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3153 IC9,10,11,12,14 Psychiatric > Depression > Flashcards

Depression Flashcards

1
Q

Which psychiatric disorder is highly associated with suicide?

A
  1. Schizophrenia (46.3%)
  2. Depression (26.8%)
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2
Q

What are the 3 best predictors of suicide?

A
  1. Hx of attempted suicide using highly lethal means
  2. Coexisting significant physical illness
  3. Delusions
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3
Q

Components of suicide risk assessment:

A
  • Rapport
  • Collateral information (w consent)
  • Suicide inquiry (ideation, suicide plan, intent, explore ambivalence)
  • Consultation with specialist when in doubt
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4
Q

Suicide risk management

A
  1. Identify and manage underlying disorders (e.g., depression)
  2. Identify risk factors
  • Prior attempts
  • Past/current psychiatric disorders
  • Key symptoms: anhedonia, hopelessness, anxiety, impulsivity, aggression, delusions
  • FH of suicide, child maltreatment
  • Stressors: triggering events
  • Access to meds (drug overdose), firearms, other lethal means
  1. Identify protective factors
  2. Removing means
  3. Activating support system
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5
Q

Suicide questions to ask:

A

Most impt to ask: Have you had any thoughts of killing yourself?

  • refer to counseling

Additional questions: to seek IMMEDIATE help (emergency room)

  • Have you had intention of acting on them?
  • Have you started to work out details on how to kill yourself?
  • Have you done anything / prepared to do anything to end your life? Was this within the past 3 months?
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6
Q

Etiology of major depressive disorder

A
  1. Biological (neuroendocrine)
  • Hormonal influences (incr secretion of cortisol, major stress hormone)
  • Monoamine hypothesis (dcr neurotransmitter in the brain - Norepinephrine, Serotonin, Dopamine)
  1. Psychological
  • Loss, negative self-esteem
  1. Psychosocial
  • Isolation, loss of social support
  1. Genetics
  • S/S genotype on SERT gene: more vulnerable to depression of early life stress
  • L/L genotype more immune to depressive effects of early life trauma
  1. Medical disorders
  2. Pharmacological (intoxication, withdrawal)
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7
Q

Secondary causes for depression: Medical disorders

A
  • Endocrine disorders (Hypothyroidism, Cushing syndrome, Diabetes)
  • Deficiency states (Anemia)
  • Infections - can cause dysphoric mood
  • Metabolic disorders (electrolyte imbalance, hepatic encephalopathy)
  • Cardiovascular: CAD, CHF, MI
  • Neurological: Alzheimer’s, Epilepsy, Parkinson’s, post-stroke, pain - frustration, depression
  • Malignancy, cancer
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8
Q

Secondary causes for depression: Psychiatric disorders

A
  • Alcoholism
  • Anxiety disorders
  • Eating disorders
  • Schizophrenia
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9
Q

Secondary causes for depression: Drug-induced

A
  • Lipid-soluble beta-blockers (*propranolol can cause psychosis)
  • Psychotropics: CNS depressants (BZD, opioids, barbiturates), anticonvulsants, tetrabenazine
  • Withdrawal from alcohol, stimulants**
  • Systemic corticosteroids (can cause anxiety, psychosis, depression)
  • Isotretinoin (Vit A)
  • Interferon-B-1a (Hep C tx)
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10
Q

DSM-5 Criteria
(In SAD CAGES)

A

A) At least 5 out of 9 symptoms (including depressed mood or loss of interest) over the most of the same 2 weeks, causing significant distress or functional impairment)

  • Loss of interest
  • Sleep: insomnia
  • Appetite: LOA, weight loss
  • Depressed mood
  • Concentration: impaired concentration and decision making
  • Activity: psychomotor retardation or agitation (retardation: slowed speech, decreased movement, and impaired cognitive function) (agitation: restlessness and anxiety, repetitive and unintentional movements)
  • Guilt
  • Energy: dcr energy, fatigue
  • Suicidal: thoughts or attempts

B) Symptoms cause significant distress or impairment

C) Symptoms NOT caused by underlying medical conditions or substance

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11
Q

What is the 1st line treatment for MDD?

A

Mild depression - psychosocial treatments
Mod-severe depression - psychosocial + pharmacological treatments

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12
Q

What is persistent depressive disorder (dysthymia)?

A

If patient has depressed mood + 2 or more symptoms, for 2 years, but does not fulfill MDD diagnosis

  • May be treated with antidepressants as well
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13
Q

What are 2 differential diagnosis for MDD?

A
  1. Adjustment disorder
  • Symptoms occur within 3 months of onset of a stressor, but once stressor is terminated, symptoms do not persist for additional 6 months
  1. Acute stress disorder
  • Symptoms occur within 1 month of a traumatic event and last 3 days to 1 month (if prolong >1m: PTSD)
  • Symptoms include: intense fear, helplessness, horror, dissociation, re-experiencing, avoidance, increased arousal

These disorders are NOT to be treated with antidepressants, they can be treated with benzodiazepines instead

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14
Q

General assessments

A
  • History of present illness
  • Psychiatric history – history of manic/hypomanic episodes - bipolar depression cannot use antidepressants
  • Substance use – cigarettes, alcohol, substances
  • Complete medical history and medication history (Drug allergy? Other medications? Compliance?)
  • Family, social, forensic, developmental, and occupational history (1st-degree FH of illness, treatment, and response; review psychosocial circumstances every visit)
  • Physical and neurological exam (Injury? Esp head trauma?)
  • Mental state exam (Suicidal, homicidal ideations and risks; Reassess MSE every interview to evaluate efficacy and tolerability)
  • Labs and other investigations - Vital signs (BP, O2), weight, BMI, FBC, urea, electrolyte, creatinine, LFTs, TFTs, ECG, FBG, lipid panel, urine toxicology

FBC: rule out anemia, infection
TFTs: rule out hypothyroidism - depressed mood
ECG, CVD: cardiovascular events and depression

Exclude general medical conditions or substance-induced/withdrawal symptoms (e.g., psychosis, depression, mania, anxiety, insomnia)

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15
Q

Compare the onset, consciousness, memory b/w Depression, Delirium, Dementia, and Withdrawal/intoxication

A

ONSET:

  • Depression: cyclical (worse when there’s a stressor)
  • Delirium: Acute
  • Dementia: Insidious, progressive
  • Withdrawal/intoxication: Acute

Consciousness

  • Depression: Generally unimpaired
  • Delirium: Impaired
  • Dementia: Clear until later stages
  • Withdrawal/intoxication: Continuum of unimpaired to impaired

Memory

  • Depression: Intact
  • Delirium: Poor
  • Dementia: Poor short and long-term memory
  • Withdrawal/intoxication: Intact
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16
Q

Psychiatric rating scales

A

Clinician Rated: Hamilton rating scale for depression (HAM-D) to evaluate recovery GOLD STANDARD

  • Therapy goal: symptom-free
  • Remission =<7
  • Response = 50% improvement

Self-rated screening/assessment tool: PHQ-9 / PHQ-2

  • Score 1-4: minimal symptoms (in remission)
  • Score 5-9: mild depression
  • Score 10-14: mod depression
  • Score 15-19: mod-severe depression
  • Score >=20: severe depression

10 and above: warrants starting of antidepressants

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17
Q

PHQ2

A

Over the past two weeks, how often have you been bothered by any of the following problems?

  1. Little interest or pleasure in doing things
  2. Feeling down, depressed, or hopeless

VS PHQ9 - basically all 9 symptoms of In SAD CAGES

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18
Q

Goals of treatment in MDD

A
  1. Remission of symptoms (symptom-free)
  2. Treatment adherence
  3. Suicide prevention
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19
Q

Non-pharmacological therapy in MDD

A
  • Sleep hygiene
  • Psychotherapy (1st line for mild depression, includes coping mechanisms; not suitable as monotherapy for mod-severe MDD)
  • Counseling
  • Neurostimulation (reserved for severe/refractory depression) - Electroconvulsive treatment (ECT), rTMS
  • Light therapy - for seasonal affective disorder
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20
Q

What classes do the following drugs belong to?

  • Amitriptyline
  • Vortioxetine
  • Moclobemide
  • Clomipramine
  • Fluoxetine
  • Mirtazapine
  • Venlafaxine
  • Bupropion
  • Duloxetine
  • Agomelatine
  • Fluvoxamine
  • Escitalopram
  • Trazodone
  • Ketamine
A
  • TCAs: Amitriptyline, Clomipramine
  • SSRIs: Fluoxetine, Fluvoxamine, Escitalopram
  • SNRIs: Venlafaxine, Duloxetine
  • SMS: Vortioxetine
  • NaSSA: Mirtazapine (antagonist of the a2 autoreceptors)
  • RIMA (reversible MAOi): Moclobemide
  • NDRI: Bupropion
  • Melatonin receptor agonist (act on MT1 and MT2 receptors, indirectly increases NA and dopamine): Agomelatine
  • SARI: Trazodone
  • Glutamate NMDA receptor (calcium ion channel) antagonist: Ketamine (anesthetic)
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21
Q

Which antidepressant has the fastest oral onset?

A

Mirtazapine

  • works directly on autoreceptors to incr neurotransmitter release, does not inhibit reuptake of neurotransmitters (within 1 week)

Oral Escitalopram also has quick onset as it is very potent (within 1 week)

FYI:

  • Onset of IV ketamine within 1h
  • Onset of ECT within 1min
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22
Q

All SSRI are in SDL except:

A

Paroxetine and Escitalopram

*Also note that bupropion is NOT subsidized

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23
Q

Common indications for antidepressants

  • TCAs

*Dose for amitriptyline, clomipramine

A

Besides depression,

Amitriptyline (30-300mg/day, max dose 300mg/day) - neuropathic pain, migraine prophylaxis

Clomipramine (max dose 300mg/day) - OCD (2nd line), Cataplexy a/w narcolepsy

Nortriptyline - neuropathic pain

Imipramine
Dothiepin

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24
Q

Common indications for antidepressants

  • SSRIs

*Dose for fluoxetine

A

Besides depression, used for anxiety disorders due to its serotonergic properties

Fluoxetine (20-60mg OM, max 80mg): OCD
Fluvoxamine: OCD
Escitalopram: Anxiety disorders
Citalopram: Panic disorders
Paroxetine: Anxiety disorders
Sertraline: OCD, Panic disorder

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25
Q

Common indications for antidepressants

  • SNRI
A

Besides depression,

Venlafaxine: GAD, PD
Duloxetine: GAD, chronic musculoskeletal pain, diabetic neuropathy, stress urinary incontinence, fibromyalgia

*Venlafaxine has similar structure to tramadol

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26
Q

Common indications for antidepressants

  • RIMA: Moclobemide
A

Besides depression,

Moclobemide: Social anxiety disorder

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27
Q

Common indications for antidepressants

  • NDRI: Bupropion
A

Besides depression,

Buproprion can be used for smoking cessation (increases NA and dopamine at ventral tegmental area)

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28
Q

Common indications for antidepressants

  • SARI: Trazodone
A

Not typically used as an antidepressant as antidepressant dose of 300-600mg per day is too sedating, not tolerable

May use off-label for insomnia, commonly use PO 25mg at bedtime PRN for insomnia

It is also anti-hypertensive

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29
Q

NaSSA: Mirtazapine dose

A

15-45mg/day, max dose 45mg/day

30
Q

Why are TCAs not the first line DOC for depression?

A

TCA - a/w many adverse events

Antidepressant effects via:

  • Norepinephrine reuptake
  • Serotonin reuptake

ADRs:

  1. Sedation, weight gain
  • H1 histamine receptor antagonism (however, tolerance to sedation can develop in 1-2 weeks)
  1. Postural hypotension
  • a1-adrenoceptor sympathetic block
  1. Dry mouth, blurred vision, constipation/urinary retention
  • Muscarinic receptor antagonism

Also:
- GI effects (N/V/D) (5-HT3 agonism)
- Sexual dysfunction (5-HT2 agonism)
- Seizures due to proconvulsant properties of TCAs
- Conductance abnormalities - arrhythmias, ECG changes
- Fatal on overdose

31
Q

PK Characteristics of Fluoxetine

A

Fluoxetine

  • Half-life: 4-6 days
  • Active metabolite: Norfluoxetine (half-life: 4-16 days)
32
Q

PK Characteristics of Vortioxetine

A

Vortioxetine

  • Half-life: 66 hours (in circulation for ~2.75days)
33
Q

PK Characteristics of Bupropion

A

Bupropion

Metabolites:

  • 3 amphetamine-like metabolites
  • Increases alertness and increases NA activation: may cause insomnia

Dosing:

- Therefore, always dosed in the day instead of night
- 1st and 2nd dose should be spaced 8h apart

Half-life:

  • Half-life: 10-21h
  • due to short half-life, sustained release formulation is used (swallow whole, do not crush)

Bupropion is suitable for patients with no energy/feel sleepy as it is a stimulating antidepressant

34
Q

PK Characteristics of Sertraline (SSRI)

A

Sertraline

  • Bioavailability 36%, increases by 30-40% with food intake
  • Counseling point: Sertraline take with food to increase absorption
35
Q

General side effects of serotonergic agents (SSRI/SNRI/TCA/SMS/SARI)

A

GI - N/V/D [5HT3 agonism]
Sexual dysfunction [5HT2 agonism]

36
Q

Side effects of TCA

A

GI - N/V/D [5HT3 agonism]
Sexual dysfunction [5HT2 agonism]

Anticholinergic [M1 antagonism]
Sedation, weight gain [H1 antagonism]
Orthostatic hypotension [a1 antagonism]
Arrhythmias, ECG changes [conductance abnormalities]
Seizures [proconvulsant]

Fatal on overdose

37
Q

Side effects of SSRI

Note that the SEs of SSRI are seen in other serotonergic agents as well

A

GI - N/V/D [5HT3 agonism]
Sexual dysfunction [5HT2 agonist]

Headache, transient nervousness during initiation

Fluoxetine: Insomnia

Paroxetine: most anticholinergic, sedating, weight gain, withdrawal (short half-life), avoid in elderly

Escitalopram/Citalopram: ECG changes - QTc prolongation if high dose used in elderly => can result in sudden cardiac death, TDP

Others:
Hyponatremia (SIADH)
Bleeding risk (esp with concurrent antiplatelet/anticoagulant)
EPSE

38
Q

Side effects of Venlafaxine (SNRI)

A

GI - N/V/D [5HT3 agonism]
Sexual dysfunction [5HT2 agonism]

Due to increase NE,

  • causes or worsens hypertension (incr BP)
  • worsen anxiety, agitation (at least initially)
  • worsen LOA (not first choice if pt has loss of appetite)
39
Q

Side effects of Duloxetine (SNRI)

A

GI - N/V/D [5HT3 agonism]
Sexual dysfunction [5HT2 agonism]

Urinary hesitation (rmb it can be used to treat stress urinary incontinence)

Due to increase NE,

  • worsen anxiety, agitation (at least initially)
  • worsen LOA (not first choice if pt has loss of appetite)
40
Q

Side effects of Mirtazapine (a2-adrenoceptor antagonist, increases serotonin and NE)

A

Somnolence (beneficial for pt with insomnia) [H1 antagonism]

Increase appetite, weight gain (beneficial in pt with LOA) => *Need to monitor FBG, HbA1c, lipids

Reverse GI and sexual side effects of SSRI/SNRI [5HT3 and 5HT2 antagonism]

Mirtazapine is a sedating and appetite stimulating antidepressant; may monitor FBG/HbA1c and lipids annually

41
Q

Side effects of Bupropion

*Bupropion (NDRI) blocks reuptake of NE and dopamine, no serotonergic effects

*Also state which group of patients Bupropion is contraindicated in

A

Think about amphetamine like metabolites

Seizure
Insomnia
Anxiety
Psychosis

(Not suitable for hx of seizure, psychosis, eating disorder)

Decrease sexual effects of SSRI/SNRI since no serotonergic effect

Contraindicated with pt with eating disorder

  • poor eating can increase risk of seizure

Due to increase NE,

  • worsen anxiety, agitation (at least initially)
  • worsen LOA (not first choice if pt has loss of appetite)

Bupropion may be a suitable choice for pt with no energy, sleepy

42
Q

Side effect of MAOi

A

Hypertensive crisis (due to accumulation of tyramine)

  • Less in reversible (RIMA) Moclobemide
43
Q

Side effect of Trazodone

A

GI - N/V/D [5HT3 agonism]
Sexual dysfunction [5HT2 agonism]

Sedation [H1 antagonism]
Orthostatic hypotension [a1 adrenoceptor antagonism]

Rare: priapism

44
Q

Side effect of Agomelatine

A

MT1 agonist, MT2 agonist, 5HT2C antagonist (incr DA, incr NE)

GI SEs

Increase LFTs, risk of transaminitis (incr risk with CYP1A2 inhibitors)

Less sexual dysfunction

Contraindicated with Fluvoxamine and Ciprofloxacin (CYP1A2 inhibitors) as it is a CYP1A2 substrate

45
Q

Suicidality risk with antidepressants

  • who should be counseled?
A

Suicidality association in patients =<24y, mandatory counseling required

46
Q

What adjunctive treatments may be used in MDD?

A
  1. Second-generation antipsychotics (SGAs)
  2. Short-course of PRN hypnotics/anxiolytics (help sleep/relax)
47
Q

Adjunctive treatment: SGA

  • Which drugs?
  • MOA
  • SE
A

Aripiprazole, Brexpiprazole, Quetiapine

MOA:

  • 5-HT1A partial agonism: anxiolytic effects
  • 5-HT2A antagonism: antidepressant effects, improve negative symptoms

=> improve mood

SE:

  • EPSE (Aripiprazole, Brexpiprazole)
  • Metabolic SE (Quetiapine)
48
Q

Adjunctive treatment: Esketamine (Spravato IN)

  • MOA
  • SE
A

MOA: NMDA receptor antagonist

SE: headache, dissociation, confusion, dizziness, hallucination, nausea, sedation, anxiety, increase BP

Use as: Adjunct to SSRI/SNRI for TRD

49
Q

Adjunctive treatment: PRN Hypnotics (help sleep/relax)

  • Which drugs?
  • MOA
  • SE
A
  1. Benzodiazepines
  • MOA: potentiates GABA
  • SE: drowsiness, weakness, amnesia, dependence
  1. Z-hypnotics
  • MOA: preferentially binds to BZD-binding sites with y and a1 subunits (thus causing sedation)
  • SE: Taste disturbance (Zopiclone), complex sleep behaviors (sleep-walking), dependence
  1. Antihistamines
  • SE: Drowsiness, anticholinergic SE, constipation
50
Q

Complementary and Alternative Medicines

  • Therapeutic lifestyle/behavioral change
  • Nutritional
  • Avoid
A
  1. Therapeutic lifestyle/behavioral changes
  • Sleep hygiene
  • Exercise
  • Relaxation techniques

Nutritional

  • Vit B12
  • L-methylfolate
  • Vit D
  • Omega-3 fatty acids

AVOID:

  • St John Wort (significant DDI with antidepressant as it is an inducer, do not use concomitantly)
51
Q

Pharmacological Management of MDD

Describe:
- Indication:
- Choice:
- 1st line:
- Efficacy:

A

Antidepressants

  • Indication: mod-severe MDD, certain anxiety disorders, dysthymia (*NOT used in bipolar)
  • Choice: Selection based on target symptoms, comorbid conditions, DDIs, prior response, patient preference
  • 1st line monotherapy: Mirtazapine, SSRI, SNRI, Bupropion, Agomelatine > TCA > MAOi
  • Efficacy: response rate 50%, remission rate 30% with first antidepressant; ALL antidepressants have similar efficacy for uncomplicated first episode of MDD
52
Q

ACUTE phase treatment of MDD

  • Adequate trial
  • Onset
  • Time course of treatment response
A

Adequate trial = adequate dose + duration (4-8weeks)

Onset:

  • Delayed onset of effectiveness due to gradual downregulation of presynaptic autoreceptors in the synapse
  • (e.g., SSRI Fluvoxamine inhibits serotonin uptake within 1h, but mood symptoms only improve after 1-2months)

Time course of treatment response:

  • Physical symptoms may improve in 1-2 weeks (insomnia, LOA)
  • Mood symptoms may take longer 4-8 weeks
53
Q

CONTINUATION phase treatment of MDD

  • How long more to continue treatment?
A

1st episode of uncomplicated MDD: continue for at least another 4-9months

54
Q

What is the total treatment duration for MDD?

A

Total (acute + continuation) = at least 6-12months

If patient stops treatment early, likelihood of recurrence is high

55
Q

Treatment approach: No Response

When and how to switch antidepressant?

  • When to switch
  • Cross titration
  • Direct switch
  • Switching from serotonergic antidepressant to non-serotonergic agent
  • Wash out for MAOi
A
  • Switch when completely ineffective/intolerable to adequate dose in 2-4 weeks (however if there’s response than adequate trial is 4-8 weeks; if some response may increase dose to max)
  • If cross-titration: watch for serotonin syndrome if serotonergic agents
  • If direct switch: one SSRI can be stopped totally and the next serotonergic agent initiated
  • If switching from serotonergic antidepressant used daily for the past 2 months to non-serotonergic agent:

=> gradual cross-tapering over several weeks can reduce risk of antidepressant discontinuation syndrome

  • Wash out period necessary for MAOIs (so as to avoid serotonergic syndrome)

=> Moclobemide to another antidepressant: 24h washout
=> Another antidepressant to Moclobemide: washout at least 1 week (5 week if stopping Fluoxetine)

56
Q

Treatment approach: Partial Response

A

Augmentation

Combine a 2nd antidepressant (with diff MOA) to the existing antidepressant that has a partial response

  • E.g., add Mirtazapine, Bupropion-SR, Lithium, Adjunctive SGAs (Quetiapine, Aripiprazole, Brexpiprazole)
57
Q

Treatment approach: treatment resistant depression

  • Define TRD
  • Tx approach for TRD
A

TRD: no response to 2 or more adequate trials (4-8 weeks) of antidepressants

Treatment:

  • Neurostimulation: ECT, rTMS
  • Symbyax (Olanzapine 6mg + Fluoxetine 25mg) capsule
  • Spravato nasal spray (Esketamine), adjunct to SSRI/SNRI
58
Q

Antidepressant discontinuation syndrome
(*NOT withdrawal)

  • Which antidepressants more likely to produce discontinuation syndrome?
  • What are the symptoms?
  • Onset
  • Duration
  • Resolve
A

Worse with abrupt stopping of a regular treatment, esp antidepressants with short half-life: e.g., Paroxetine, Venlafaxine

Symptoms: (*NOT deadly, no need A&E)
(FINISH)

  • Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating)
  • Insomnia (w vivid dreams, nightmares)
  • Nausea (sometimes vomiting)
  • Imbalance (dizziness, vertigo, light-headedness)
  • Sensory disturbances (burning, tingling, electric-like sensations)
  • Hyperarousal (anxiety, irritability, agitation, aggression, mania)

Onset

  • 36-72h

Duration:

  • 3-7 days

Resolve:

  • Typically resolve without treatment over 1-2 weeks
59
Q

Antidepressant discontinuation syndrome

  • How to avoid?
  • Which antidepressants may not need?
A

Gradually taper dose (by half tablet of lowest strength every 1-2 weeks) if pt had been on regular dosing for more than 6-8 weeks

Fluoxetine, Bupropion have long half-life, no need for gradual tapering of dose

60
Q

Antidepressant-induced mania

  • Mechanism
  • Onset
A

Mechanism is unknown: incr in NE and Dopamine transmission

Fast onset: initial few days to 2 weeks (as fast as 3 days)

Use of antidepressant increases the risk of developing mania/bipolar disorder (diagnosis: bipolar depression rather than MDD)

61
Q

[Medical comorbidities and DOC]

BPH, narrow angle glaucoma

A

Avoid TCA and Paroxetine (due to anticholinergic effects - antagonist of M1)

62
Q

[Medical comorbidities and DOC]

  • Underweight
A

Mirtazapine (incr appetite, incr weight gain)

63
Q

[Medical comorbidities and DOC]

  • Chronic pain/neuropathy
A

Duloxetine

64
Q

[Medical comorbidities and DOC]

  • Hypertension
A

Avoid TCAs, SNRIs => incr sympathetic tone, worsens HTN

Both inhibit the reuptake of norepinephrine, resulting in increase of sympathetic nervous system, which increases the HR, which contributes to increase in BP

Consider Sertraline

65
Q

[Medical comorbidities and DOC]

  • Cardiovascular disease
A

Consider Sertraline (antiplatelet effect)

Avoid TCA and Escitalopram => risk of ECG changes

66
Q

[Medical comorbidities and DOC]

  • Seizures
A

Avoid TCAs (proconvulsant), Bupropion

Consider SSRIs, SNRIs

67
Q

[Medical comorbidities and DOC]

  • Eating disorder
A

Consider Fluoxetine

Avoid Bupropion (contraindicated) => risk of seizures
Also avoid SNRIs such as Venlafaxine

68
Q

[Medical comorbidities and DOC]

  • Insomnia
A

Consider mirtazapine

Avoid Bupropion (amphetamine like metabolites, worsens insomnia)

Fluoxetine and Escitalopram also cause insomnia

69
Q

[Medical comorbidities and DOC]

  • Elderly
A

Avoid TCAs (anticholinergic + postural hypotension)

Avoid Paroxetine

Avoid Escitalopram at high doses (ECG changes esp in elderly)

Hyponatremia - a/w all antidepressants, esp SSRI (lower risk with Agomelatine, Mirtazapine, Bupropion)

70
Q

[Medical comorbidities and DOC]

Tamoxifen therapy
(Tamoxifen is a CYP2D6 substrate that must be converted to active drug)

A

Consider: Venlafaxine/Desvenlafaxine, Escitalopram

Avoid CYP2D6 inhibitors: Paroxetine, Fluoxetine, Bupropion

71
Q

[Medical comorbidities and DOC]

Pregnancy

A

Avoid Paroxetine and Bupropion

May consider Nortriptyline in late pregnancy

3153 IC9,10,11,12,14 Psychiatric (10 decks)

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