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Flashcards in Antidepressants Deck (72)
1

Where is the monoamine system located

Upper brainstem and limbic system

2

What are the NT involved in the monoamine system

NE,5HT, DA

3

What is the purpose of NE

Study and get things done

4

What is the purpose of 5HT

Everyday life NT- appetite, mood, emotion, sleep

5

What is the purpose of DA

Joy of life, feel good and party, attention

6

What other receptors are involved in the monoamine system

5HT3,2
H1
Alpha 1adrenergic
M- cholinergic

7

5HT3

Agonist- N/V/D
Antagonist- anti emetic

8

5 HT2

Agonist- insomnia, anxiety, akathesia, sexual dysfunction

9

H1

Weight gain and sedation

10

M cholinergic

Antagonist- constipation, dry mouth, drowsiness and confusion

11

Alpha 1 adrenergic

Orthostatic hypotension

12

Rules for diagnosing depression

Must have 5 of the SIGECAPS symptoms (1 of them must be from the interest category), change from normal functioning, and must rule out physical problems- tsh, hgb, b12

13

SIGECAPS

S- sleep- insomnia or hypersomnia
I- interest- depressed mood or adhedonia
G- guilt- feelings of worthlessness
E- energy- decreased energy
C-concentration- inability to make decisions or focus
A-appetite- wit changes or loss of enjoyment of food
S-suicidie- recurring thoughts of suicide

14

Who is most successful at suicide

Older men

15

What questions should you ask about suicide and when should you've concerned?

Always be concerned
Be especially concerned and make sure to ask if they have a plan

16

Etiologic hypothesis of depression

Stress diathesis- threshold for depression, environment determines if we exceed it
Biological hypothesis- aided by fact that drugs help
Catecholamine hypothesis- body runs out of NE AND 5HT
Dsregulation hypothesis- imbalance between NE and 5HT

17

Role of psychotherapy and CBT

Used in mild to moderate depression- works synergistically with antidepressants.
Takes longer to help but has a lower rate of remission

18

When do you use pharmacotherapy for depression

In severe depression

19

ECT

Safe for pregnant and elderly
Very quickly down regulates beta receptors in the brain which correspond to a decrease in depression.
Use if patient has depression that is refractory to 2-3 drugs that have been used for at least 12 weeks

20

Pharmacotherapy

Takes 4 -6 weeks to see mood changes
Changes in mood correspond to decrease in beta receptor density not changes in hormone or NT levels

21

Pharmacotherapy AE

Transient insomnia, anxiety, and jitteriness
Sexual dysfunction occurs but this is not transient

22

Types of drugs used to tx depression

SSRI
TCA
MOA
venlafaxine
Duloxetine
Nefazodone
Trazodone
Bupropion
Mirtazapine

23

SSRI- drug names

Fluoxetine
Citalopram
Paroxetine
Sertaline
Fluvoxamine
Escitalopram

24

SSRI MOA

Blocks serotonin reuptake
5HT2 agonist
Down regulation of beta receptors

25

SSRI AE

Insomnia, anxiety, diarrhea
Sexual dysfunction
Serotonin syndrome

26

How is sexual dysfunction Dealt with

PDE5 inhibitor

27

What is serotonin syndrome

Occurs when have excess serotonin, have taken to many drugs that stimulate serotonin
Fishing, wheezing, hyperthermia, N/V/D
Hypertension, myoclonus, headache, seizure, ataxia
Treat by stopping the serotonin drugs, cooling blankets, nifedipine for HTN, clonazepam for the myoclonus, and anti convulsants for the seizures

28

SSRI withdrawal

Shooting electric pains, anxiety, flu like symptoms
Headache, insomnia, dizziness
Must titration down the dosage especially if using SSRIs with a short half life ie paroxetine or venlafaxine
Fluoxetine doesn't have to be titrated down BC it has a long half life and active metabolite

29

Fluoxetine

SSRI with very long half life and most psychomotor activating of the SSRI so good for pts with motor depression

30

Citalopram

Least psychomotor activating of the SSRI so good for pts with psychomotor activation

31

Paroxetine

Short half life,must be tapered down
Do not give to pregnant woma

32

What SSRI do you not give in pregnancy

Paroxetine
Sertaline

33

SSRI USE

DOC for depression with comorbid anxiety
Can change between them if one doesn't work another might

34

TCA drug names

Imipramine --> desipramine
Amotryptaline--> nortriptaline
Dsipramine and nortriptaline are metabolites

35

TCA- MOA

Inhibit NE AND 5HT reuptake
Muscarinic, alpha 1, and H1 antagonists

36

TCA AE

Orthostatic hypotension, Weight gain, and anti cholinergic
Sexual dysfunction
Serotonin syndrome if given with other antidepressants
Lowers the seizure threshold
Cardiac events
OD- can kill

37

Mechanism of cardiac toxicity for TCA

Block the NA Channels causing prolonged QT interval leading to torsades des pointes --> vfib--> death
Tx OD with NAHCO3 BC it act on NA channels

38

TCA's and teratogenicity

The non metabolite TCA (Imipramine and amitriptalline) can cause heart failure, tachycardia, seizures, and urinary retention in newborns.

39

TCA uses

Alternative to SSRI.
Used in depression with comorbid pain- fibromyalgia, Migraine, chronic pain, and atypical depression.
B/c NE IS THE NT OF PAIN

40

TCA contraindications

History of CAD, seizure history, BPH, dementia, or constipation

41

MOA- drugs

Isocarboxacid
Phenelzine
Tranycypromine

42

TCA MOA

Blocks MAOA (5Ht, NE, and Tyrammine) and MAOB (DA)

43

MAO AE

Orthostatic hypotension, weight gain, anti cholinergic
Sexual dysfunction
Serotonin syndrome if given with other antidepressants or meperidine, tramadol, or dextrometorphan
Wine and cheese syndrome
TERATOGENIC

44

Wine and cheese syndrome

Hypertensive crisis that leads to fatal hemmorhages
Wine and cheese have a lot of tyrammine, normally it's cleared nfirst pass metabolism, if there is an mao inhibitor then it might not be cleared this causes excess release of NE from peripheral neurons.

45

Mao drug interactions

Meperidine, phenylephrine, and sympathmimetics
Lead to hypertension, fever, and delirium

46

MAO uses

Atypical depression for tx refractory depression
Other drugs have better safety profiles.
When switching to Mao from another antidepressant make sure to taper off it the previous drug for at least two weeks and 5-6 weeks if it is fluoxetine.

47

Venlafaxine MOA

At low doses acts as a 5HT reuptake inhibitor, at high doses acts as a NE reuptake inhibitor

48

Venlafaxine AE

At low doses has the same AE as SSRI, including withdrawal BC of the short half life
Be careful inpatients with uncontrolled HTN

49

Duloxetine MOA

Blocks NE AND 5HT reuptake at low doses

50

Duloxetine uses

Depression with pain , it is FDA approved for diabetic pain

51

Duloxetine AE

Drug interactions
Hepatotoxicity

52

Nefazodone MOA

Blocks 5HT and NE reuptake
5HT2A, H1, M antagonist

53

Nefazodone uses

Good for depression with anxiety and insomnia and sexual dysfunction

54

Nefazodone AE

Sedation, GI complaints, drumouth, constipation

55

Nefazodone- AE

Drug interactions
Hepatotoxicity

56

Trazodone- MOA

5ht reuptake inhibitor and 5HT2 antagonist
Blocks H1 and alpha 1

57

Trazode AE

Orthostatic hypotension
Very sedating
Priapism

58

Trazondone uses

Used for sedation to counter insomnia with other antidepressants and hypotonic

59

Bupropion MOA

Blocked NE AND DA reuptake
This is the same MOA AS COCAINE

60

Buproprion AE

CAN INCREASE SEIZURES AND SEXUAL FUNCTION
Psychomotor activation, headache, insomnia, psychosis,and anorexia
Can cause weight loss

61

Bupropion use

Help patients quit skiing and to counter sedation

62

Bupropion CI

Seizure history
Anxiety
Bulimia

63

Mirtazapine MOA

Antagonizes the presynaptic alpha 2 receptors increasing NE RELEASE
Block 5HT3 and 2,and H1

64

Mirtazapine uses

Good for DEPRESSION with comorbid anxiety, reduced sexual function and has a low risk of OD
This is the sleep, sex, and food antidepressant

65

Mirtapazine AE

Sedative effect, weight gain, neutropenia, and agranulocytosis

66

What to think about when prescribing antidepressants

Comorbid conditions
Which drugs has pt had success with, or their first degree relatives
Adverse events

67

Treating depression phases

Acute, continuation, maintenance

68

Acute phase

Week 1- Improvement in sleep and appetite
1-3 weeks- everyday life improvements- activity, sex drive, self care, sleeping and appetite normalization
2-6 weeks- suicide and depression subside

69

Continuation phase

4-9 months of maintaining the same dose as during the acute phase to keep it in remission

70

Maintenance phase

Long term therapy depends on the person and their circumstances

71

Treatment outcomes

Response- dec symptoms by 50%, this occurs in 60% of patients
Remission- attitude returns to normal, this occurs in 30% of patients, has a decreased chance of relapse

72

Treatment regimen in depression

Start with SSRI they are the safest, least AE, and most studied
If that doesn't work can change meds, add bupropion or another agent, or augment to with- lithium, anticonvulsant, th, or buspirone.