What is the lifetime prevalence of depression?
16%
How many depressed patients seek treatment?
1/3
Anxiety and Substance abuse are what to depression?
Comorbidities
Who is more likely to be depressed? gender?
>= 65 years old.
Women are more likely than men
What are the risk factors of depression?
Who is most likely to complete suicide?
- Gender- Female
- 18-29 and >65
- Family history
- Prior episodes of depression or suicide attempt
- Comorbid psychiatric illness
- Social Stressor
How is the onset of depression presented?
The symptoms gradually develop over days
Risk of Reoccurrence
- 1 episode:
- 2 episodes
- 3 episodes
Pts with recurrent depression are at an increase risk for what?
50-60%
70%
90%
Bipolar
What is the monoamine hypothesis?
These hypotheses dont explain what?
Lack of DA, 5-HT, and NE
The lag time for antidepressants to take effect
What are the target signs and symptoms of depression?
At least one of these needs to be?
- Depression
- Sleep (insomnia, hypersomnia)
- Loss of interest
- Guilt
- Energy loss
- Loss of concentration
- Loss or gain appetite
- Psychomotor (agitation or retardation)
- Suicide
One either Depression or loss of interest
Differential Diagnosis of Major Depressive disorder?
- Bipolar affective disorder (manic symptoms)
- Substance-induced mood disorder
- Mood disorder caused by general medical condition
- Dementia
- Dysthymia- Greater than two years of depressed mood
- Adjustment disorder with depressed mood
What are the common medical conditions that are associated with depression?
- Hypothyroidism
- Heart disease CHF, MI
- Post stroke
- Parkinsons
- Alzheimers
- AIDS
- Anemia
- Anxiety disorder
- Schizophrenia
- Alcholism
- Eating disorder
Monamine Oxidase Inhitors
- Phenelzine (Nardil)
- Tanylcyprmine (Parnate)
- Selegiline (EmSam)- Patch
Tertiary Amine TCAs name them
What do they cause more of?
- Amitriptyline
- Doxepin
- Imipramine
Cause more SEs all TCAs are primarily used off label for sleep and pain disorders in adults
Secondary Amine TCAs
- Protriptyline
- Nortriptyline
- Despiramine
What are the key points when providing TCAs?
Whats dangerous
SEs
Who to avoid in?
- They are Dangerous in overdose
- Cardiac and Anticholinergic SEs- Dry mouth, constipation,
- Avoid in elderly
What are the SSRIs?
- Citalopram (celexa)
- Escitalopram (Lexapro)
- Fluaxetine (Prozac, Prozac weekly, Sarafem)
- Fluvoxmine (Luvox, ER)- only for OCD
- Paroxetine (Paxil and CR) - Mild anticholinergic, Avoid in elderly
- Sertraline (Zoloft)
SNRIs used in Depression
- Venlafaxine (Effector, XR)
- Desvenlafaxine (Pristiq)
- Duloxetine (DM neuropathy) - Cymbalta
- Levomilnacipran (Fetzima)
SEs for SNRIs and SSRIs
What is the Key take away with the Side Effects
- S- Stomach (N/V/D)- Due to receptors in gut
- S- Sexual Dysfunction
- R-Restlessness
- I-Insomnia
- Headache
- Weight gain can be a good thing
- Withdrawal from abrupt discontinuation
Most of these SEs stop after 1-2 weeks
Except for sexual dysfunction and Weight Gain
Citalopram Special SEs?
What doses to avoid?
What about old people?
- QTc prolongation
- avoid dose > 40 mg
- Patients > 60 should avoid dose > 20
SNRIs have been know to increase?
Diastolic BP
Duloxetine has a?
Should be avoided in?
- LFT warning
- Avoid use in patients with pre-existing liver insufficiency and alcoholics
Withdrawal reactions with SNRIs and SSRIs
- Agents with short half lifes- SNRIs but also some SSRIs
- Dizziness, Insomnia, fatigue, anxiety, agitation, nausea, vomit, sweating, tingling, sensory disturbances (Brainzaps)
- Taper dose when disconituing
Mertazapine (Rameron)
Interacts with?
AEs due to histamine blockade?
Clonadine interaction
AE- Somnolence, weight gain, Constipation, Lower risk of sexual dysfunction than SSRIs
Bupropion (Wellbutrin)
AEs?
Contraindication?
Could worsen and known to cause? Should be taken when?
- Insomnia, Tremor, Nervousness, dry mouth
- Contra in seizures and eating disorders
- Can worsen anxietym known to cause insomnia so take in the morning
Multiple Serotonin Effector drugs that act like a SSRI + Buspirone?
Do you take either of them with food?
What types of SEs do these show?
- Vilazodone (Viibryd) - Take with food - Partial Agonist
- High rates of Nausea and Diarrhea, Less sexual Dysfunction
- Vortioxetine (Trentillix)
- High rates of Nausea, Sexual Dysfunction
- High rates of Nausea and Diarrhea, Less sexual Dysfunction
- High rates of Nausea, Sexual Dysfunction
This drug is a mized serotonin actor and may cause hepatotoxicity what is the drug
what should be monitored and what is it an Inhibitor of?
What other Side effects can this drug cause?
Nafazodone, LFTs should be monitored and it is a potent inhibitor of CYP3A4
- Dizziness, Orthostatic hypotension, dry mouth, nausea
This drug is typically sedating and is mainly used to treat insomnia. What is the drug what SEs does it have?
- Dizziness, Orthostatic hypotension, dry mouth, nausea
- Trazodone
When selecting an antidepressent what 9 things should you take into account?
- Past treatment success
- Family treatment history if it worked for a family member it has a good chance of working for then and vice versa
- Patient preference is important if they think something will work the placebo effect will help it work
- Convience like a once a day med, if someone is having to take it BID there is a good chance of non adherance
- Drug interactions should always be taken into consideration
- Adverse effects
- Safety and overdose. Example- A drug like Trazadone has a overdose potential plus if someone has overdosed on something before you never want to give it to them again
- Existing medical condition, hepatoxicity type
- Cost lucky most SSRIs are low cost
What antidepressant are 2D6 Inhibitors?
Buproprion, Fluoxetine, Paroxetine
What antidepressant are 3A4 inhibitors?
Nefazodone, Fluvoxamine
What drugs are 2C9/19 inhbitors?
One of these is also a 3A4 inhibitor
And one is a 2D6 inhibitor
Fluvoxamine 3A4
Fluoxetine 2D6
An MAOI like linezolid has what interactions?
Severe serotonin syndrome with any antidepressant.
Also interacts with Meperidine
What antidepressants are associated with serotonin syndrome?
SSRI, SNRI, TCA, Nefazodone, Vilazodone, St. Johns Wort, Mirtazepine
Adverse effect considerations to take into account with TCAs?
- Not for elderly
- Suicide
- Anticholinergic SEs
- Not for someone with BPH, Cardiac problems, very sedating
SSRI SE considerations?
Sexual dysfunction
Bupropion SE consinderations?
- Insomina
- Seizure disorders
Trazodone SE consinderations?
Sedation
SE consinderations?
Nefazodone
Hepatotoxicity
SE consinderations?
Venlafaxine
High BP and HTN
SE consinderations?
Mirtazepine
Sedation, Weight Gain
If someone is experiencing Sexual dysfunction from a SSRI or SNRI what actions can be taken to reduce this?
- Reduction of dose can be helpful
- Wait for adaptation the person to adapt
- Taking drug holidays not fluoxetine but other drugs has helped
- Changing the antidepressant to Bupropion, Nefazodone, Mirtazepine
- There are "Antidotes"
- Bupropion
- Nefazodone
- Mirtazepine
- Cyproheptadine
- Sildenafil
- Bupropion
- Nefazodone
- Mirtazepine
- Cyproheptadine
- Sildenafil
Safety in overdose Drugs to consider
TCAs, SSRs, Trazodone, Bupropion, MAOIs
- TCAs- Death
- SSRIs- Generally safe but there is some QT prolongation
- Trazodone Safe
- Bupropion Safe
- MAOIs- HTN crisis, serotonin syndrome
It is important to counsel patients on how antidepressants work and how they usually take up to at least a month to take full effect.
So the patient doesnt expect to just immidiately feel better this would cause nonadherence if they feel it isnt working.
In the first week the patient can be expected to see what types of improvement?
1-3 weeks?
4 weeks?
- Week 1
- Decreased anxiety
- Improvement of sleep
- increased appetite
- Week 1-3
- Increased acitivity, Sex drive?, Self care and memory
- Thinking and movements normalize
- Sleeping and eating patterns normalize
- Week 4
- Relief of depressed mood
- Less hopeless
- Thoughts of suicide subside
- Decreased anxiety
- Improvement of sleep
- increased appetite
- Increased acitivity, Sex drive?, Self care and memory
- Thinking and movements normalize
- Sleeping and eating patterns normalize
- Relief of depressed mood
- Less hopeless
- Thoughts of suicide subside
Counseling tips when giving someone antidepressants?
- Delayed onset
- SEs
- Nonaddicting
- Nature of deseas and how to antidepressant works
- Continue medication even if no s/sx od depression
- Likely successfull
- Follow-up
- Contact medical previder if feeling suicidal
- Avoid alcohol
STOPPEd at SUMMARY!
