Depression

Question 1

Symptoms of depression: “SIGECAPS”

Answer 1

Sleep changes
Interest loss
Guilt
Energy loss
Concentration loss
Appetite changes
Psychomotor agitation
Suicidal

Question 2

Diagnosis of depression requires:

Answer 2

5 symptoms of SIGECAPS in a 2 week period. One symptom must be either depressed mood or loss of interest/pleasure

Question 3

Medications that can worsen depression

Answer 3

Hormones and heart medications

Question 4

Treatment phases and goals

Answer 4

Acute phase: 6-12 weeks; goal of remission
Continuation phase: 4-9 months; goal to eliminate symptoms and prevent relapse
Maintenance phase: 12-36 months; goal to prevent recurrence

Question 5

How to discontinue antidepressants

Answer 5

Taper, do not stop abruptly; this may cause recurring symptoms

Question 6

Highest risk of relapse is within ___ months of discontinuation

Answer 6

2

Question 7

Time to effects of antidepressants

Answer 7

Week 1: energy, sleep, appetite
Week 2: sadness, libido, self-care, concentration, suicide risk
Week 4: depressed mood, hopelessness, interest
Takes 4-6 weeks to see a response from the medication

Question 8

Nonresponse: ___% decrease in baseline symptoms
Partial response: ___% decrease in baseline symptoms
Partial remission: ___% decrease in baseline symptoms

Answer 8

<25%
25-49%
>50%

Question 9

First line treatment options

Answer 9

SSRI, SNRI, bupropion, mirtazapine

Question 10

Second line treatment options

Answer 10

Switch to a different first line option or augment with an antidepressant with a different MOA

Question 11

Third line treatment options

Answer 11

Consider TCA or MAO-I

Question 12

6 different SSRIs

Answer 12

Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)

Question 13

The maximum recommended dose for citalopram is ___mg or ___mg for people age 60+

Answer 13

40mg

20mg

Question 14

___ is the SSRI which is the most activation and has the least sexual dysfunction

Answer 14

Fluoxetine

Question 15

___ is the SSRI with the longest half-life and is best for non-adherent patients

Answer 15

Fluoxetine

Question 16

The washout period for all SSRIs is ___ weeks besides fluoxetine, which has a washout period of ___ weeks

Answer 16

2

5

Question 17

___ is the SSRI which is pregnancy category D and has a high rate of sexual side effects

Answer 17

Paroxetine

Question 18

___ is the SSRI which causes GI side effects and has a high rate of sexual side effects

Answer 18

Sertraline

Question 19

4 different SNRIs

Answer 19

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

Question 20

The initial dose of venlafaxine is ___mg/day and the usual dose is ___mg/day

Answer 20

37.5-75mg/day

75-225mg/day

Question 21

This SSRI can cause QT prolongation

Answer 21

Citalopram

Question 22

This SNRI is associated with CV adverse effects

Answer 22

Venlafaxine

Question 23

This SNRI is associated with an increased risk of hyperlipidemia

Answer 23

Dexvenlafaxine

Question 24

This SNRI is contraindicated with hepatic impairment

Answer 24

Duloxetine

Question 25

True or False: SNRIs cause greater sexual dysfunction than SSRIs

Answer 25

False. SNRIs cause little sexual dysfunction

Question 26

The primary symptom of serotonin syndrome is ___

Answer 26

Myoclonus (muscle rigidity)

Question 27

How to treat serotonin syndrome

Answer 27

1. Discontinue med 2. Hydration and antipyretics (Tylenol, ibuprofen) 3. Serotonin antagonist in more severe cases (cyproheptadine)

Question 28

Symptoms of discontinuation syndrome (abrupt stopping of SSRI or SNRI)

Answer 28

Flu-like symptoms

Question 29

This SSRI is least likely to cause discontinuation syndrome

Answer 29

Fluoxetine due to its long half-life

Question 30

This antidepressant is useful for co-management of depression and smoking cessation/patients with ADHD with the added benefit of causing no sexual dysfunction

Answer 30

Bupropion

Question 31

Avoid this antidepressant in patients with eating disorders, alcohol use, and seizures

Answer 31

Bupropion

Question 32

Bupropion IR dosing

Answer 32

100mg BID. Max of 450mg daily (divided TID) | Max of 150mg/dose

Question 33

Bupropion XR dosing

Answer 33

150-450mg QD

Question 34

Adverse effects of bupropion include:

Answer 34

Weight gain, increased lipids, and drowsiness

Question 35

A rare (usually during first month of treatment) adverse effect of this antidepressant is priapism

Answer 35

Trazodone

Question 36

True or False: The antidepressant effect of trazodone is only seen at higher doses

Answer 36

True. Also, its side-effects limit its use as an antidepressant

Question 37

TCAs commonly have ___ side effects

Answer 37

Anticholinergic (dry)

Question 38

___ can lower seizure threshold and have a risk of overdose in suicide

Answer 38

TCAs

Question 39

Examples of TCAs

Answer 39

``` Tertiary amines - Greater inhibition of serotonin reuptake > NE Amitriptyline Clomipramine Doxepin Imipramine ``` Secondary amines - Greater inhibition of NE > serotonin; less anticholinergic side effects Desipramine Nortriptyline

Question 40

Examples of MAO-Is

Answer 40

Phenelzine Tranylcypromine Selegiline

Question 41

This MAO-I comes as a patch

Answer 41

Selegiline

Question 42

Avoid taking MAO-Is with food that contain ___

Answer 42

Tyramine (beer, cheese, dry meat, fava beans) | Can cause hypertensive crisis (increase BP, diaphoresis, NV, HA)

Question 43

First line therapy should be tried for at least ___ weeks before switching to an alternative therapy

Answer 43

4

Question 44

Antidepressants should be continued for at least ___ year

Answer 44

1

Question 45

All antidepressants have a BBW for ___ in people aged ___

Answer 45

Suicidal thoughts | 18-24

Question 46

In elderly patients, initiate antidepressants at ___ the normal dose and titrate more ___

Answer 46

1/2 | Slowly