Depression Flashcards
Adequate trial
Full effects may take 6 to 8 weeks, patient can expect to start feeling somewhat better within a few weeks but I will take a month or two to see full effect
Medications that can cause or worsen depression
Beta blockers particularly propranolol, clonidine, corticosteroids, cyclosporine, ethanol, isotretinoin, indomethacin, interferons, methadone, oral contraceptives, methyldopa, methylphenidate, procainamide, reserpine, statins, antidepressants
Monoamine oxidase inhibitors
Drugs: phenelzine, tranylcypromine, and isocarboxazid
Due to the risk of drug interactions and drug food Interactions these agents are no longer recommended and are restricted to patient unresponsive to other treatments
Major risk of serotonin syndrome given with another serotonergic medication
Switching medications
It’s changing the patient to another medication or discontinuing one of these medications recommend tapering off over several weeks or they have withdrawal symptoms
Withdrawal symptoms: anxiety, agitation, insomnia, dizziness, flulike symptoms
Resistant depression
May need to do one of the following:
- Increase the dose
- Use a combination of antidepressant
- Use augmentation with buspirone (BuSpar), aripiprazole (Abilify), olanzapine plus fluoxetine (Symbyax), quetiapine (Seroquel)
- Some trials suggest ketamine maybe useful
Treatment of PTSD
- SSRI: sertraline and paroxetine
SSRIs: selective serotonin reuptake inhibitors
Drugs: fluoxetine (prozac), paroxetine (Paxil, new-brisdelle (cat X IN PREGNANCY)), fluvoxamine (Luvox), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro)
Blackbox warning: increased risk of suicidal thinking especially in adolescence
Contraindications: SSRI and in AOI, do not stop suddenly, do not initiate in patients being treated with one Mayselwood on methylene blue, do not use brisdelle in pregnancy
Side effects: sexual side effects: somnolence, insomnia, nausea, xerostomia, diaphoresis, weakness, tremor, dizziness, headache; also carries increased bleeding risk concurrent use of anticoagulants, antiplatelets, NSAIDs, ginkgo, thrombolytics
Note: increased risk of QT prolongation with citalopram or Celexa and escitalopram or Lexapro
Note there is now a Prozac weekly dose that can be given to patients who are already on fluoxetine daily seven days after the last daily dose
SSRI and serotonin partial agonist combination mechanism
Drug: vilazodone (vibryd)
Must take with food
What box warning: increased risk of suicidal behavior
Contraindication: concomitant use with MAOIs, do not initiate in patients being treated with the linezolid or methylene blue
Side effects: diarrhea, nausea/vomiting, insomnia, decreased libido but less sexual side effects compared to SSRIs and SNRIs
SSRI counseling
- Dispense MacGuide and counsel especially in adolescents from risk of suicide
- To reduce your risk of side effects you may start this drug overdose and gradually increase
- This medication does not work only taken as needed
- It may take one to two weeks to fill a benefit from the stroke and 6 to 8 weeks to fill the full effect
SNRIs: serotonin and norepinephrine reuptake inhibitors
Drugs: venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq)
Many of these drugs have many indication: Cymbalta is indicated for pain depression fibromyalgia and anxiety disorder (this is a good choice for a patient that has both pain and depression)
Blackbox warning: suicidal thinking
Contraindication: use with MAOI, do not initiate patients receiving linezolid or methylene blue
Side effects: similar to SSRIs plus increased pulse, dilated pupils, dry mouth and excessive sweating due to norepinephrine; all carry a warning for increased blood pressure but the highest risk is with venlafaxine or Effexor; increased bleeding risk with other agents that increased bleeding
SNRI counseling
- Dispense med guide
- Make calls stomach upset and nausea if so try extended-release formulations
- When taking pristiq or Desvenlafaxine, you may see the capsule in your store
- Give it an adequate trial
Tricyclic antidepressants
MOA: norepinephrine and serotonin reuptake inhibitors primarily and block acetylcholine and histamine receptors which contribute to the side effect profile
Drugs tertiary amines: amitriptyline (Elavil), doxepin, clomipramine (anafranil), imipramine ( tofranil)
Drugs secondary amines: amoxapine, desipramine (norpramine), nortriptyline (Pamelor)
Main tricyclic used for depression: amitriptyline, nortriptyline, doxepin
Blackbox warning: suicidal thinking
Contraindication: do not use with MAOIs. Do not use if urinary retention or new angle glaucoma
Side effects: cardiotoxicity particularly QT prolongation, orthostasis and tachycardia; anti-cholinergic such as dry mouth, blurred vision, urinary retention, constipation; vivid dreams, weight gain, sedation, myoclonus(muscle twitching), increased fall risk
Tricyclic counseling
- Dispense medication guide
- This medication can cause constipation and therefore you may need a stool softener or laxative
- This drug may cause dry, blurry vision and you may need an eyedrop lubricant
- This drug may cause dry mouth: exercise dental hygiene
- This drug may cause difficulty urinating
- If you experience anxiety insomnia or vivid dreams these usually go away with time
- Give this medication an adequate trial
MAOIs
MOA: inhibits the enzyme monoamine oxidase which breaks down catecholamines including sir turning, norepinephrine, epinephrine and dopamine. If these neurotransmitters increased dramatically, hypertensive crisis and death can result
Drugs: isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (parnate)
Blackbox warning: suicidal thinking
Contraindications: watch for drug drug and drug food Interactions, hypertensive crisis can occur when taking with TCAs, SSRIs, SNRIs and many other drugs and tyramine rich foods
Side effects: anti-cholinergic effects, orthostasis, sedation, sexual dysfunction, weight gain, headache, insomnia
MAOIs inhibitor counseling
Avoid tyramine rich foods such as aged cheese, pickled herring coming Heast extract, air dried meats, sauerkraut, soy sauce, fava beans and some red wines and particularly beer
Warn patients regarding the need to avoid interacting foods and drugs (interacting drugs: other antidepressants, meperidine or Demerol, decongestants, CNS drugs)
Seek immediate medical care if you experience the following: some severe headache, nausea, stiffnecked, vomiting, a faster slow heartbeat or change the way your heartbeats, tight chest pain, a lot of sweating, confusion, dilated peoples and sensitivity to light
Other formulation: EMSAM patch (selegiline ) change once daily at the same time and rotate sites not using the same site two days in a row
