Depression

Question 1

Major depression symptoms

Answer 1

depressed most of day, most days; diminished interest in activities, dec weight/wt inc; insomnia, hypersomnia, fatigue; feeling worthless, guilty; dec ability to concentrate, recurrent thoughts of death

Question 2

Subgroups of depression

Answer 2

psychotic, atypical, seasonal, postpartum, melancholia, catatonic

Question 3

Pathophysiology of depression

Answer 3

reduced neurotransmitters: serotonin, norepi, DA, mostly invloving limbic and hypothalamus

Question 4

Treatment options for depression

Answer 4

psychotherapy, electroconvulsive therapy, antidepressants

Question 5

Electroconvulsive therapy

Answer 5

unilateral/ bilateral seizures that change level of neurotransmitters, response faster than drugs, may need 6-12 months of therapy, most pts respond, be careful w/ stoke or MI

Question 6

Antidepressant treatment

Answer 6

onset requires weeks, appears to restore the neurotransmitter mediated balance in the brain between serotonin, norepi, and DA, 60-70% efficacy no matter the agent, don’t d/c abruptly, shouldn’t be on 2 from same class

Question 7

SSRIs

Answer 7

paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitaloprom (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), vortioxetine (Brintellix)

Question 8

SSRI MOA

Answer 8

inhibits the reuptake of serotonin at the pre-synaptic serotonin transporter pump, inc brain serotonin levels, not fatal if overdose

Question 9

SSRI ADRs

Answer 9

CNS abnormalities, GI upset, st change, hyponatremia, decreased libido

Question 10

Fluoxetine (Prozac)

Answer 10

Long T1/2- active metabolites, , activating, causes insomnia, wt loss, minor dopamine antagonist

Question 11

Fluoxetine (Prozac) dosage

Answer 11

20 mg PO daily, only one available once a week option, 90 mg PO weekly, good for noncompliant pts, must adhere first 2 weeks

Question 12

Parocetine (Paxil)

Answer 12

wt gain and sedation prominent, take at bedtime, 20-40 mg PO once daily

Question 13

Sertraline (Zoloft)

Answer 13

25-100 mg PO once daily, middle of the road in terms of effects on sleep and appetite, DA agonist (Minor), good for parkinson’s

Question 14

Citalopram (Celexa)

Answer 14

20-40 mg PO daily, only effects serotonin, not DA or Ach, fewest ADRs, better for mild to mod depression

Question 15

Fluoxamine (Luvox)

Answer 15

50-100 PO daily, only indicated for OCD, can also be used to boost activity of antipsychotic agents

Question 16

All SSRIs are

Answer 16

highly protein bound, inhibit P450 system, increase effects of TCAs, inc/dec lithium, dec clearance of trazodone and diazepam, inc toxicity of MAOIs, may displace protein bound drugs

Question 17

SNRIs

Answer 17

Venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafacine (Pristiq)

Question 18

SNRI MOA

Answer 18

inhibit neuronal serotonin and nor epi reuptake results in inc brain serotonin and norepi levels

Question 19

Venlafaxine (effexor)

Answer 19

take with food, may be effective for resistant depression, ADR exceptions, less sexual side effects, HTN

Question 20

Venlafaxine (effexor) dosage

Answer 20

75-150mg PO BID, used most frequently as XR formulation: 75-150 PO daily

Question 21

Desvenlafaxine sodium (Pristiq)

Answer 21

Longer T1/2 than venlafaxine,, requires adjustment for impaired renal function, ADR profile is very similar to venlafaxine

Question 22

Duloxetine (Cymbalta)

Answer 22

40-60 mg PO daily, quicker onset, effective in one week? used reg for diabetic peripheral neuropathy, hepatoxic

Question 23

Tricyclic antidepressants

Answer 23

Amitriptyline (Elavil), doxepin (sinequan), nortriptyline (Pamelor), imipramine (tofranil), clomipramine (Anafranil), desipramine (Norpamin)… and more

Question 24

MOA of TCA

Answer 24

inhibit the of reuptake of norepi and/or serotonin, causing a relative inc in [neurotransmitter], can be fatal in overdose

Question 25

TCA ADRs

Answer 25

most common: ach effects, sedation and orthostatic hypotension, TCAs lower the seizure threshold and may precipitate seizures, tachycardia, arrhythmias, elderly are at risk of sedation and hyTN

Question 26

Amitriptyline

Answer 26

10-100mg PO daily, generally at bedtime, used reg for insomnia in young pop

Question 27

Trazodone (Desyrel)

Answer 27

inhibit serotonin reuptake, 100 mg PO once daily at bedtime, often used in combo w/SSRIs for insomnia, no ACh ADRs, may cause priapism, take w/ food

Question 28

Bupropion (Wellbutrin) MOA

Answer 28

mild DA reuptake inhibitor, little effect on norepi, no effect on seritonin or monoamine oxidase

Question 29

Bupropion (Wellbutrin)

Answer 29

Contraindicated in pts w/ seizure disorders and psychosis, lack of cardiovascular, ACh, and sexual side effects, Wt loss, insomnia, agitation, HA, a DOC for smoking cessation, also available as wellbutrin SR/XL

Question 30

Mirtazapine (Remeron)

Answer 30

enhances central norep and serotonin activity by antagonizing central pre-synaptic a2 receptors, often as adjunct (30mg), monotherapy for insomnia, possibly faster onset

Question 31

Mirtazapine (Remeron) ADRs

Answer 31

somnolence, at low dose, dizziness, increased appetite/wt gain, orthostatic hyTN, and hallucinations

Question 32

MAOIs

Answer 32

Phenelzine (Nardil), Selegiline (Eldepryl, Zelapar), tranylcypromine (parnate)- none use very often, must have 2 week washout period when switching from other vice versa

Question 33

MAOI MOA

Answer 33

impair degradation of norepinephrine, serotonin, and dopamine leading to inc neurotransmitter conc; prevents metabolism of tyramine in GI and liver causing release of norepi and severe HTN, rarely use w/ another class

Question 34

MAOI ADRs

Answer 34

orthostatic hypotension, delayed ejaculation, wt gain, and edema, can switch bipolar pts into mania, liver toxic, lot of DIs

Question 35

Withdrawal of antidepressants

Answer 35

1-5 days after d/c, fatigue, insomnia, dizziness, tremor, confusion, agitation, memory probs

Question 36

Treatment of withdrawals

Answer 36

resume antidepressant if possible, reassurance and supportive care, not life threatening rxns, can be disturbing

Question 37

Serotonin syndrome

Answer 37

symptoms complex characterized by mental status changes, agitation, diaphoresis, diarrhea*, incoordination and tachy

Question 38

Cause of serotonin syndrome

Answer 38

believed to be from serotonergic hyperstimulation, can develop when taking a combo of serotonergic meds or when changing from one serotonergic drug to another, also from DI that applify the seroonergic effect of single drug

Question 39

Treatment serotonin syndrome

Answer 39

d/c all serotonergic meds, supportive care

Question 40

Suicide warning for antidepressants

Answer 40

boxed warning on most if not all agents, inc in suicide thinking and behavior, not completed attempts

Question 41

Treatment resistance

Answer 41

clinical trial have documented that most persons do not recover completely from depression w/ 1st drug therapy, many will require therapy w/ 2 or more concurrent agents, for recurrent disease, must treat x2years