Depression Flashcards
What is the DSM-5 criteria for a depression diagnosis? (M SIG E CAPS)
M - mood (depressed)
S - sleep (increased/decreased)
I - interest/pleasure (diminished)
G - guilt or feelings of worthlessness
E - energy (decreased)
C - concentration (decreased)
A - appetite (increased/decreased)
P - psychomotor agitation or retardation
S - suicidal ideation
at least 5 of these symptoms (including depressed mood or diminished interest/pleasure) must be present within a 2 week period
What are 5 drug classes that can cause or worsen depression?
ADHD medications (ex. atomoxetine)
Analgesics (ex. indomethacin)
Antiretrovirals (ex. efavirenz, rilpivirine)
Cardiovascular meds (ex. beta blockers)
Hormones (ex. hormonal contraception, anabolic steroids)
What are some natural products that may be helpful in depression?
St. John’s Wort
SAMe (S-adenosyl-L-methionine)
5-HTP (5-hydroxytryptophan)
valerian
(less evidence of efficacy than with standard treatments)
If a pt is pregnant, what are the first-line options if treatment of depression is needed?
SSRIs, such as sertraline or escitalopram are first-line options.
- Still a risk of persistent pulmonary hypertension of the newborn (PPHN) when using SSRIs during pregancy
- Ideally, psychotherapy would be the only treatment, but sometimes treatment is warranted
Avoid paroxetine due to potential cardiac effects
What are the treatment options for postpartum depression?
SSRIs are preferred
IV brexanolone (Zulresso) and PO zuranolone (Zurzuvae) are C-IV drugs that are indicated for postpartum depression
What are the symptoms of serotonin syndrome? What drug class carries the biggest risk for serotonin syndrome?
Symptoms:
- severe nausea
- dizziness
- headache
- diarrhea
- agitation
- tachycardia
- hallucinations
- muscle rigidity
Risk is greatest when using MAO inhibitors with another serotonergic medication, especially at higher doses.
What is the MOA of SSRIs? What is 1 contraindication and 3 warnings? Which SSRI is most activating, which SSRI is most sedating?
MOA - increase 5-HT by inhibiting its reuptake in the neuronal synapse
Contraindication
- do not use with MAO inhibitors or linezolid (serotonin syndrome)
Warnings
- QT prolongation (max doses of citalopram and escitalopram in elderly)
- SIADH/hyponatremia
- bleeding
Most activating: fluoxetine
Most sedating: paroxetine
What is the max dose of citalopram? What is max dose if pt ≥ 60 years old?
Max dose: 40mg/day
If ≥ 60 years: 20mg/day (QT prolongation)
What is the max dose of escitalopram? What is max dose if pt ≥ 60 years old?
Max dose: 20mg/day
If ≥ 60 years: 10mg/day (QT prolongation)
What is Brisdelle (paroxetine) used for? When is it contraindicated? What is Paxil CR (paroxetine) approved for?
Brisdelle is used for mod-severe vasomotor symptoms associated with menopause. It is contraindicated in pregnancy (CV effects).
Paxil CR is approved for premenstrual dysphoric disorder (PMDD)
Which SSRI is preferred in patients with cardiac risk?
Sertraline
Which SSRI does NOT need a 2 week wash out period with MAO inhibitors?
Fluoxetine has a long half life, so it needs a five week washout period if switching to an MAO inhibitor.
Which SSRIs are CYP2D6 inhibitors? (3)
fluoxetine
paroxetine
fluvoxamine
*this is why venlafaxine is preferred when in combination with tamoxifen)
*some antipsychotic drugs are CYP2D6 substrates and may need a lower dose when given in combo w/ fluoxetine or paroxetine
Which medications used an SSRI combined mechanism?
vilazodone (Viibryd): SSRI and 5-HT1A partial agonist
vortioxetine (Trintellix): SSRI, 5-HT3 receptor antagonist, and 5-HT1A antagonist
How is the MOA of SNRIs different than SSRIs? What indications do these medications have? What is 1 contraindication and 2 warnings? What side effects does this class have that SSRIs don’t?
MOA - increase 5-HT by inhibiting it’s reuptake in the neuronal synapse AND inhibit reuptake of norepinephrine.
Added indications of venlafaxine and duloxetine:
- generalized anxiety disorder (GAD)
- panic disorder
- social anxiety disorder
Contraindication:
- cannot use with MAO inhibitors
Warnings:
- SIADH/hyponatremia
- bleeding
New side effects:
- due to inc. NE: increased HR, dilated pupils, dry mouth, excessive sweating, constipation
- increased BP (greatest w/ venlafaxine)
What is the MOA of tricyclic antidepressants? What is 1 contraindication, what are the 3 main side effects?
MOA - inhibit NE and 5-HT reuptake, but also block ACh and histamine receptors.
- secondary amines are relatively selective for NE (nortriptyline)
- tertiary amines can be slightly more effective, but have a worse side effect profile (amitriptyline, doxepin)
Contraindication
- do not use with MAO inhibitors, linezolid, or IV methylene blue
Side effects
1. Cardiotoxicity - QT prolongation w/ overdose, orthostasis
2. Anticholinergic - dry mouth, blurred vision, urinary retention, constipation
3. Seizures
Which medication is a dopamine and norepinephrine reuptake inhibitor? What is the max dose? What are 3 contraindications? What are some side effects? What side effect does it NOT have?
bupropion (Wellbutrin SR, Wellbutrin XL)
Max dose: 450mg/day (due to seizure risk)
Contraindications:
- seizure disorder
- hx of anorexia/bulimia
- do not use with MAO inhibitors, linezolid, IV methylene blue, or other forms of bupropion
Side effects:
- dry mouth
- CNS stimulation (insomnia, restlessness)
- tremors/seizures
- weight loss
RARE sexual dysfunction (can use if issues with other antidepressants)
What is the MOA of monoamine oxidase inhibitors? What are 4 drugs in this class? What are 2 warnings with this class?
MOA - inhibit the enzyme monoamine oxidase, which breaks down catecholamines, including 5-HT, NE, epi, and DA
- isocarboxazid (Marplan)
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Selegiline - transdermal patch, MAO-B selective inhibitor
Warnings
1. watch for drug-drug and drug-food interactions (could be fatal if missed)
2. hypertensive crisis or serotonin syndrome if taken with TCAs, SSRIs, SNRIs, many other drugs, and tyramine-rich foods
What is mirtazapine’s MOA? What meds is it contraindicated with? What are 3 side effects?
MOA - tetracycline antidepressant. Has central alpha-2 adrenergic antagonist effects, which results in an increased release of NE and 5-HT
Contraindications:
- do not use with MAO inhibitors, linezolid, or IV methylene blue
Side effects:
- sedation
- increased appetite
- weight gain
What is the boxed warning with nefazodone?
Boxed warning: hepatotoxicity
When is depression deemed “treatment-resistant”? What are the options in this case?
depression that does not fully respond to two full treatment trails is considered treatment-resistant.
pts should receive a 4-8 week trial of medication at a therapeutic dose before concluding that a drug is not working.
Options:
- change to new antidepressant
- increase dose
- use combination of antidepressants w/ different MOAs
- augment w/ buspirone or low dose of an atypical antipsychotic (ex. aripiprazole, olanzapine, quetiapine, brexpiprazole, cariprazine)
What are 3 side effects of aripiprazole?
- anxiety
- insomnia
- akathisia
What are 4 side effects of olanzapine?
- sedation
- weight gain
- increased lipids
- increased glucose
What are 5 side effects of quetiapine?
- sedation
- orthostasis
- weight gain
- increased lipids
- increased glucose
