69 - depression (ott)

Question 1

Risk of Recurrence
1 episode: ___ - ___ %
2 episodes: ___ %
3 episodes: ___ %

Answer 1

50-60%
70%
90%

Question 2

risk factors for depression

Answer 2

• female sex
• middle age
• single
• white
• low economic status
• unemployment
• physical disability
• lack of social support
• stressful life events/adverse childhood experiences
• prior episodes or suicide attempts
• co-morbid medical disorders
• co-morbid substance use disorder

Question 3

disease course

occurs at any age, but commonly seen in early adulthood ___ - ___ s

symptoms develop over ___ to ___

usually see a response to treatment, but not aggressive enough to achieve ___

remission = a period of __ or more months with no symptoms or only __ - __ symptoms
- remission is possible and is the treatment goal

Answer 3

• 20-30
• days, weeks
• remission
• 2, 1-2

Question 5

Recurrence

• risk becomes lower overtime as duration of ___ increases
• persistent mild symtpms during remission is a predictor of ___
• function ___ during the episode and goes back to baseline upon remission

Answer 5

• remission
• recurrence
• deteriorates

Question 6

DSM-5 Diagnostic Criteria

at least one of the symptoms must be ___ mood or loss of ___ or pleasure in doing things
- symptoms must cause clinically significant impairment in functioning
- no history of ___
- not attributed to the psychological effects of a ___ or another condition

Answer 6

• depressed
• interest
• mania
• substance

Question 7

DSM-5 Diagnostic Criteria Mnemonic

SIGE CAPS

Answer 7

• sleep (insomnia/hypersomnia)
• interest decreased
• guilt/worthlessness
• energy loss/fatigue
• concentration difficulties
• appetite change
• psychomotor agitation/retardation
• suicidal ideation

Question 8

depression specifiers

with anxious distress
- higher ___ risk
- longer duration of illness
- ___ treatment response

with melancholic features
- anhedonia
- psychomotor ___ /agitation worse in the ___ , more likely in ___

with atypical features
- ___ mood
- weight ___
- hypersomnia, more likely in ___ patients

Answer 8

• suicide
• poor
• retardation, elderly
• reactive
• gain
• younger

Question 9

depression specifiers

with psychosis
- hallucinations/delusions
- may or may not be congruent with ___

with catatonia
- stupor, blunt affect, extreme ___ , negativism, psychomotor ___ , posturing, echolalia

with peripartum onset
- occurs during pregnancy or ___ weeks following birth

with seasonal pattern
- symptoms have a relationship to the time of the year (fall/winter) and remit in the spring

Answer 9

• mood
• withdrawals, retardation
• 4

Question 10

self administered rating scales

• depression: ___
• depression (clinical trials): ___
• bipolar: ___

Answer 10

• (PHQ9) - patient health questionnaire
• (QIDS-R-16) - quick inventory of depressive symptomatology self report
• (MDQ) - mood disorder questionnaire

Question 11

goals of treatment

1) reduced or eliminate s/s of depression
2) restore ___ and psychosocial functioning to baseline
3) reduce the risk of ___ and recurrence
4) reduce the risk of harmful consequences ( ___ ideation)

Answer 11

• occupational
• relapse
• suicidal

Question 12

phases of treatment

acute:
- __ - __ weeks or remission of symptoms
- Goal: induce ___

continuation:
- __ - __ additional months, recommended for all patients
- Goal: prevent ___

maintenance:
- patient-specific ___
- often indefinite treatment if ___ or greater major depressive episodes
- Goal: prevent ___

Answer 12

• 6-12
• remission
• 4-9
• relapse
• duration
• 3
• recurrence

Question 13

SSRIs

___ (Lexapro)

dose range: 5-10 mg/day

clinical pearls
- pure S enantiomer of citalopram
- substrate of ___

Answer 13

escitalopram
- 2C19

Question 14

Risk of Suicidality

boxed warning for suicidaily in ___ antidepressant medications (for patients less than or equal to ___ years of age)
- decreased risk in those __ and onlder

closely monitor for increased ___ and changes in behavior during the first 1-2 months of therapy and after any dose changes

Answer 14

• ALL, 24
• 65
• suicidality

Question 15

SSRIs

___ (Celexa)

dose range: 10-40 mg/day
- > 60 years: do not exceed 20 mg

clinical pearls
- dose dependent ___ prolongation
- substrate of ___ and ___

Answer 15

citalopram
- QTc
- 2C19 and 3A4

Question 16

SSRIs

___ (Prozac)

dosage range: 10-80 mg/day

clinical pearls:
- weekly DR oral formulation (90 mg/week)
- ___ t 1/2 (96-144 hrs)
- activating potential
- ___ and ___ inhibitor (norfluoxetine) - active

Answer 16

flucoxetine
long
CYP 2D6, 3A4

Question 17

SSRIs

___ (Luvox)

dosage range: 50-300 mg/day

clinical pearls
- indicated for ___ treatment
- inhibitor of ___ and ___

Answer 17

fluvoxamine
- OCD
- 1A2, 2C19

not super common

Question 18

SSRIs

___ (Paxil)

dosage range:
- 10-60 mg/day
- 12.5-75 mg/day

clinical pearls
- must ___ due to ___ effects
- weight ___, sedation
- ___ wall defect risk to fetus
- inhibits ___ and ____

Answer 18

paroxetine
- taper, anticholinergic
- gain
- septal
- 2D6, 2B6

Ott doesnt like this drug (hard to stop)

Question 19

SSRIs

___ (Zoloft)

dosage range: 25-200 mg/day

clinical pearls
- more ___ upset than other antidepressants
- inhibitor of ___ , ___ , and ___

Answer 19

sertraline
- GI
- 2C19, 2D6, 3A4

Question 20

SSRIs - Adverse Effects/Key Points

• onset of action in __ - ___ weeks
• full dose response in ___ - ___ weeks

AE
- variable sedation
- weight gain ( ___ )
- weight loss ( ___ )
- increased ___ risk ( ___ inhibition)
- hypo ___ (especially in elderly)
- ___ dysfunction
- anxiety/agitation (upon initiation)
- emotional blunting
- decreased ___ mineral density

Answer 20

• 1-2
• 4-6
• paroxetine
• fluoxetine
• bleeding, platelet
• hyponatremia
• sexual

Question 21

SNRIS

___ (Pristiq)

dose range: 50-400 mg/day

clinical pearls
- active metabolite of ___
- dose limiting SE: ___
- flate dose response curve for doses 50-400 mg/day
- no major ___ interactions

Answer 21

desvenlafaxine
- venlafaxine
- nausea
- CYP

Ott has never had a patient go above 100 mg/day

Question 22

SNRIs

___ (Cymbalta)

dose range: 30-120 mg/day
- doses > 60 mg do not increase the response

clinical pearls
- slow titration or divided dosing help with ___
- FDA warning for ___
- new dosage form: Drizalma Sprinkle
- inhibitor of ___

Otts favorite, can also help with pain

Answer 22

duloxetine
- nausea
- hepatotoxicity
- 2D6

Question 23

SNRIs

___ (Fetzima)

dosage range: 40-120 mg/day

clinical pearls
- must adjust in ___ impairment or strong ___ inhibitors
- rare - seizures/glaucoma
- substrate ___

Answer 23

levomilnacipran
- renal, 3A4
- 3A4

Question 24

SNRIs

___ (Savella)

dosage range: 12.5-200 mg/day

clinical pearls
- indicated for ___
- renal dosing adjustments

Answer 24

milnacipran
- fibromyalgia

Question 25

# SNRIs ___ (Effexor) dosage range: 75-327 mg/day clinical pearls - must be > ___ mg/day to have NE effects - ___ inhibitor at higher doses - substrate ___ and ___

Answer 25

venlafaxine - 150 - 2D6 - 2D6, 3A4

Question 26

# SNRIs - AE/Key Points - onset of action in __ - ___ weeks - full dose response in ___ - ___ weeks useful in ___ syndrome, musculoskeletal pain, fibromyalgia, and ___ pain duloxetine: obtain ___ at baseline and when symptomatic or every ___ months

Answer 26

- 1-2 - 4-6 - pain, neuropathic - LFTs, 6

Question 27

# SNRIs - AE/Key Points - **___ elevation** - sweating - variable sedation - increased bleeding risk (platelet inhibition) - hyponatremia (especially in elderly) - sexual dysfunction - anxiety and agitation - **___** - decreased bone mineral density

Answer 27

- BP - nausea

Question 28

# TCAs blockade of reuptake transporter ( ___ , ___ , and ___ ) inhibits the reuptake of 5HT, NE, and DA ___ (Elavil) - ___ amine dose range: 50-300 mg/day Clinical pearls - used to lower doses for neuropathic pain

Answer 28

- SERT, NET, DAT amitriptyline, tertiary

Question 29

# TCAs - AE/key points more often used for ___ ___ syndromes than depression - amitriptyline or nortriptyline side effects often limit higher doses - ___ : sedation, reduced seizure threshold, confusion - ___ : blurred vision, urinary retention, consipation - cardiovascular: orthostatic hypotension, ___ cardia - other: weight ___ , sexual dysfunction Narrow therapeutic index - fatal in overdose as low as 1000 mg (4-10 tablets) due to cardiac ___ or ___

Answer 29

neuropathic pain - CNS - anticholinergics - tachycardia - gain - arrhythmias, seizures

Question 30

# MAO Inhibitors ___ (Marplan) - 20-60 mg/day ___ (Nardil) - 45-90 mg/mL ___ (Ensam) - patch: 6-12 mg/day ___ (Parnate) - 20-60 mg/day

Answer 30

- iscarboxazid - phenelzine - selegiline - tranylcypromaine

Question 31

# MAO Inhibitors Clinical pearls - must have ___ week washout period before switching antidepressants ( 5 week washout period if switching from ___ ) - all require ___ diet, except ___ - caution due to HTN ___ and ___ syndrome - 3rd-4th line option

Answer 31

- 2, fluoxetine - tyramine, selegiline patch - crisis, serotonin -

Question 32

# Selegiline Patch (Ensam) selective ___ inhibition at lower dose at lower doses - must be used as monotherapy administration - rotate patch ___ to prevent irritation, do not cut or expose to direct heat tyramine diet NOT required with the ___ mg patch - required for 9 mg and 12 mg adverse effects - ___ tension, dry mouth ___ , headache, GI upset

Answer 32

- MAO-B - daily - 6 mg - hypotension, insomnia

Question 33

# MAOis CI - ____ - adrena tumor causing increased BP - ___ or ___ dysfunction - ___ diseases - excessive ___ use - elective surgery - concomitant ____ - cardiovascular disease - use of other ___ medications

Answer 33

- pheochromocytoma - hepatic, renal - cerebrovascular - caffeine - sympathomimetics - serotonergic

Question 34

# MAOis - hypertensive crisis ___ diet is required with MAOis - when this builds up, caused increased BP

Answer 34

tyramine

Question 35

# bupropion (Wellbutrin) MOA: ___ and ___ reuptake inhibitor - stimulating - ___ and ___ suppression - some misuse potential, similar structure to cathinones/ ___ Dosing - SR/ __ dosing: 150-450 mg/day - if using SR, give second dose no later than __ pm clinical pearls - ___ inhibitor - CI in active ___ and ___ disorders - can be used in combination with ___ and ___

Answer 35

- DA, NE - insomnia, appetite - bath salts - XL - 4 pm - 2D6 - seizure, eating - SSRIs, SNRIs | Ott prefers XL (SR seizures) even for smoking cessation

Question 36

# mirtazapine (Remeron) Mechanism - presynaptic ____ blockage as well as 5HT __ , 5HT __ , and ___ blockade dosing - 7.5-45 mg/day - **sedation and increased appetite occur with doses less than or equal to ___ mg/day** clinical pearls - substrate ___ , ___ , ___ - warnings: ___ increased ___ - can be used in combination with ___ and ___

Answer 36

- a2, 5HT2, 5HT3, H2 - 15 - 1A2, 2D6, 3A4 - agranulocytosis, cholesterol - SSRIs, SNRIs

Question 37

# trazodone (Desyrel) Mechanism - selectively inhibits ___ reuptake and acts as antagonist at 5HT __ , 5HT2, H1, and a1 dosing: 150-600 mg/day - ___ doses needed for depression - off label for ___ : 50-150 mg at bedtime drug interactions - trazodone → (CYP ___ ) → m-CPP → (CYP ___ ) → inactive metabolites SE - orthostatic hypotension - risk of ___ - medical emergency

Answer 37

- 5HT, 5HT1 - high - insomnia - 3A4, 2D6 - priapism

Question 38

# vilazodone (Viibryd) mechanism - primarily SSRI, may have some 5HT1a ___ which may provide anxiolytic effects - do not use in combination with ___ and ___ dosing - 10 mg once daily x7 days, 20 mg once daily x7 days for a target dose of 40 mg once daily clinical pearls - take with ___ - significant ___ - ___ increases bioavailability - substrate ___ - reduce target dose to 20 mg with strong 3A4 inhibitors - AE: insomnia, nausea, diarrhea, sexual dysfunction

Answer 38

- agonism - SSRIs, SNRIs - food - nausea - food - 3A4

Question 39

# vortioxetine (Trintellix) mechanism - SSRI + 5HT1A ___ + 5HT3 ___ - do not use in combination with ___ and ___ dosing - 10 mg once daily with meals - target dose of 20 mg once daily clinical pearls - possibly less ___ dysfunction - substrate ___ - reduce target dose to 10 mg daily with strong inhibitors - AE: ___ , vomiting, constipation

Answer 39

- agonist, antagonist - SSRIs, SNRIs - sexual - 2D6 - nausea

Question 40

# serotonin sydrome medical ___ due to excessive amounts of serotonin in the CNS may be caused by: - overdose - combined use of serotonergic drugs - drug inteactions serotonergic agents - Li - serotonergic antidepressants - buspirone - linezolid - amphetamines - dextromethorphan - triptans - st john's wort - tramadol - fentanyl - cocaine - LSD

Answer 40

emergency

Question 41

# serotonin syndrome - treatment ___ the offending agent + supportive care potentially could use serotonin blockers - ___ (variable efficacy) 70% of patients recover within 24 hours

Answer 41

stop cyproheptadine

Question 42

# antidepressant withdrawal syndrome - occurs due to abrupt cessation of antidepressant - common with ALL antidepressants EXCEPT ___ - risk can be minimized by slow dose taper over 1-2 weeks - antidepressants with ___ activity should be tapered no matter what - symptoms can mimic those of depresion (agitation, irritability, GI disturbance, "brain ___ ") - NOT ___ but extremely uncomfortable

Answer 42

- fluoxetine - anticholinergic - zaps - life-threatening

Question 43

augmentation agents (8)

Answer 43

- antipsychotics - Li - anticonvulsants - pindolol - triiodothyronine (T3) - BZDs - buspirone - atomoxetine

Question 44

# augmentation - atypical antipsychotics 5HT2a ___ and partial 5HT1a ___ - indirect effects on NE transmission - dosing is ___ for depression than with other disease states FDA approved augmentation agents (4) - ___ (Abilify) 2-15 mg/day - ___ (Rexulti) 0.5-3 mg/day - ___ (Vraylar) 1.5-3 mg/day - ___ (Seroquel) 50-300 mg/day additional agents - ___ / fluoxetine (Symbyax) 6/25-25/50 mg/day - ___ (Risperdl) 1-3 g/day

Answer 44

- antagonism, agonism - lower - aripiprazole - brexpiprazole - cariprazine - quetiapine - olanzapine - risperidone | aripiprazole is Ott's favorite

Question 45

# antidepressants for specific purposes post-partum depression - allosteric modulator of allopregnanolone - ___ - IV only, __ hours infusion, excessive ___ boxed warning, REMS program - ___ - oral dose, 14 day dosing, boxed warning for ___ driving (CNS depression) treatment-resistant depression - ___ nasal spray - NMDA receptor antagonist - also use for MDD with suicidal ideation - induction and maintenance phases, REMS program to give in clinic, stay in clinic for 2 hours post dose

Answer 45

- brexanolone, 60, sedation - zuranolone, impaired - esketamine

Question 46

# overall key counseling points - may take ___ - ___ weeks to see beneficial effects of antidepressant - must be taken as prescribed - need to continue medication for ___ - ___ months yo decrease risk of recurrence - abrupt d/c can lead to antidepressant ___ syndrome - possible increase in suicidal thinking during the first few ___ of therapay

Answer 46

- 2-4 - 6-9 - withdrawal - weeks

Question 47

# non-pharmacologic treatment ___ is most common mild depression or episodes without psychosis may use psychotherapy **without** drug therapy if - history of response - patient preference - medication CI - pregnancy

Answer 47

psychotherapy | only paroxetine is teratogenic

Question 48

# electroconvulsive therapy (ECT) unilateral or bilateral placement of ___ - 10-15 min procedure administration - 2-3 times weekly as induction - usual course if 6-12 treatments - continue until maximal response - can use as maintenance advantages - efficacy in treatment ___ - can continue drug therapy - age not a factor - safe in pregnancy disadvantages - temporary memory loss - stigma - CI in recent ___ or hemorrhagic stroke or if loose teeth

Answer 48

- electrodes - resistance - MI

Question 49

# other non-pharmacologic optioins - ___ nerve stimulation - transcranial ___ stimulation

Answer 49

- vagus - magnetic

Question 50

steps to manage depression

Answer 50