Antidepressants

Question 1

First line antidepressants

Answer 1

SSRI
SNRI
Bupropion
Mirtazapine
Vortioxetine

Question 2

Adequate trial of antidepressant

Answer 2

4-8 weeks

Question 3

Remission definition

Answer 3

3 weeks with no symptoms of depressed mood & anhedonia, and no more than 3 remaining symptoms of depression

Remission = goal of therapy

Question 4

Onset of effectiveness

Answer 4

2-4 weeks: improvement in physical symptoms (energy, sleep)

-If partial response at 4 weeks, need longer trial

4-6 weeks: full effect

8 weeks: response

12 weeks: remission

Question 5

Maintenance of therapy

Answer 5

Once reached remission (at least 12 weeks!) continue for another 6-9 months

If risk factor for recurrent depression, treat for 2 years or longer
(frequent recurrent episodes, severe episodes, chronic episodes, presence of comorbid psych condition, residual symptoms)

Question 6

1A2 sub, inhib, inducer

Answer 6

Substrate:
Duloxetine

Inducer:
Cannabis, tobacco

Inhibitor:
Caffeine, fluvoxamine

Question 7

2C19 sub, inducer, inhib

Answer 7

Substrate:
Citalopram
Escitalopram
Fluoextine
Imipramine
Viladozone

Inducer:
St Johns wort

Inhibitor
Amitriptyline
Cannabis
Fluoxetine
Fluvoxamine
Imipramine

Question 8

2D6 sub, inhibitor

Answer 8

Substrate:
Amitriptyline
Desipramine
Duloxetine
Fluoxetine
Imipramine
Nefazodone
Nortriptyline
Trazodone
Venlafaxine
Vortioxetine

Inhibitor
Bupropion
Cannabis
Duloxetine
Fluoxetine
Paroxetine
Sertraline

Question 9

3A4 sub, inducer, inhib

Answer 9

Substrate
Citalopram
Escitalopram
Levomilnacipran
Nefazodone
Trazodone
Venlafaxine
Vilazodone

Inducer
St Johns wort

Inhib
Fluvoxamine
Nefazodone

Question 10

SSRI with longest half life

Answer 10

fluoxetine (1-4 days)

Question 11

Most activating SSRIs

Answer 11

Fluoxetine
Sertraline

Question 12

Most sedating SSRIs

Answer 12

Paroxetine
Fluvoxamine

Question 13

Most common ADR of SSRI

Answer 13

GI upset
Insomnia
Restlessness
Headache
Sexual dysfunction (>=50% of ppl)

Question 14

Intervention for SSRI induced sexual dysfunction

Answer 14

1. Wait and see
2. Add bupropion
3. Lower SSRI dose
4. Add PDE-5 inhibitor in men
5. Weak data, but add buspirone or mirtazapine

Question 15

Serotonin syndrome

Answer 15

3 clusters of symptoms:
-Neuromuscular hyperactivity (myoconlus, rigidity, tremors)
-Altered Mental Status (agitation, confusion, hypomania)
-Autonomic instability (hyperthermia, diaphoresis)

Hunter criteria used to identify

Treatment:
1. D/C offending agent
2. Supportive measures
3 Give cyproheptadine; a benzo for myoclonus; antiseizure meds; nifedipine for HTN

Question 16

Other serotonergic meds to increase risk of serotonin syndrome

Answer 16

MAOIs
Dextromethorphan
Meperidine
Tramadol
Sympathomimetics
Linezolid
Lithium
TCAs
SNRIs

Question 17

Withdrawal of SSRI

Answer 17

Flu-like symptoms (nausea, chills)
Neurologic symptoms (paresthesias, insomnia, anxiety, electric shock sensations)

Gradual dose reduction needed even for long half life

Question 18

Citalopram ADR

Answer 18

QTc prolongation, especially doses > 40mg

FDA now limits daily dose to <= 40mg

20mg max if hepatic impairment, >60, 2C19 poor metabolizer, or 2C19 inhibitor

Question 19

Renal adjustment needed for these SNRIs

Answer 19

Desvenlafaxine
Levomilnacipran

Avoid duloxetine in severe renal impairment

Question 20

SNRI for hepatic insufficency

Answer 20

Desvenlafaxine - bypasses CYP metabolism

Question 21

SNRIs and hypertension

Answer 21

Usually mild and not clinically significant UNLESS uncontrolled HTN

Question 22

SNRI with orthostatic hypotension

Answer 22

Levomilnacipran
Desvenlafaxine

Question 23

Vilazodone (viibryd) CI

Answer 23

History of seizure

Question 24

Vortioxetine (trintellex) unique MOA

Answer 24

SSRI +
-serotonin 1A agonist
-serotonin 1B partial agonist
-serotonin 3 antagonist
-serotonin-1D antagonist
-serotonin-7 antagonist

Improves cognitive function

Lower risk of sexual dysfunction

Question 25

Trazodone unique ADR

Answer 25

Priapism (medical emergency)

Question 26

Nefazodone BBW

Answer 26

Liver toxicity Must monitor LFTs 2-3rd line agent

Question 27

Mirtazapine sedative effect, other ADRs

Answer 27

Sedating at lower doses Insomnia at higher doses weight gain (inc. appetite), constipation, asthenia

Question 28

Bupropion unique ADR

Answer 28

Increased risk of seizures

Question 29

Bupropion seizure risk management

Answer 29

1. Avoid use in all susceptible patients 2. Do not give >150mg/dose or >450mg/day 3. Avoid dose titrations more often than every 4 days (XR, SR) or 3 days (IR)

Question 30

Bupropion + Dextromethorphan

Answer 30

Combination for treatment of depression

Question 31

Tertiary amine TCAs

Answer 31

Amitriptyline Imipramine More potent for serotonergic reuptake inhibition

Question 32

Secondary amine TCAs

Answer 32

Nortriptyline Desipramine More selective for norepinephrine reuptake inhibition Less anticholinergic

Question 33

TCA in overdose

Answer 33

Cardiotoxic - causing prolonged QTc and TdP, seizures Do not give to actively suicidal patient

Question 34

TCA ADRs

Answer 34

Anticholinergic (amitriptyline) Sedation (amitriptyline) Orthostatic hypotension (imipramine) Cardiotoxic (amitriptyline & imipramine)

Question 35

Avoid TCAs in these populations

Answer 35

Cardiac disease Seizure disorder Actively suicidal

Question 36

Nonselective MAOIs

Answer 36

Isocarboxazid Phenelzine Tranylcypromine

Question 37

MAOIs + tyramine

Answer 37

Potential for hypertensive crisis Avoid aged cheese, preserved meats, wine, beer

Question 38

Gepirone

Answer 38

New antidepressant Take with food QTc prolongation No sexual dysfunction side effect

Question 39

Antidepressants and suicidality

Answer 39

ALL carry BBW for increased risk of suicide in children, adolescents, young adults up to 24. Highest risk at initiation or dose adjustment -- since physical symptoms improve first, more energy to act out. Do not avoid treatment due to risk of suicide

Question 40

SGA with FDA approval for adjust to antidepressants

Answer 40

Aripiprazole Brexpiprazole Cariprazine Quetiapine ER Almost all used

Question 41

Treatment resistant depression

Answer 41

1. Olanazpine + fluoxetine 2. Esketamine (onset within hours)