Depression Flashcards by Renny Oye

T/F? Pt needs instructions on how to respond to worsened mood, critical for adolescents and young adults?

True

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Depression diagnosis criteria?

DSM-5 criteria - at least 5 of the ff sx during the same 2 wk period

Depressed mood

Marked diminished interest/pleasure

Significant weight loss or gain

Insomnia or hypersomnia

Psychomotor agitation or retardation

Fatigue of loss of energy

Feelings of worthlessness

Diminished ability to concentrate

Recurrent Suicidial ideation

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What condition need to be rule-out prior to starting antidepressant therapy?

Bipolar disorder

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List medications that cause or worsen depression

Beta-blockers, particularly propranolol

Clonidine, Corticosteroids, Cyclosporine

Ethanol

Isotretinion, Indomethacin, Interferons

Methadone, Methyldopa, Methylphenidate/ADHD meds/Atomoxetine

OCPs, anabolic steroids (Pt and medication specific)

Procainamide

Reserpine

Statins (pt specific)

Varenicline

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List medical conditions that can cause or worsen depression

Stroke

Parkinson dx

Dementia

Thyroid disorders (esp, hypothyroidism)

Low Vit D levels

Metabolic conditions (hypercalcemia), Multiple sclerosis, Malignancy

OAB

Infectious dx

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What’s the lag effect ass with antidepressant?

Physical sx (such as low energy) improve within a few weeks

Psychological sx (such as low mood) may take a month or longer

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What Grp of antidepressant is pregnancy cat C? Exception?

SSRIs

Paroxetine (Cat. D)

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Paroxetine is usually pregnancy cat D, which formulation of paroxetine is preg cat. X?

Brisdelle

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What’s the new warning ass with SSRIs?

Bcuz of potential risk of persistent pulmonary hypertension of the newborn (PPHN)

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What grp is the second recommended for pregnancy and depression?

Tricyclics

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Which natural pdts may be helpful for depression?

St. John’s wort or SAMe (S-adenosyl-L-methionine)

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What’s the issue with using St. John’s wort?

Can’t use with other serotonergic agents

Broad-spectrum CYP450 enzyme inducer and has many significant drug interactions

It’s photosensitizer and serotonergic

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What’s a medical food pdt used for depression?

L-methylfolate (Deplin)

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List SSRIs (Selective Serotonin Reuptake Inhibitors) agents

Fluoxetine (Prozac)

Paroxetine (Paxil)

Fluvoxamine (Luvox)

Sertraline (Zoloft)

Citalopram (Celexa)

Escitalopram (Lexapro - S-enantiomer of citalopram)

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What’s the brand name of Fluoxetine (SSRIs)?

Prozac

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What’s the brand name of Paroxetine (SSRIs)?

Paxil

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What’s the brand name of Sertraline (SSRIs)?

Zoloft

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What’s the brand name of Citalopram (SSRIs)?

Celexa

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What’s the brand name of Escitalopram (SSRIs)?

Lexapro (S-enantiomer of citalopram)

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CI to SSRIs use?

Potentially lethal DI with MAOIs

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General SE of SSRIs?

Sexual SE: reduced libido, ejaculation difficulties, anorgasmia

Somnolence

Insomnia

Nausea

Xerostomia

Diaphoresis (dose-related)

Weakness

Tremor

Dizziness

Headache (may help for migraines if taken continuously)

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SE specific to Fluoxetine?

Fluoxetine may be activating. Take dose in AM to prevent this

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Which SSRIs SE is of more concern in elderly?

SIADH

Hyponatremia

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What may cause an increase in bleeding while using SSRIs?

Concurrent use of:

Anticoagulants

Antiplatelet

NSAIDs

Ginkgo

Thrombolytics

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Which SSRI has FDA warning of QT prolongation? In what grp? At what dose?

Citalopram At > 40mg/day 60+ years - > 20mg/day

How do u switch from fluoxetine daily to fluoxetine weekly?

Start 7 days after last daily dose Weekly fluoxetine is dosed at 90mg/week

What agent is the SSRI and 5-HT1A partial agonist?

Vilazodone (Viibryd)

Is food a consideration when using Vilazodone (Viibryd), a SSRI and 5-HT1A Partial Agonist?

Yes. Use with food

SEs of Vilazodone (Viibryd), a SSRI and 5-HT1A Partial Agonist?

Reduced libido (but less sexual SEs compared to SSRI and SNRIs) Diarrhea Nausea/vomiting Insomnia

Bleeding risk and Vilazodone (Viibryd)?

Same as SSRIs (increased bleeding risk with concurrent use of anticoagulants, antiplatelets, NSAIDs, gingko, thrombolytics

List agent that's SSRI, 5-HT3-1D, 5-HT7 receptor antagonist; 5-HT1A Agonist; and Partial 5-HT1B agonist

Vortioxetine (Brintellex)

SEs of Vortioxetine (Brintellex)?

Same as SSRIs and Vilazodone (increased bleeding risk with concurrent use of anticoagulants, antiplatelets, NSAIDs, gingko, thrombolytics

All SSRI req a 2-wk washout period when going to an MAOI or from an MAOI to an SSRI, except?

Fluoxetine. Req a 5-week washout period (due to long half-life of at least 7days)

Whats the top choice for antidepressant in cardiac pts?

Sertraline

How should sertraline oral concentrate be used?

Must be diluted before use Don't use with disulfiram

List Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs ) agents

Venlafaxine (Effexor, Effexor XR) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) Levomilnacipran (Fetzima)

What's the brand name of Venlafaxine (SNRIs)?

Effexor Effexor XR

What's the brand name of Duloxetine (SNRIs)?

Cymbalta

What's the brand name of Desvenlafaxine (SNRIs)?

Pristiq

CI to SNRIs use?

Potentially lethal DI: SNRIs and MAOIs (2 wks washout req)

In addition to SEs similar to SNRIs, what other SE is a concern for SNRIs?

Increase in BP

In what SNRIs is the increase in BP risk greatest?

Venlafaxine when dosed > 150mg/day

SNRIs and bleeding risk?

Same as SSRIs, Vortioxetine (Brinand Vilazodone (increased bleeding risk with concurrent use of anticoagulants, antiplatelets, NSAIDs, gingko, thrombolytics

SNRIs, SSRIs, Tricyclics and MAOI?

Same as SSRIs.....2 wk wash out if going to or from MAOI Fluoxetine req 5 wk wash

Linezolid or methylene blue IV and SSRI, SNRIs, Vilazodone (Viibryd), Vortioxetine (Brintellex)?

Avoid staring SSRIs, etc if pt is on Linezolid and methylene blue IV

What med decreases the effectiveness of Duloxetine?

Tamoxifen

T/F? Duloxetine is a 2D6 inhibitor?

True

What counseling pt is unique to Desvenlafaxine and bowel movements?

Pt may see what looks like a tab in their stool. This is the empty shell from the tablet after the medicine was absorbed by your body

Effect of alcohol and Levomilnacipran?

Alcohol may cause the med to be released quickly

How long does it take to feel a benefit from SSRI and SNRIs? To feel the full effect on mood?

1-2 wks 6-8 wks

MOA of Tricyclics?

Tertiary Amines - Amitriptyline - Doxepin - Clomipramine - Imipramine - Trimipramine Secondary Amines - Amoxapine - Desipramine (Norpramine) - Maprotiline - Nortriptyline (Pamelor) - Protriptyline (Vivactil)

What's the difference btw tertiary and secondary amines (Tricyclics)?

Secondary amine - relatively selective for NE Tertiary amine - may be slightly more effective, but have worse SE profile

What's the dosing of Amitriptyline (Tricyclics)?

Depression - 100-150mg bid Neuropathic pain/migraine prophylaxis: 10-50mg QHS

What's the dosing of Nortriptyline (Tricyclics)?

Depression: 25mg TID-QID

What's the dosing of Doxepin (Tricyclics)?

Depression: 100-300mg daily

Main SEs of tricyclics?

Cardiotoxicity (esp Orthostasis) Anticholinergic (dry mouth, blurred vision, urinary retention, constipation)

What's the cardiotoxic SE of Tricyclics?

QT prolongation with overdose Orthostasis Tachycardia

What's the anticholinergic SE of Tricyclics?

Dry mouth Blurred vision Urinary retention Constipation (may use a stool softener or laxative)

What SEs usually go away with time from Tricyclics use?

Anxiety or Insomnia or Vivid dreams

Which antidepressant is a good choice if a pt has both pain and depression?

Duloxetine

Which antidepressant is a good choice if a pt has neuropathic pain/ migraine prophylaxis?

Amitriptyline 10-50mg QHS

MOA of MAOIs?

Inhibit enzyme monoamine oxidase, which breaks down catecholamines, including 5-HT, NE, EPU, DA. If these NTs increase dramatically, hypertensive crisis and death can result

List of MAOI agents used in depression

Isocarboxazid (Marplan) Phenelzine (Nardil) Tranycypromine (Parnate)

CI to monoamine oxidase inhibitors (MAOI) use?

Not commonly used, but watch out for drug-drug and drug-food interactions

What's the brand name of Isocarboxazid (MAOIs) used in depression?

Marplan

What's the brand name of Phenelzine (MAOIs) used in depression?

Nardil

What's the brand name of Tranylcypromine (MAOIs) used in depression?

Parnate

SEs of MAOIs?

Anticholinergic effect (dry eyes, dry mouth, constipation, urinary retention) Orthostasis Sedation (except Tranylcypromine (Parnate), which causes stimulation) Sexual dysfunction Weight gain Headache Insomnia

Name the MAOI that comes in a patch?

Selegiline (Emsam)

What types of food should be avoided when using MAOIs?

Tyramine-rich foods anything aged, fermented, pickled or smoked

Emsam (Selegiline) patch application?

Change once daily Pick a time of the day u can remember. Apply to either outer surface of the upper arm. Rotate site and don't use same site 2 days in a row Wash hands with soap after applying Don't expose to heat Washout period includes patch

List Dopamine (DA) and Norepinephrine (NE) Reuptake inhibitors agents

Bupropion Mirtazapine (Remeron) Trazodone Nefazodone

What's the brand name of Bupropion used in depression?

Aplenzin Budeprion SR, Budeprion XL, Wellbutrin SR and XL, Wellbutrin, Forfivo XL

CIs to Bupropion use?

Seizure disorder Don't exceed 450mg/d due to seizure risk Bipolar disorder Anorexic

SEs of Bupropion?

Dry mouth Insomnia Tremors/seizures (dose-related)

Bupropion has no effect on serotonin (5-HT), effect of this?

No sexual dysfunction

What's the brand name of Mirtazapine (DA and NE Reuptake inhibitor)?

Remeron

SEs of Mirtazapine (Remeron)?

Sedation Increase appetite, weight gain

Whys Trazodone rarely used?

Sedation

What's a se of Trazodone, that's a medical emergency?

Risk of Priapism

SE of Nefazodone?

Hepatoxicity (t4, rarely used)

CI to bupropion use

Any pt on Buproban or Zyban for smoking cessation; same drug Any to with seizure hx; Bupropion lowers seizure threshold

What's the max single dose and daily dose of Bupropion?

Max single dose: 150mg Max daily dose: 450mg

When should Mirtazapine (Remeron) be used?

At night, it's sedating and increases appetites

What must be done to classify depression as tx resistance depression?

Rule-out bipolar disorder Check if antidepressant is at optimal dose, sometimes use combo standard antidepressants Augment with various options

List agents that are used in Tx Resistance Depression Only

Aripiprazole (Abilify, Abilify Discmelt) Olanzapine/Fluoxetine (Symbyax) Quetiapine extended release (Seroquel, Seroquel XR)

What's the brand name of Aripiprazole for Tx Resistance Depression?

Abilify Abilify Discmelt

What's the brand name of Olanzpine/Fluoxetine for Tx Resistance Depression?

Symbyax

What's the brand name of Quetiapine extended release for Tx Resistance Depression?

Seroquel Seroquel XR

What's the warnings associated with agents used in tx resistance depression (Aripiprazole - Abilify, Abilify Discmelt; Olanzapine/Fluoxetine - Symbyax; Quetiapine ext release - Seroquel, Seroquel XR)

Risk of Neuroleptic Malignant Syndrome Risk of Tardauve Dyskinesia Risk of Leukopenia, Neutropenia, Agranulocytosis

CI to Olanzapine/Fluoxetine (Symbyax) use?

Don't use Symbyax with: Pimozide Thioridazine Other QT prolongating drugs/conditions

SEs of agents used in tx resistance depression (Aripiprazole - Abilify, Abilify Discmelt; Olanzapine/Fluoxetine - Symbyax; Quetiapine ext release - Seroquel, Seroquel XR)?

Metabolic issues e.g. Dyslipidemia, wt gain, diabetes Orthostatic/dizziness

Which metabolic issue is less with Aripiprazole (Abilify, Abilify Discmelt)?

Diabetes

SE particular to Abilify (Aripiprazole)?

Anxiety Insomnia Constipation

SE particular to Olanzapine?

Sedation Weight gain Increased lipids, glucose EPS QT prolongation (lower risk)

SE particular to Quetiapine (Seroquel, Seroquel XR)?

Sedation Orthostasis Weight gain, increased lipids and glucose All these are similar to Olanzapine Little risk of EPS (unlike Olanzapine)

Which SSRI is used in PMDD?

Fluoxetine (Sarafem)

Brand name of Fluoxetine + Olanzapine?

Symbyax