Depression

Question 1

what are 1st line meds?

Answer 1

SSRI - citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
*most effective and well tolerated
SNRI - venlafaxine, desvenlafaxine, duloxetine (but not levomilnacipran)
Dual Acting (NDRI) - bupropion, mirtazapine
Other (serotonergic) - vortrioxetine

Question 2

what are 2nd line meds?

Answer 2

levomilnacipran (SNRI), moclobemide (MAOI), quetiapine (SGA), trazodone (serotonin receptor antagonist), vilazodone (SRI & partial agonist) & TCAs (Amitriptyline, Nortriptyline, Clomipramine)

Question 3

what are 3rd line meds?

Answer 3

MAOI: phenelzine, tranylcypromine

Question 4

when can patients expect to see improvement?

Answer 4

2-4 weeks, however may notice some improvement in sleep, appetite and mood in 1-2 weeks

Question 5

a minimum therapeutic dose should be achieved in __ weeks, and increased if necessary over ___ weeks.

Answer 5

a minimum therapeutic dose should be achieved in 2 weeks, and increased if necessary over 4-6 weeks.

Question 6

can antidepressants be abruptly discontinued? why or why not?

Answer 6

if used for >6 weeks, will cause discontinuation syndrome

Question 7

what are symptoms of discontinuation syndrome? when do they start and end?

Answer 7

FINISH (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances eg. dizziness, hyperarousal). Symptoms start in few days, and may last 1-2 weeks.

Question 8

how to avoid discontinuation syndrome?

Answer 8

taper by 25% every week over 4-6 weeks

Question 9

what antidepressants cause more discontinuation symptoms?

Answer 9

paroxetine and venlafaxine

Question 10

how long is the treatment duration?

Answer 10

minimum 9 months and up to 2 years if psych comorbidities, residual symptoms, frequent/chronic/severe episodes

Question 11

when to switch to another antidepressant?

Answer 11

during week 3-8 if side effects intolerable or persist more than 2 weeks, or if not responding to dose increases.

Question 12

when switching between antidepressants, what factors determine whether to switch within or between drug class?

Answer 12

switch within if there is some improvement
switch between if there is no improvement

Question 13

how to switch between antidepressants not requiring washout?

Answer 13

crossover technique - dose of the first agent is tapered while the dose of the new antidepressant is gradually increased

Question 14

which antidepressants require a washout when switching TO? how long?

Answer 14

when switching to an irreversible MAOI, must have washout period that is 5 half-lives of first antidepressant

Question 15

which antidepressants require a washout when switching FROM? how long?

Answer 15

when switching from:
- MAOI, a 2 week washout is needed
- Moclobemide, a 5 day washout is needed
- Fluoxetine to iMAOI, a 5 week washout is needed
- Fluoxetine to other, 4-7 day washout is needed

Question 16

what are tx options when there is a partial response to treatment?

Answer 16

-add on SGA (aripiprazole, olanzapine, quetiapine, risperidone, brexpiprazole) for short term only & monitor for EPS, wt gain, CV s/e
-other: lithium, triiodothyronine, bupropion

Question 17

can antidepressants be used in pregnancy?

Answer 17

yes, with some caveats and exceptions:
-paroxetine causes CV malformations
-fluoxetine may cause malformations but controversial
-use lowest effective dose
-may cause neonatal withdrawal sx (tremor, irritability, sleep/resp disturbances)
-use during 3rd trimester may increase risk of pulmonary hypertension

Question 18

can antidepressants be used while breastfeeding?

Answer 18

yes, consider sertraline, citalopram or escitalopram

Question 19

which antidepressants are the most sedating?

Answer 19

mirtazapine and TCAs

Question 20

which antidepressants cause the most weight gain?

Answer 20

mirtazapine and TCAs and some SSRI/SNRI

Question 21

which antidepressants cause the most sexual dysfunction?

Answer 21

paroxetine and SSRI/SNRIs

Question 22

which antidepressants cause the least sexual dysfunction?

Answer 22

bupropion and mirtazapine

Question 23

which antidepressants cause insomnia?

Answer 23

bupropion

Question 24

which antidepressants cause weight loss?

Answer 24

bupropion

Question 25

which antidepressants cause QT prolongation?

Answer 25

citalopram, escitalopram, mirtazapine

Question 26

which antidepressant causes most anticholinergic side effects?

Answer 26

paroxetine (dry mouth, constipation)

Question 27

reversible MAOI

Answer 27

reversible = phenelzine and tranylcypromine
- fatal DDI (SSRI, TCS, levodopa, alcohol, meperidine, sympathomimetics)
- fatal food interactions with tyramine rich foods eg. aged cheese, overripe/spoiled/expired/fermented, fava, soy
- s/e: edema, ortho hypo, insomnia, sexual dysfunction

Question 28

irreversible MAOI

Answer 28

irreversible = moclobemide
- fatal DDI (SSRI, TCS, levodopa, alcohol, meperidine, sympathomimetics + opioids, antipsychotics, selegiline, cimetidine)
- s/e: nausea, insomnia, dizziness

Question 29

TCAs

Answer 29

amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine
- anticholinergic s/e (dry mouth, blurred vision, constipation, urinary hesitancy, tachycardia, delerium)
- antihistaminergic s/e (sedation, weight gain)
other s/e: ortho hypo, sexual dysfunction, decreased seizure threshold

Question 30

SSRI

Answer 30

citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

common s/e on initiation: stomach upset (take w food) except f), headache, dizziness, drowsiness, anxiety (usually resolve after 2w)

Sertraline must be w food for efficacy

Question 31

SNRI

Answer 31

venlafaxine, desvenlafaxine, duloxetine, levomilnacipran
common s/e: nausea, drowsiness

Question 32

are there any supplements for depression?

Answer 32

St. John’s Wort - potential 1st line for mild-mod
S-adenosyl-L-methionine - 2nd line for mild-mod
L-methylfolate - beneficial adjunct to SSRI
Omega-3 & Vit D - no clinically significant benefit

Question 33

dual action antidepressants

Answer 33

bupropion -agitation, insomnia, wt loss, CI in anorexia, bulemia, seizures
mirtazapine -wt gain, sedation, QT

Question 34

serotonin modulators

Answer 34

trazodone -drowsiness, ortho hypo, nausea, headache, dry mouth, priapism
vortrioxetine -nausea, constipation, d/c sx