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Antidepressants Flashcards

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1
Q

DSM-5 Diagnostic Criteria – Major Depressive Episode (MDD)

A

Major
Depressive
Episode
Depressed
mood
Weight change
Sleep disturbances
Agitation/retardation
Fatigue
Guilt
Decreased
concentration
Suicidal ideation Loss of interest
or pleasure

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2
Q

Symptoms present most
of the day, nearly every day
Symptoms present > – weeks
and represent a change from
previous functioning

A

2

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3
Q

Must have > – symptoms

A

5

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4
Q

DSM-5 Diagnostic Criteria – MDD
(4)

A
  • symptoms cause clinically
    significant distress or
    impairment in social,
    occupational, or other
    important areas of functioning
  • not attributable to the
    physiological effects of a
    substance or another medical
    condition
  • not better explained by
    another psychiatric illness
  • has never been a manic
    episode or a hypomanic
    episode
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5
Q

Monoamine
Hypothesis of
Depression
* Depression due to

A

deficiency of
monoamine neurotransmitters (NT)
– norepinephrine
– serotonin

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6
Q

Monoamine
Hypothesis of
Depression
Evidence
– Depletion of NT induces depression
(2)

A

– Antidepressants increase levels of NT
– Onset of antidepressant activity
(decrease in depressive symptoms) is
correlated with down-regulation of
receptors

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7
Q

Oral Side Effects Associated with
Antidepressants
* Common
(2)

A

– Xerostomia (96%)
– Dysguesia (65%)

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8
Q

Oral Side Effects Associated with
Antidepressants
* Less Common

A

– Hypersalivation, stomatitis,
dysphagia, bruxism, glossiitis,
tardive dyskinesia, hairy
tongue, salivary gland
enlargement, tongue edema,
gingivitis, halitosis, ulcers, jaw
stiffness, candidiasis, sinusitis,
erythema multiforme, Steven-
Johnson syndrome, gumline
erosion, periodontal disease,
tooth disease

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9
Q

Monoamine Oxidase Inhibitors
(MAO-I)
(2)

A
  • phenelzine (Nardil)
  • tranylcypromine
    (Parnate)
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10
Q

Monoamine Oxidase Inhibitors
* drug-drug and
drug-food interactions
(2)

A

– hypertensive crisis
– serotonin syndrome

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11
Q

Common Side Effects of MAO-I
(7)

A
  • Dry mouth
  • Nausea, diarrhea or constipation
  • Headache
  • Drowsiness or Insomnia
  • Dizziness or lightheadedness
  • Weight gain
  • Sexual dysfunction
  • Significant morbidity and mortality associated
    with overdose
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12
Q

Hypertensive Crisis
* Defined by diastolic blood pressure > – mmHg
* Potentially fatal reaction characterized by:
(8)

A

120

– Occipital headache – may radiate frontally
– Palpitation
– Neck stiffness or soreness
– Nausea and/or vomiting
– Sweating
– Dilated pupils, photophobia
– Tachycardia or bradycardia
– Chest pain

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13
Q

Suggested Tyramine Dietary
Modifications for MAO-I
* Foods to AVOID
(6)

A

– Dried, aged, smoked,
fermented, spoiled, or
improperly stored meat,
poultry and fish
– Broad bean pods
– Aged cheeses
– Tap and nonpasteurized beers
– Marmite, sauerkraut
– Soy products/tofu

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14
Q

Suggested Tyramine Dietary
Modifications for MAO-I
* Foods ALLOWED
(5)

A

– Fresh or processed meat,
poultry and fish
– All other vegetables
– Processed and cottage
cheese, ricotta cheese,
yogurt
– Canned or bottled beers and
alcohol
– Brewer’s and baker’s yeast

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15
Q

Warnings:
Do not use if you are now taking a
prescription

A

monoamine oxidase inhibitor
(MAOI) (certain drugs for depression,
psychiatric or emotional conditions, or
Parkinson’s disease), or for 2 weeks after
stopping the MAOI drug. If you do not know
if your prescription drug contains an MAOI,
ask a doctor or pharmacist before taking this
product

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16
Q

Hypertensive Crisis –
Drug Interactions to AVOID
(4)

A
  • Decongestants
  • Stimulants
  • Antidepressants with
    NRI activity
  • Appetite suppressants
    with NRI activity
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17
Q
  • Decongestants
    (4)
A

– phenylephrine
– ephedrine (ma huang,
ephedra)
– pseudoephedrine
– oxymetazoline

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18
Q
  • Stimulants
    (2)
A

– amphetamines
– methylphenidate

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19
Q
  • Antidepressants with
    NRI activity
    (3)
A

– TCA
– SNRI (venlafaxine,
desvenlafaxine,
duloxetine)
– bupropion, mirtazapine

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20
Q
  • Appetite suppressants
    with NRI activity
    (1)
A

– phentermine

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21
Q

Serotonin Syndrome
(3)

A
  • Addition or increase of
    known serotonergic agent to
    an established medication
    regimen
  • Other etiologies (infectious,
    metabolic, substance abuse
    or withdrawal) have ruled
    out.
  • Antipsychotic has not been
    started or increased prior to
    the onset of sign/symptoms
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22
Q

Serotonin Syndrome
* Three of more of the
following symptoms:

A

– Agitation
– Diaphoresis
– Diarrhea
– Fever
– Hyperreflexia
– Incoordination
– Mental status changes
(confusion, hypomania)
– Myoclonus
– Shivering
– Tremor

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23
Q

Serotonin Syndrome –
Drug Interactions to AVOID
(4)

A
  • Antidepressants
  • Other TCA structure
    drugs
  • Pain Medication
  • Cough Suppressants
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24
Q
  • Antidepressants
    (4)
A

– SSRI
– TCA (clomipramine)
– SNRI
– Mirtazapine

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25
* Other TCA structure drugs (2)
– Cyclobenzaprine – Carbamazepine
26
* Pain Medication (5)
– Meperidine – Tramadol ✔ – Methadone – Propoxyphene – Fentanyl
27
* Cough Suppressants (1)
– Dextromethorphan
28
MAO-I: Summary Advantages (1)
* May be useful in treatment refractory depression
29
MAO-I: Summary Disadvantages (7)
* Tolerability * Significant risk of morbidity and mortality associated with overdose * Oral side effect – dry mouth * Dietary restrictions * Significant drug interaction risk * Hypertensive crisis * Serotonin syndrome
30
Tricyclic Antidepressants (TCA) (2)
* Tertiary TCA – amitriptyline (Elavil) * Secondary TCA – nortriptyline (Pamelor)
31
Side Effect Profile of TCA (4)
* cardiac conduction disturbances - QTc prolongation * seizures * sexual dysfunction * significant risk of morbidity and mortality associated with overdose
32
Drug Interactions with TCA
* TCA + CNS Depressants (ex. opioid pain medication) = additive CNS depressant effects
33
TCA: Summary Advantages (2)
* May be useful in treatment refractory depression * More commonly used for chronic pain (diabetic peripheral neuropathic pain, fibromyalgia, chronic musculoskeletal pain) and insomnia
34
TCA: Summary Disadvantages (4)
* Tolerability * Significant risk of morbidity and mortality associated with overdose * Oral side effect – dry mouth * Overall high side effect burden – including weight gain, sedation and sexual dysfunction * Significant risk for drug interactions (additive CNS depressant effects)
35
Selective Serotonin Reuptake Inhibitors (SSRI) (5)
* fluoxetine (Prozac) * paroxetine (Paxil, Paxil CR, Pexeva) * sertraline (Zoloft) * citalopram (Celexa) * escitalopram (Lexapro)
36
Mechanism of Action and Side Effect Profile of SSRI (2)
– minimal to no effect on H1, M1 or alpha1 receptors – side effect profile - GI upset, headache, insomnia, restlessness, anxiety, weight gain, sexual dysfunction
37
Side Effects Important in Dentistry (2)
* Increased risk for bleeding and bruising * Bruxism
38
Drug Interactions with NSAID * Pharmacodynamic interactions (2)
– SSRI – decrease platelet aggregation * INCREASED RISK FOR BLEEDING
39
Drug Interactions with Opioid Medications (codeine, hydrocodone and oxycodone) (4)
* Pharmacokinetic interaction * Drugs that INHIBIT CYP450 2D6 PREVENT the metabolism of codeine, hydrocodone and oxycodone to an active medication. * OUTCOME: pain relieving effects are REDUCED * Antidepressants – Paroxetine (Paxil) – Fluoxetine (Prozac)
40
SSRI: Summary Advantages (4)
* (+) safety associated with overdose * Recommended 1st line in all depression treatment algorithms * (+) safety profile in patients with medical illnesses * Relatively well tolerated
41
SSRI: Summary Disadvantages (4)
* Tolerability * Oral side effect – bruxism, increased risk for bleeding * Long term side effects – weight gain and sexual dysfunction * Significant risk for drug interactions
42
Side Effect Profile - Venlafaxine and Duloxetine * Side effect profile (2)
– no effect on H1, M1 or alpha1 receptors – side effect profile - nausea, elevated BP, weight gain, sexual dysfunction
43
SNRI: Summary Advantages (4)
* (+) Safety profile in overdose * Recommended 1st line in all depression treatment algorithms * Used to treat depression and pain (diabetic peripheral neuropathic pain, fibromyalgia, chronic musculoskeletal pain) * Relatively well tolerated
44
SNRI: Summary Disadvantages (4)
* Tolerability * No specific oral side effects * Long term side effects – weight gain and sexual dysfunction * Low risk for drug interactions
45
Side Effect Profile of Bupropion * contraindications (3) * caution use in --- * no effect on (3)receptors * side effect profile - (3)
– seizure history – history of significant head trauma – anorexia or bulimia psychosis H1, M1 or alpha1 – insomnia, seizures (less common) – low risk of sexual dysfunction – low risk of weight gain
46
Drug Interactions with Opioid Medications (codeine, hydrocodone and oxycodone) (4)
* Pharmacokinetic interaction * Drugs that INHIBIT CYP450 2D6 PREVENT the metabolism of codeine, hydrocodone and oxycodone to an active medication. * OUTCOME: pain relieving effects are REDUCED * Antidepressants – Paroxetine (Paxil) – Fluoxetine (Prozac) – Bupropion (Wellbutrin)
47
NDRI - Bupropion: Summary Advantages (5)
* Recommended 1st line in depression treatment algorithms * Low risk of sexual dysfunction * Low risk risk for weight gain * Used for smoking cessation * Relatively well tolerated
48
NDRI - Bupropion: Summary Disadvantages (4)
* Tolerability * No specific oral side effects * Potential for seizures associated with overdose * Significant risk for drug interactions
49
Side Effect Profile of Mirtazapine (3)
* no effect on M1 or alpha1 receptors * (+) effect on H1 receptors * side effect profile – Sedation – dry mouth – weight gain – low risk of sexual dysfunction
50
Presynaptic Alpha2 Antagonist - Mirtazapine: Summary Advantages (3)
* (+) Safety profile in overdose * Recommended 1st line in depression treatment algorithms * Low risk for sexual dysfunction
51
Presynaptic Alpha2 Antagonist - Mirtazapine: Summary Disadvantages (4)
* Tolerability * Oral side effect – dry mouth * Long term side effects - weight gain, sedation * Low risk for drug interactions
52
Goals of Antidepressant Therapy (7)
* REMISSION = resolution of depression symptoms * Improve functioning * Reduce risk of relapse * Increase quality of life * Decrease depression morbidity * Decrease depression mortality * Decrease healthcare costs
53
Definitions of Response and Remission % Reduction in Score Remission Response Partial Response Nonresponse
≥75% 50% - 74% 25% - 49% <25%
54
Selection of Antidepressant Therapy Empiric selection of antidepressant therapy: (5)
* past history of AD response * family history of AD response * concurrent disease states/drug therapy * adverse effect profile * cost
55
Selection of Antidepressant Therapy * Treatment Guidelines (APA 2019) (5)
* Psychotherapy can be used alone for mild-moderate depression * Pharmacotherapy can use used alone for mild- moderate depression * Pharmacotherapy +/- psychotherapy for moderate- severe depression * SSRI, SNRI, bupropion and mirtazapine are recommended as 1st line therapy * Only complimentary therapy recommended 1st line is St. John’s wort (CANMAT 2016, VA/DoD 2016)
56
Efficacy of AD (3)
* All antidepressants demonstrate equivalent efficacy - 70%. * onset - days to weeks (depending on type of symptom) * therapeutic trial - 6-8 weeks
57
Nonremission is Common * ---% remission * ---% response with residual symptoms * --% partial response * --% nonresponse * --% intolerant
35–45 10–20 15 25 7–15
58
Symptom Remission first week (3)
* Decreased Anxiety * Improvement in Sleep * Improvement in Appetite
59
Symptom Remission 1-3 Weeks (3)
* Increased Activity, Sex Drive, Self-care, and Memory * Thinking and Movements Normalize * Sleeping and Eating Patterns Normalize
60
Symptom Remission 2-4 Weeks (3)
Relief of Depressed Mood * Less Hopeless/ Helpless * Thoughts of Suicide Subside
61
Maintenance Antidepressant Therapy * first episode - * second episode - * > 2 episodes - * elderly patients -
continue AD for 9-12 months continue AD for 5 years continue AD for lifetime consider continuing AD for longer; maybe indefinitely
62

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