120: Antidepressants Flashcards

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1
Q

Which classes of antidepressants are useful in the treatment of chronic pain?

A

SNRIs (serotonin-norepinephrine reuptake inhibitors)

TCAs

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2
Q

Which class of antidepressants is especially useful for treating migraine?

A

TCAs

(Especially amitryptiline)

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3
Q

Which amino acid is a precursor for serotonin?

A

Tryptophan

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4
Q

Tyrosine is a precursor for which neurotransmitters?

A

Dopamine, NE

(Dopamine is a precursor for NE)

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5
Q

List 3 common features of all classes of antidepressants

A
  • Takes 3-8 weeks to be maximally effective
  • All have equivalant response and remission rates
    • 50-70% response
    • 35-50% remission
  • Placebo-drug differences depend on the level of severity of depression
    • More severe depression = less placebo effect
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6
Q

If a patient experiences partial improvement at the maximally tolderated dose of antidepressant A, what is the next step in their management?

A

Add another antidepressant of a different class

OR

Target residual symptoms with other treatments

Remeber: The goal of treatment is complete response

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7
Q
A

c. Bupropion

  • Helpful in depression w/o anxiety symptoms
  • Will treat comorbid tobacco dependence
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9
Q

How should you select a first-line antidepressant?

(What factors should influence your decision?)

A
  • Side effect profile
  • Past response
  • Comorbid medical and psichiatric problems

Remember: no significant differences in efficacy among first line medications

Consider psychotherapy in addition

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10
Q

Which classes of antidepressants are first line for treating depression?

A
  • SSRI
  • SNRI
  • Mirtazapine
  • Bupropion

Select agent based on side-effect profile

All have comparable efficacy

TCAs and MAOIs are not first line due to higher side effect burden, potential for lethal overdose

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11
Q

What are the 6 most common side effects of SSRIs and SNRIs?

Which ones usually improve?

A
  • GI upset
  • Anxiety, agitation
  • Insomnia
  • Headache
  • Sweating
  • Sexual dysfunction

All except sexual dysfunction usually improve

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12
Q

List 3 serious risks of antidepressant treatment

A
  • Increased risk of suicidal thinking, behavior in young people
    • Highest in the first few days on the medication
    • Risk of treatment < risk of untreated depression
  • Serotonin syndrome
  • Do not give antidepressant monotherapy for anyone with bipolar disorder
    • Increases manic episodes
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13
Q

What is serotonin syndrome?

How can it be avoided?

A

Result of increased 5HT activity in the brain, usually from multiple serotoninergic drugs

  • Mental status change
  • Hyperthermia
  • Hyperreflexivity

Never combine MAOIs with TCAs or SSRIs

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14
Q

Which SSRI has the longest half life?

Why is this important?

A

Fluoxetine

  • No need to taper
  • Requires long wash-out if transitioning to MAOI
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15
Q

Which SSRI has the highest risk of drug-drug interactions?

Why?

A

Paroxetine

It is a potent CYP26 inhibitor

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16
Q

Which SSRI has the shortest half life?

Why is this important?

A

Paroxetine

Results in the worst discontinuation symptoms (must taper)

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17
Q

Which SSRI should be avoided in anyone with cardiac comorbidities?

A

Citalopram

Dose-depenent QT prolongation

18
Q

Which SSRI is preferred in pregnancy?

A

Sertraline

19
Q

What is the most common side effect of the SNRIs?

A

Hypertension

(In addition to the side effects common to all agents that increase 5HT and NE: GI upset, weight gain, sweating, sexual dysfunction)

20
Q

What is the mechanism of action of TCAs?

A

Inhibit NE and 5HT reuptake

21
Q

What are the common side effects of TCAs?

A
  • Sedation
  • Weight gain
  • Orthostatic hypotension
  • Arrhythmia (may be fatal)
  • Seizure
  • Sexual dysfunction
  • Anticholinergic effects
    • Dry mouth, urinary retention, constipation
22
Q

What special diet must be followed when a patient is on a MAOI?

What happens if they do not follow this diet?

A

Tyramine free diet:

No aged cheese, red wine, fava beans, cured meats

Can cause hypertensive crisis if ingested while on MAOI

23
Q

Which antidepressant should you prescribe to a patient that does not have anxiety symptoms and does not want to experience weight gain or sexual dysfunction?

A

Buproprion

May worsening existing anxiety symptoms

(Mirtazapine does not have sexual side effects, but can cause weight gain)

24
Q

Which antidepressants carry the lowest risk of switch to mania if there is undiagnosed bipolar disorder?

A

Bupropion

Mirtazapine

25
Q

What are the mechanisms of action of mirtazapine?

A
  • blocks
    • Alpha-2
    • 5HT-2 and 5HT-3
    • H1
  • Increased NE and 5HT release
26
Q

Which antidepressant is often used elderly patients with insomnia and low appetite?

A

Mirtazapine

Side effects of sedation and weight gain may be helpful!

27
Q

What is the mechanism of trazodone?

A
  • 5HT-2 receptor block
  • Alpha-1 block
  • Histamine block

(Not great for depression, effective for insomnia)

28
Q

Which antidepressant has the potential side effect of priapism?

A

Trazodone