Antidepressant Agents Flashcards by Sammy B

Major Depressive or Unipolar Disorder:

lifetime prevalence?

5-20%

How well did you know this?

Not at all

Perfectly

Major Depressive or Unipolar Disorder consists of core depressive symptoms plus “_______ symptoms”

vegetative (ie abnormal sleep/motor activity)

How well did you know this?

Not at all

Perfectly

Major Depressive or Unipolar Disorder:

Pts are most responsive to?

Usually responds specifically to electroconvulsive therapy (ECT) or antidepressants

Pharmacotherapy» psychotherapy

How well did you know this?

Not at all

Perfectly

Dysthmia= is a _____ form of depression

milder**–> generally no long-term responses to drug therapy but pharmacotherapy is superior to placebo

How well did you know this?

Not at all

Perfectly

Dysthymia:

higher in males or females?

3x higher in females

How well did you know this?

Not at all

Perfectly

Bipolar Disorder 1=

Cyclic, episodes of mania (bipolar I)

How well did you know this?

Not at all

Perfectly

Bipolar 2=

hypomania, depressed mood

How well did you know this?

Not at all

Perfectly

Psychotic Sx can be present in Bipolar 1 or 2?

Elevated, expressive, or irritable mood –> psychotic symptoms can be present in bipolar I

How well did you know this?

Not at all

Perfectly

Factors favoring treatment with an antidepressant (list 4)

Presence of agitation or problems with sleep or appetite

Moderate to severe symptoms

History of response to antidepressant therapy

Patient preference

How well did you know this?

Not at all

Perfectly

For treatment resistant depression, what are some medication options?

first–> try switching meds, or combining antidepressants

Buspirone (anti- anxiety), or atypical antipsychotics ( i.e. aripiprazole-olanzapine-quetiapine), OR
Lamotrigine or Lithium (mood stabilizers)

How well did you know this?

Not at all

Perfectly

Symptoms of Depression At least 5 of 9 for at least 2 weeks: SIGECAPS

Sleep* – too much or too little*

Interest – decreased  loss of interest in life – anhedonia

Guilt – increased  feelings of worthlessness

Energy* – decreased*

Concentration - decreased

Appetite – increased or decreased –> >5% change in body weight in 1 month*

Psychomotor agitation/retardation*

Suicidal ideation – thoughts about death or suicide

How well did you know this?

Not at all

Perfectly

Monoamine Theory of Depression:

what is the initial observation?

Reserpine (used as anti-hypertensive) depleted brain NE and 5HT –> induced depression
**Effective antidepressant drugs shared property of enhancing availability of NE-5HT in synapse

–overall lacking support

How well did you know this?

Not at all

Perfectly

Shift in Focus of Hypotheses for Depression:
Dysregulation=
synaptic changes=

Dysregulation of pre-and post-synaptic control of NE-5HT neurotransmission

Synaptic changes produced by antidepressants then lead to alterations of gene expression

How well did you know this?

Not at all

Perfectly

An adequate trial of medication for treatment of depression generally would be:

4-8 weeks

How well did you know this?

Not at all

Perfectly

A 25-year-old woman has a long history of depressive symptoms accompanied by body aches and pain secondary to a car accident 2 years ago. Physical and laboratory tests are unremarkable. Which of the following drugs might be useful in this patient?

Amitriptyline (TCAD)
Fluoxetine (SSRI)
Sertraline (SSRI)
Mirtazapine (α2 antagonist)
Duloxetine (SNRI)

Amytriptiline= cheaper, and good for neuropathic pain

and Duloxetine

How well did you know this?

Not at all

Perfectly

Newer agent for Treatment resistant depression that is an NMDA receptor antagonist is known as _______

*S-ketamine
-> recently approved for intranasal tx, unknown mechanism. BUT it’s expensive: $1200 for 4 weeks, administered 2x a week/for 4 weeks

How well did you know this?

Not at all

Perfectly

New drug for post-partum depression which is a Positive allosteric modulator (PAM) is known as _______

Brexanolone (Zulresso)

=a neuroactive steroid (NAS) that binds to a different subunit (δ) on GABA-A receptor than benzodiazepines (α)

IV infusion over 60 hours with medical supervision - significant improvement in symptoms at 60 hrs - maintained 30 days

Sedation and sudden loss of consciousness possible

Cost of drug alone currently $34,000

How well did you know this?

Not at all

Perfectly

List some acute S/E of SSRIs

Acute effects –often diminish over time)

Nausea-diarrhea [5HT3] (increase 5HT effects in GI tract)

Activation-insomnia (commonly)

Restlessness [5HT2] (akathisia), somnolence possible

How well did you know this?

Not at all

Perfectly

List some delayed onset S/E of SSRIs

Weight gain

Sexual dysfunction [5HT3]

Cognitive blunting

How well did you know this?

Not at all

Perfectly

SSRIs fatality rate?

Withdrawal Sx?

Very low likelihood of fatalities in OD

w/drawal–>Flu-like or neurologic symptoms –> severity related to half-life (shorter > longer

How well did you know this?

Not at all

Perfectly

Which SSRI will result in greater withdrawal sx? [paroxetine or fluoxetine?

[paroxetine > fluoxetine])

shorter half life» longer

How well did you know this?

Not at all

Perfectly

SNRI’s S/E: list

**Venlafaxine - Duloxetine

Hypertension, anxiety, nausea, somnolence, sweating, dizziness, sexual dysfxn

**More rapid appearance of withdrawal symptoms than SSRIs, except paroxetine

How well did you know this?

Not at all

Perfectly

Norepinephrine Dopamine Reuptake Inhibitors (NDRIs): list 1 example of a med & it’s S/E

Bupropion!

Dizziness, dry mouth, tremor, insomnia, anxiety, aggravation of psychosis

**Potential for seizures at high doses

How well did you know this?

Not at all

Perfectly

Trazadone:

-major S/E?

Study These Flashcards

Drowsiness

–Overdose –>minor problems only

Mirtazapine: S/E?

Somnolence Increased appetite --> **weight gain (great for Pts who are cant sleep and cant eat ) **mirtazapine= good for Pts who cant eat and cant sleep

T/F: TCAs have declining use

T! poor side effect profile, declining use, 2nd-3rd line agents

Which TCA causes greater sedation: amitriptyline or desipramine?

Sedation: Lassitude, fatigue, sleepiness [Amitriptyline > Desipramine]

Which TCA causes the MOST antimuscarinic effects?

Amitriptyline > Desipramine-Nortriptyline] Blurred vision, constipation, dry mouth, urinary hesitancy, fuzzy thinking Higher doses--> aggravation of narrow angle glaucoma, paralytic ileus, urinary retention, delirium

TCAs: | cardiac S/E?

Orthostatic hypotension (α1 blockade) EKG abnormalities (quinidine-like effects) --> arrhythmias --> sudden death in OD

TCAs: neurologic S/E?

Tremor, paresthesias, can see seizures in OD Metabolic-endocrine: Weight gain histamine blocking action, sexual disturbances

A Pt OD on Amitriptyline and is now experiencing arrhythmias. What would you give him for immediate tx?

sodium bicarb

MAOIs S/E: list ex's

**Postural hypotension (chronic increase in false NT) Milder anti-cholinergic effect Sedation (phenelzine) CNS stimulation (tranylcypromine) Liver damage **Seizures, shock, hyperthermia in overdose

Which agent would be a poor choice in a 70-year-old with depressive symptoms due the drug having significant alpha-1 receptor antagonism, thus having a higher risk for falls due to orthostatic hypotension? ``` Fluoxetine (SSRI) Amitriptyline (TCAD) Bupropion (NDRI) Phenelzine (MAOI) Sertraline (SSRI) ```

Amitriptyline (TCAD)

S-Ketamine causes ______ BP after administration. It's contraindicated IF Pt has ______

Increased BP Contraindicated if AV malformation or history of intracerebral hemorrhage Controlled substance [CIII] with potential for dependence and abuse

Fluoxetine is comparable to the tricyclic antidepressant amitriptyline in: Producing orthostatic hypotension Causing dry mouth and blurred vision Producing life-threatening EKG changes Alleviating the symptoms of depression

Alleviating the symptoms of depression

Most antidepressant agents have an _____ CNS depressant effect when used with other sedatives

additive

MAOIs + decongestants or with foods high in Tyramine (beer-wine-cheese)=

HYPERTENSIVE CRISIS **Results from acute increase in NE release

SSRIs + MAOIs=

serotonin syndrome** | --occurs with just MAOIs

Pt presents with rapid changes in mental status (confusion), and HTN and tachycardia-->

**serotonin syndrome Also occurs w/ SSRIs or MAOIs + opioid analgesics [meperidine-tramadol] or antitussive [ dextromethorphan]

DDIs: | SSRIs--> ______ of P450 drug metabolizing enzymes

**inhibition w/ Fluoxetine / paroxetine or fluvoxamine Less concern with sertraline and citalopram Can decrease efficacy of drugs requiring activation by CYP2D6 (codeine – tramadol)

Why should you worry about prescribing an elderly Pt on an SSRI with St. John’s Wort?

Possible induction of P450 drug metabolizing enzymes Reports of serotonin syndrome in elderly patients taking St. John’s Wort and SSRIs

A 26-year-old man is receiving pharmacotherapy for a psychiatric disorder. He comes to the emergency room with elevated blood pressure, sweating, headache, and vomiting. His companion tells the physician that the patient became ill at a party where he ate triple-cheese pizza and was drinking Guinness beer. The patient is most likely taking a drug from which therapeutic class? Serotonin selective reuptake inhibitors Tricyclic antidepressants Monoamine oxidase inhibitors Serotonin norepinephrine reuptake inhibitors

MAOIs

Ex's of atypical antipsychotics that can be used for tx resistant depression:

aripiprazole-olanzapine-quetiapine)

To be effective in acute and chronic pain management, tramadol and codeine must be converted to an active form by CYP2D6. Cases of inadequate pain control have occurred when these agents were administered to patients who were being treated with: Fluoxetine Amitriptyline Bupropion Escitalopram

fluoxetine

SSRIs are much less effective than tricyclic antidepressants in the management of: ``` Bulimia Chronic pain of neuropathic origin Generalized anxiety disorder Obsessive-compulsive disorder Premenstrual dysphoric disorder ```

Chronic pain of neuropathic origin

SSRIs / Heterocyclic agents / TCADS: describe the pharmocokinetics

Incomplete absorption, significant 1st pass effect High protein binding/lipid solubility (high Vd) **Wide interpatient variations in Cp for a given dose

MAOIs: | T/F--> inhibition is irreversible

True!! Inhibition is irreversible – continues after drug no longer detectable (2 weeks) Best to monitor platelet MAO inhibition for determination of duration of MAOI drug effect

first line tx for depression=

**Generic SSRIs are usually first line: Sertraline – Fluoxetine –Citalopram=Escitalopram SNRIs (esp. Venlafaxine)--> May be more effective. Side effects > SSRIs Bupropion: Equal efficacy, Less weight gain and sexual side effects

Wellbutrin is NOT effective for tx of ______ depression

anxious

Mirtazapine might be a good choice for treatment of depression in patients who complain of: Sexual dysfunction Insomnia Weight gain Constipation

insomnia

Bupropion: - Is not sedating - Does not cause weight gain - Is contraindicated in patients with seizure disorder - All of the above

ALL know this for exam

_____ is the most rapid and effective (70-90%) tx for SEVERE ACUTE depression

ECT --> Can be life-saving if patient is suicidal Usually 6-12 treatments at a frequency of 2-3 per week

ECT: | list ADRs

Medical-->cardiopulmonary events, fractures, orodental injuries, headache Cognitive--> acute confusion, retrograde and anterograde amnesia

Anterograde amnesia=

while drug is in your system you don’t form memories

A 36-year-old woman presents with symptoms of major depression that are unrelated to a general medical condition, bereavement, or substance abuse. She is not currently taking any prescription or over-the-counter medications. Drug treatment is to be initiated with sertraline. In your information to the patient, you would tell her: Sertraline may take 2 weeks or longer for onset of Antidepressive effect It is preferable that she take the drug in the morning Some nausea and GI upset may be present She should notify you if she anticipates using other prescription drugs All the above

ALL

Which of the following statements concerning the side effects and toxicities of antidepressant drug use is FALSE? Concomitant use of SSRIs and MAOIs may result in a serotonin syndrome. SSRIs (e.g., fluoxetine) can induce hypomania in patients with bipolar disorder. Tricyclic antidepressants (e.g., amitriptyline) have a lower incidence of anticholinergic side effects than SSRIs. Inhibitors of dopamine and norepinephrine reuptake (e.g., bupropion) have been observed to cause anxiety and restlessness due to their mild stimulant action. None of the above

Answer= Tricyclic antidepressants (e.g., amitriptyline) have a lower incidence of anticholinergic side effects than SSRIs. -B- watch out with SSRIs with Pts you may suspect bipolar D- true

Regarding the clinical use of antidepressants, which statement is accurate? Chronic use of SSRIs (venlafaxine) increases the activity of hepatic drug-metabolizing enzymes In the treatment of major depressive disorders, citalopram is usually more effective than paroxetine MAOIs can be effective in depressions with attendant anxiety, phobic features, and hypochondriasis Weight gain often occurs during the first few weeks in patients taking SSRIs

MAOIs can be effective in depressions with attendant anxiety, phobic features, and hypochondriasis SSRIs decrease activity of hepatic drug-metabolizing enzymes -citalopram and paroxetine are equally efficacious D- may lose weight initially due to all the S/E

A recently widowed 76-year-old female patient was treated with a benzodiazepine for several weeks (appropriate?) after the death of her husband, but she did not like the daytime sedation it caused even at low dosage. Living independently, she has no major medical problems but appears rather infirm for age and has poor eyesight. Because her depressive symptoms are not abating, you decide on a trial of an antidepressant medication. Which would be the most appropriate choice for this patient? ``` Amitriptyline Trazodone Mirtazapine Phenelzine Citalopram ```

citalopram

Antidepressant Agents Flashcards

(58 cards)