depression and bipolar disorder therapeutics Flashcards Preview

PT2 Psych 7-12 > depression and bipolar disorder therapeutics > Flashcards

Flashcards in depression and bipolar disorder therapeutics Deck (112)
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1
Q

questionnaires to evaluate depression

A

PHQ-2

PHQ-9

2
Q

response to treatment is defined as

A

50% reduction in baseline score of PHQ-9

70-75% reach this

3
Q

remission of depression defined as

A

-normal PHQ scores under 5
-symptom free for 2 months
(only 30% reach this)

4
Q

SSRI drugs

A
fluoxetine
sertraline
paroxetine
citalopram
escitalopram
fluvoxamine
5
Q

SSRI with longest half life

A

fluoxetine

6
Q

best tolerated SSRIs

A

sertraline and escitalopram

7
Q

general SSRI side effects

A
  • nausea
  • GI irritation
  • diarrhea (remits after 1 week)
  • headache
  • sexual dysfunction
8
Q

side effects unique for fluoxetine

A
  • anxiety/activation

- insomnia

9
Q

side effects unique for sertraline

A
  • anxiety/activation

- insomnia

10
Q

side effects unique for paroxetine

A
  • sedation
  • weight gain
  • anticholinergic effects
11
Q

side effects unique for fluvoxamine

A

sedation

12
Q

side effects unique for citalopram

A

QT prolongation

13
Q

how to deal with GI side effects of SSRIs

A
  • usually self limiting

- manage by slow titration and take with food

14
Q

how to deal with activation/anxiety effects in SSRIs

A
  • manage by titration
  • take in morning
  • bridge with benzo
15
Q

how to deal with insomnia side effects from SSRIs

A
  • take in morning

- add trazodone, mirtazapine, TCA at bedtime

16
Q

how to deal with sedation effects from SSRIs

A

take at bedtime

17
Q

how to deal with sexual dysfunction from SSRIs

A
  • add/switch to bupropion
  • add mirtazapine
  • switch to nefazodone
  • patients (may improve in 2-4 weeks)
  • add PDE-5 inhibitors
18
Q

how to deal with weight gain from SSRIs

A

-possibly switch to bupropion

19
Q

SSRI with highest weight gain rate

A

paroxetine

20
Q

time in SSRI therapy suicidal risk increases the most

A

weeks 1-3

21
Q

unusual SSRI side effects

A
  • hyponatremia
  • EPS
  • sweating
  • bleeding
  • triggering manic episodes
22
Q

discontinuation syndrome symptoms

A
  • Flu-like symptoms
  • Insomnia
  • Nausea
  • Imbalance
  • Sensory disturbances
  • Hyperarousal
23
Q

serotonergic medications that can cause serotonin syndrome when used with SSRIs/SNRIs

A
MAOI
linezolid
tramadol
buspirone
triptans
dextromethorphan
24
Q

treatment for serotonin syndrome

A
  • go to ER
  • discontinue offending agent
  • supportive care
25
Q

how long do you have to be off SSRI to have discontinuation syndrome

A

24-48 hours after

26
Q

least common drug to have discontinuation syndrome

A

fluoxetine because of the long half life

27
Q

advantages of venlafaxine/desvenlafaxine

A

also works well for anxiety disorders and neuropathic pain

28
Q

adverse effects of venlafaxine/desvenlafaxine

A
  • diarrhea
  • N/V at low doses
  • hypertension at high doses
29
Q

advantages of duloxetine

A

works for neuropathic pain often used for diabetes

30
Q

adverse effects of duloxetine

A
  • diarrhea, nausea
  • anticholinergic effects
  • increased heart rate
  • small changes in BP
31
Q

bupropion MoA

A

NE/DA reuptake inhibitor

32
Q

advantages of bupropion

A
  • useful for add on for sexual dysfunction

- can be used in smoking cessation

33
Q

bupropion adverse effects

A
  • nausea
  • dizziness
  • tremor
  • insomnia
  • anxiety
  • rarely increased seizures
34
Q

trazodone MoA

A

5-HT2A antagonist

serotonin reuptake inhibitor

35
Q

advantages of trazodone

A

can be added on to SSRIs for insomnia

36
Q

adverse effects of trazodone

A
  • orthostatic hypotension

- priapism

37
Q

main adverse effect for nefazodone

A

liver toxicity

38
Q

nefazodone use

A

for sexual dysfunction

39
Q

mirtazapine advantages for its 2 serotonin activities

A
  • from 5-HT2A, treats insomnia, sexual dysfunction

- from 5HT3 anti-emetic effect

40
Q

adverse effect of mirtazapine

A

weight gain at lower doses

41
Q

advantages of TCAs

A

-can be used to treat neuropathic pain and insomnia

42
Q

adverse effects of TCAs

A
  • anticholinergic
  • neurologic
  • cardiovascular
  • weight gain
  • sexual dysfunction
  • cholinergic rebound if stopped abruptly
43
Q

TCAs with tertiary amines

A

amitriptyline
imipramine
doxepin
clomipramine

44
Q

TCAs with secondary amines

A

nortriptyline

desipramine

45
Q

TCA group with worse side effects

A

tertiary amines

46
Q

adverse effects of TCAs in high doses

A

cardiac
convulsions
coma

47
Q

what happens if TCAs are abruptly stopped

A

cholinergic rebound

48
Q

how to deal with anticholinergic side effects from TCAs

A
  • artificial saliva or sugarless gum
  • artificial tears
  • decrease dose
49
Q

how to deal with neurologic side effects from TCAs

A
  • take at night
  • change agent if seizure occurs
  • titrate slowly for anxiety
  • for tremor use beta blockers
50
Q

how to deal with CV side effects from TCAs

A
  • Pt education
  • use nortriptyline
  • baseline/serial EKG
51
Q

antidepressants with GI side effects

A

fluoxetine
sertraline
venlafaxine
desvenlafaxine

52
Q

antidepressants with insomnia side effects

A

fluoxetine
sertraline
bupropion

53
Q

antidepressants with sedation side effects

A

paroxetine
fluvoxamine
miertazapine
TCAs

54
Q

antidepressants with diarrhea side effect

A

sertraline

55
Q

antidepressants with sexual dysfunction side effect

A

paroxetine
fluoxetine
TCAs

56
Q

antidepressants with anticholinergic side effects

A

paroxetine

TCAs

57
Q

antidepressants with weight gain side effect

A

paroxetine
TCAs
mirtazapine

58
Q

when to use MAOI

A
  • in atypical depression
  • significant anxiety
  • phobias
59
Q

MAOI drugs

A

phenelzine

tranylcypromine

60
Q

adverse effects of MAOIs

A
  • orthostasis
  • weight gain
  • sedation or activation
  • hypertensive crisis (cheese effect)
61
Q

drug interactions with MAOIs

A
  • cold/sinus medications
  • amphetamines
  • pressors
  • meperidine (certain death)
  • SSRIs/SNRIs
62
Q

paroxetine inhibits what CYPs

A

2D6

63
Q

fluoxetine inhibits what CYPs

A

2D6
2C9
2C19

64
Q

duloxetine inhibits what CYPs

A

2D6

65
Q

bupropion inhibits what CYPs

A

2D6

66
Q

fluvoxamine inhibits what CYPs

A

3A4
1A2
2C9
2C19

67
Q

nefazodone inhibits what CYPs

A

3A4

68
Q

TCAs inhibit what CYPs

A

3A4

69
Q

if pt. has comorbid smoking or parkinsons what drug do we use

A

bupropion

70
Q

if Pt. has comorbid anxiety what drugs do we use

A

SSRIs first
venlafaxine
TCA

71
Q

if Pt. has comorbid weight gain, sedation, nausea what drug do we use

A

mirtazapine

72
Q

if Pt. has comorbid alzheimers what drug do we use

A

SSRIs

bupropion

73
Q

if Pt. has comorbid alzheimers what drug do we avoid

A

TCAs

74
Q

if Pt. has comorbid DM what drugs do we use

A
  • TCAs for neuropathy
  • SSRIs may help BG
  • duloxetine for neuropathy
75
Q

if Pt. has comorbid insomnia what drugs do we use

A

trazodone
mirtazapine
TCAs

76
Q

drug of choice for pregnancy

A
  • SSRI - consider sertraline

- baby may have withdrawal symptoms for a few days

77
Q

paroxetine use in pregnancy

A
  • if they are already on it and doing well don’t D/C

- do not start it though

78
Q

antidepressants in pregnancy

A
  • if mom is already on one and it is working don’t stop it

- consider tapering before due to do reduce withdrawal in baby

79
Q

antidepressant of choice in breast feeding

A

sertraline

80
Q

first line in elderly w/ depression

A

SSRIs

AVOID TCAs

81
Q

considerations for children w/ depression

A
  • high suicidality concern

- monitor for impulsivity

82
Q

drug of choice in children w/ MDD

A

fluoxetine

83
Q

time course of response in week 1

A
  • anxiety/agitation
  • GI upset
  • after few days anxiety decreases and sleep improves
84
Q

time course of response in weeks 1-3

A
  • cognitive symptoms improve
  • increased activity and energy (suicide risk)
  • improved concentration
  • increased libido
  • sleep/appetite normalize
85
Q

time course of response in weeks 4-6

A
  • depressed mood subsides
  • re-experience pleasure
  • less suicidal thoughts
86
Q

length of treatment with antidepressants

A

-6-12 months for initial treatment, after symptoms remit

87
Q

who do we consider lifetime treatment w/ antidepressants

A
  • elderly

- 3rd episode

88
Q

what to do for pts. refractory to treatment

A
  • ensure adherence/dose optimization
  • switch to another agent w/ different MoA
  • combine SSRIs w/ bupropion, trazodone, mirtazapine, or TCA
  • use atypical antipsychotics or lithium
89
Q

drugs for severe acute manic symptoms in ER

A
  • 1-3 mg IV lorazepam
  • IM antipsychotic (ziprasidone, aripiprazole, haloperidol)
  • start lithium 300 mg tid, increase 300 mg q 3 days to reach therapeutic dose
90
Q

metabolism/elimination of lithium

A
  • not metabolized; renally eliminated
  • T1/2 is 20 hours
  • therapeutic levels reached in 5-7 days
91
Q

lithium therapeutic serum drug concentrations

A

acute: 0.8-1.2 mEq/L
maintenance: 0.4-0.7 mEq/L

92
Q

early adverse effects of lithium

A
  • GI upset
  • fine hand tremor
  • sedation
  • ataxia
  • diabetes insipidus
  • edema
93
Q

long term adverse effect sof lithium

A
  • hypothyroidism
  • acne
  • leukocytosis
  • renal toxicity
  • bradycardia
  • memory impairment
94
Q

lithium in breastfeeding

A

don’t do it

95
Q

baseline tests when starting lithium

A
  • Thyroid
  • Blood work (CBC)
  • Electrolytes (Na, K)
  • Electrocardiogram
  • Renal function tests
  • pregnancy test
96
Q

lithium drug interactions that increase serum drug levels

A
  • NSAIDs
  • ACEI
  • thiazides
  • dehydration
97
Q

lithium drug interactions that decrease serum drug levels

A

caffeine

salt

98
Q

lithium drug interactions that cause serotonin syndrome

A

SSRIs

tramadol

99
Q

lithium drug interactions that cause neurotoxicity

A

antipsychotics

100
Q

atypical antipsychotic drugs

A
aripiprazole
lurasidone
olanzapine
quetiapine
risperidone
ziprasidone
101
Q

antipsychotic use in bipolar

A

acute mania

102
Q

adverse effects of atypical antipsychotics

A
  • increased weight, glucose, lipids
  • sedation
  • EPS
103
Q

valproate in bipolar

A

often used first line in rapid cyclers

104
Q

adverse effects of valproate

A

nasuea
sedation
hepatotoxicity

105
Q

valproate and carbamazepine in pregnancy

A

don’t do it due to neural tube defects

106
Q

valproate baseline tests at initiation

A
  • CBC
  • LFTs
  • weight
  • serum HCG (pregnancy)
107
Q

carbamazepine use in bipolar

A

useful for rapid cyclers

108
Q

adverse effects of carbamazepine

A
  • blood dyscrasias (bone marrow suppression)

- sedation

109
Q

carbamazepine baseline tests

A
  • CBC
  • LFTs
  • ECG if >40
  • serum HCG
  • asians may get genetic testing to test for HLA-B and SJS susceptibility
110
Q

lamotrigine use in bipolar

A

useful for rapid cyclers who have more than 4 cycles in a year

111
Q

lamotrigine adverse effects

A

stevens johnson syndrome

112
Q

drugs that may be used in bipolar depression

A
  • quetiapine
  • olanzapine+fluoxetine
  • lurasidone
  • lamotrigine
  • NOT TRADITIONAL ANTIDEPRESSANTS AS MONOTHERAPY*