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62 Cards in this Set
- Front
- Back
three major categories of depressive disorders
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major depressive disorder
dysthymic disorder cyclothymic disorder |
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what are the 5 "R's" of major depressive disorder
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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) |
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definition of response when applied to mood disorder drugs
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50% reduction in symptoms
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risk factors for depression (9)
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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 |
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DSM IV criteria for depression (9)
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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 |
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criteria for major depressive disorder
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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 |
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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
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acronym for symptoms of depression
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SIG E CAPS
S: sleep I: interest G: guilt E: energy C: concentration A: appetite P: psychomotor S: suicide |
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physical brain changes in the patient w/ depression
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reduced volume/thickness of the nucleus accumbens, basal ganglia, and cortex (All are involved in the pleasure pathway)
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area of the brain associated w/ depressed patients' thoughts and actions involving suicide
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parahippocampal cortex
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systems supposed to be involved in depression
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noradrenergic and serotonergic systems (dec. in the relase of 5HT and NE)
both supported by genetic evidence and response to drugs |
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effect on those who have the short allele for the serotonin transporter gene
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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 |
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what contributes to the symptoms seen in post-traumatic stress disorder?
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overactivity of the noradrenergic system
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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 |
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major classes of antidepressants
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SNRI's (include TCA's)
SSRI's NDRI's SARI's NASA's MAOI's SNRI's + DA |
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antidepressants that inhibit the reuptake of both NE and 5-HT, eventually resulting in down-regulation of post-synaptic receptors
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TCA's
(tertiary amine TCA's work more on serotonin, and secondary amine TCA's work more on norepinephrine) |
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TCA that has an additional effect on dopamine reuptake (additional to effects on 5-HT and norepi)
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amoxapine
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SNRI'S
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TCA's
Duloxetine Venlafaxine Maprotiline (very little 5-HT RI, mostly NE RI and alpha 2 RA) |
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SSRI's
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Citalopram
Escitalopram Fluoxetine (Prosac) Fluvoxamine Paroxetine Sertraline |
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NDRI's
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Bupropion
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SARI's
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Nefazodone (+ alpha blockade)
Trazodone |
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NASA's
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Mirtazapine (+ alpha and H1 blockade)
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MAOI's
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Isocarboxazid
Phenelzine Selegiline Tranylcypromine |
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SNRI's + DA
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Amoxapine
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***3 key side effects of tricyclic antidepresssants***
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cardiovascular (orthostatic hypotension, dysrhythmias)
anticholinergic (dry mouth, urinary retention, constipation, blurred vision) CNS (particularly seizures) |
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class of antidepressants that was derived to minimize the effects of antidepressants
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secondary amines
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3 C's of toxic ingestion of TCA's
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Coma
Cardiotoxicity Convulsions |
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antidepressants that selectively inhibit the reuptake of serotonin, eventually resulting in down-regulation of post-synaptic receptors
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SSRI's
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the major SSRI
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Fluoxetine (Prosac)
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most serious side effect of the SSRI's
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serotonin syndrome
sweating hyperreflexia akathisia/myoclonus shivering/tremors |
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antidepressants that selectively inhibit the reuptake of 5-HT and NE eventually resulting in down-regulation of post-synaptic receptors
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SNRI's
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the major SNRI's
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TCA's
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extended release antidepressant that has a significant withdrawal syndrome
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venlafaxine
(note: all antidepressants should be titrated slowly to prevent potential withdrawl symptoms) |
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**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 |
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antidepressants that non-selectively inhibit MAO, thereby increasing levels of NE, 5-HT, and DA
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MAOI's
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the best predictor of a completed suicide
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previous suicide attempt
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point at which grief and bereavement may indicate major depressive disorder
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normal grieving begins w/in 2-3 weeks of a loss and resolves in 6-8 weeks
signs >2 months may indicate MDD |
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Bipolar disorders (3)
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Bipolar I: full blown mania (manic w/ psychotic stymptoms)
Bipolar II: hypomania w/o psychotic episodes Cyclothymic disorder |
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DSM-IV mania criteria
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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 |
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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
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area of the brain, involved in the circadian rhythm, that has also been implicated in the pathophysiology of bipolar disorder
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suprachiasmatic nucleus
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most important gene that has been implicated in the pathophysiology of bipolar disorder
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glycogen synthas kinase 3-beta
regulates CLOCK inhibited by lithium - provides neuroprotective signals |
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drug that is indicated for acute AND maintenance treatment of mania/bipolar disorder
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lithium
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3 key actions of lithium
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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 |
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boards: important adverse effect of lithium
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induction of nephrogenic diabetes insipidus
hyponatremia and hypotension as well |
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key drug-drug interactions of lithium affecting Na/K
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diuretics and ACE inhibitors
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3 anti-bipolar mood stabilizers that were initially developed as anti-seizure medications
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carbamazepine
valproic acid lamotrigine |
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only bipolar drug that is class C in pregnancy (the others are D, do not use)
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Lamotrigine
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key side effects of carbamazepine and valproic acid
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CNS (Dizziness,Diplopia,sedation), hematologic (agranulocytosis/aplastic anemia), and hepatotoxicity
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the big bad ugly side effect that is associated w/ lamotrigine
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Steven's-Johnson syndrome
(teach your patients about the rash) |
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drugs routinely used as first line agents for depression
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SSRI's and non-cyclic SNRI's
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What is the role of cortisol during stress?
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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
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What are the two genes that are involved in determining a patients response antidepressants and CBT?
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BDNF
HTR2a |
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What is the key difference between SSRI's
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half life
CYP 450 - drug-drug interactions |
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Which SSRI's have the lowerst drug to drug interactions (CYP450)?
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citalopram
sertraline |
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Key difference between venlafaxine and duloxetine?
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Venlafaxine has less CYP 450 impact and duloxetine also inhibits platlets...More likley to have bleeding.
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In general how is a crisis managed?
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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 |
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Grounds for involuntary commmitment to a hospital?
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Imminent danger to ones self or others
Inability to care for ones self |
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Major criteria for mania?
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Elevated mood for at least 1 week
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3 organic causes of mania
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ADR of drugs or overdoses
Hyperthyroidism Neurologic |
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Bipolar tx and pregnancy?
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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 |
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Common but not life threatening ADR of Lithium
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Weight gain
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