptoms occur after remission starts)
definition of response when applied to mood disorder drugs
50% reduction in symptoms
risk factors for depression (9)
family history of episodes or depressive disorder
hx of suicide attempts
female
onset before age 40
postpartum period
comorbid medical illness
absence of social support
negative, stressful life events
active alcohol or substance abuse
DSM IV criteria for depression (9)
depressed mood most of the day, nearly every day
anhedonia
major change in appetite, weight, and sleep
psychomotor agitation/retardation
fatigue
feelings of worthlessness
excessive guilt
diminished ability to think/concentrate
recurrent thoughts of death/dying/suicide
criteria for major depressive disorder
five or more symptoms of depression present during the same 2 week period and represent a change from previous functioning

at least one of the symptoms is either depressed mood or anhedonia
depressed mood for most of the day, more days than not, as indicated either by subjective account or by observation by others, for at least 2 years

in children, disturbances must be noted for at least 1 year
dysthymic disorder
acronym for symptoms of depression
SIG E CAPS

S: sleep
I: interest
G: guilt

E: energy

C: concentration
A: appetite
P: psychomotor
S: suicide
physical brain changes in the patient w/ depression
reduced volume/thickness of the nucleus accumbens, basal ganglia, and cortex (All are involved in the pleasure pathway)
area of the brain associated w/ depressed patients' thoughts and actions involving suicide
parahippocampal cortex
systems supposed to be involved in depression
noradrenergic and serotonergic systems (dec. in the relase of 5HT and NE)

both supported by genetic evidence and response to drugs
effect on those who have the short allele for the serotonin transporter gene
amygdaloid response to threatening visual images is enhanced

coupling between cingulate cortex and amygdala is severely diminished (normally extinguishes amygdaloid response)

the result is the anxiety associated w/ depression
what contributes to the symptoms seen in post-traumatic stress disorder?
overactivity of the noradrenergic system
4 options for the treatment of depression

data suggests that combinations of these therapeutic options is more effective in the treatment of depression
pharmacotherapy
electroconvulsive therapy (used if refractory to other forms of tx)
light therapy
psychosocial therapy
major classes of antidepressants
SNRI's (include TCA's)
SSRI's
NDRI's
SARI's
NASA's
MAOI's
SNRI's + DA
antidepressants that inhibit the reuptake of both NE and 5-HT, eventually resulting in down-regulation of post-synaptic receptors
TCA's

(tertiary amine TCA's work more on serotonin, and secondary amine TCA's work more on norepinephrine)
TCA that has an additional effect on dopamine reuptake (additional to effects on 5-HT and norepi)
amoxapine
SNRI'S
TCA's
Duloxetine
Venlafaxine
Maprotiline (very little 5-HT RI, mostly NE RI and alpha 2 RA)
SSRI's
Citalopram
Escitalopram
Fluoxetine (Prosac)
Fluvoxamine
Paroxetine
Sertraline
NDRI's
Bupropion
SARI's
Nefazodone (+ alpha blockade)
Trazodone
NASA's
Mirtazapine (+ alpha and H1 blockade)
MAOI's
Isocarboxazid
Phenelzine
Selegiline
Tranylcypromine
SNRI's + DA
Amoxapine
***3 key side effects of tricyclic antidepresssants***
cardiovascular (orthostatic hypotension, dysrhythmias)
anticholinergic (dry mouth, urinary retention, constipation, blurred vision)
CNS (particularly seizures)
class of antidepressants that was derived to minimize the effects of antidepressants
secondary amines
3 C's of toxic ingestion of TCA's
Coma
Cardiotoxicity
Convulsions
antidepressants that selectively inhibit the reuptake of serotonin, eventually resulting in down-regulation of post-synaptic receptors
SSRI's
the major SSRI
Fluoxetine (Prosac)
most serious side effect of the SSRI's
serotonin syndrome

sweating
hyperreflexia
akathisia/myoclonus
shivering/tremors
antidepressants that selectively inhibit the reuptake of 5-HT and NE eventually resulting in down-regulation of post-synaptic receptors
SNRI's
the major SNRI's
TCA's
extended release antidepressant that has a significant withdrawal syndrome
venlafaxine

(note: all antidepressants should be titrated slowly to prevent potential withdrawl symptoms)
**most serious adverse effects of the MAOI's**

what molecules are involved in this mechanism
hypertensive crisis

GI MAO-A is inhibited, which is necessary for tyramine metabolism; tyramine can induce significant catecholamine release; tyramine is found in cheeses and red wines
antidepressants that non-selectively inhibit MAO, thereby increasing levels of NE, 5-HT, and DA
MAOI's
the best predictor of a completed suicide
previous suicide attempt
point at which grief and bereavement may indicate major depressive disorder
normal grieving begins w/in 2-3 weeks of a loss and resolves in 6-8 weeks

signs >2 months may indicate MDD
Bipolar disorders (3)
Bipolar I: full blown mania (manic w/ psychotic stymptoms)
Bipolar II: hypomania w/o psychotic episodes
Cyclothymic disorder
DSM-IV mania criteria
elevated mood at least one week
grandiosity
decreased need for sleep
pressured speech
flight of ideas
distractibility
increased goal-directed activity
excessive involvement in pleasurable activities
chronic bipolar disorder consisting of short periods of mild depression and short periods of hypomania

symptoms may last a few days to a few weeks

can be separated by periods of normal mood
***cyclothymic disorder
area of the brain, involved in the circadian rhythm, that has also been implicated in the pathophysiology of bipolar disorder
suprachiasmatic nucleus
most important gene that has been implicated in the pathophysiology of bipolar disorder
glycogen synthas kinase 3-beta

regulates CLOCK

inhibited by lithium - provides neuroprotective signals
drug that is indicated for acute AND maintenance treatment of mania/bipolar disorder
lithium
3 key actions of lithium
inhibit Ca-dependent release of NE, DA, 5-HT, GABA, Ach
inhibit receptor blockers and substances known to stimulate and inhibit G protein synthesis/actions
impacts phosphatidylinositol pathway
boards: important adverse effect of lithium
induction of nephrogenic diabetes insipidus

hyponatremia and hypotension as well
key drug-drug interactions of lithium affecting Na/K
diuretics and ACE inhibitors
3 anti-bipolar mood stabilizers that were initially developed as anti-seizure medications
carbamazepine
valproic acid
lamotrigine
only bipolar drug that is class C in pregnancy (the others are D, do not use)
Lamotrigine
key side effects of carbamazepine and valproic acid
CNS (Dizziness,Diplopia,sedation), hematologic (agranulocytosis/aplastic anemia), and hepatotoxicity
the big bad ugly side effect that is associated w/ lamotrigine
Steven's-Johnson syndrome

(teach your patients about the rash)
drugs routinely used as first line agents for depression
SSRI's and non-cyclic SNRI's
What is the role of cortisol during stress?
It is released from the adrenal cortex and acts throughout the body...When it binds to Glucocorticoid receptors (GR) they are activated and DAMPENS the response to stress
What are the two genes that are involved in determining a patients response antidepressants and CBT?
BDNF

HTR2a
What is the key difference between SSRI's
half life

CYP 450 - drug-drug interactions
Which SSRI's have the lowerst drug to drug interactions (CYP450)?
citalopram

sertraline
Key difference between venlafaxine and duloxetine?
Venlafaxine has less CYP 450 impact and duloxetine also inhibits platlets...More likley to have bleeding.
In general how is a crisis managed?
1. provide support
2. Evaluate the nature of the problem
3. Ensure the patient and others safety
4. Help them make an action plan w/ pertinent phone numbers and have them sign it
5. Follow up
Grounds for involuntary commmitment to a hospital?
Imminent danger to ones self or others

Inability to care for ones self
Major criteria for mania?
Elevated mood for at least 1 week
3 organic causes of mania
ADR of drugs or overdoses

Hyperthyroidism

Neurologic
Bipolar tx and pregnancy?
Plan pregnancy so you can slowly taper off the drugs

If patient has to take the lithium during pregnany inc. risk for CV malformation

Lithium is excreted in the breast milk
Common but not life threatening ADR of Lithium
Weight gain