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Flashcards in Depression -Test 2 Deck (88):
1

What is the most common diagnosis associated with psych admins?

Depression

2

How can depressive symptoms present?

—patients look sad, guilt-ridden, and hopeless
—Other patients look nervous, and irritable
—Others complain of somatic problems
—Psychosis can accompany depression
—Depression can lead to a dementia-like state

3

What are the DSM-V classifications for depression?

—Unipolar major depression (major depressive disorder)
—Persistent depressive disorder (dysthymia)
—Disruptive mood dysregulation disorder
—Premenstrual dysphoric disorder
—Substance/medication induced depressive disorder
—Depressive disorder due to another medical condition
—Other specified depressive disorder (eg, minor depression)
—Unspecified depressive disorder

4

What is the criteria for unipolar major depression?

—Characterized by a history of one or more major depressive episodes and no history of mania or hypomania .
—A major depressive episode manifests with five or more of the following symptoms for at least two consecutive weeks; at least one symptom must be either depressed mood or loss of interest or pleasure

5

What is the criteria for major depression?

—Depressed mood most the day, nearly every day
—Loss of interest or pleasure in most or all activities, nearly every day
—Insomnia or hypersomnia nearly every day
—Fatigue or low energy, nearly every day
—Significant weight loss or weight gain (eg, 5 percent within a month) or decrease or increase in appetite nearly every day.
—Psychomotor retardation or agitation nearly every day that is observable by others
—Decreased ability to concentrate, think, or make decisions, nearly every day
—Thoughts of worthlessness or excessive or inappropriate guilt, nearly every day
—Recurrent thoughts of death or suicidal ideation, or a suicide attempt
—In addition, the symptoms cause significant distress or psychosocial impairment, and are not the direct result of a substance or general medical condition. Bereavement does not exclude the diagnosis of a major depressive episode.

6

What is SIG E CAPS for? What does it stand for?

A pneumonic to help with the symptoms of major depression
—S leep disturbance
—I nterest loss
—G uilt
—E nergy loss
—C oncentration difficulties
—A ppetite disturbance
—P sychomotor retardation/ agitation
—S uicidality

7

What are the big culprits of drug induced depression?

CV agents/AntiHTN: clonidine, methyldopa, propranolol, prazosin
Misc: disulfiram
CNS: alcohol, alpha interferon
Hormones: corticosteroids

8

What are major causes of depression?

CNS: stroke, AD, MS, HD
Endocrine: hypothyroid, cushing/Addison, DM
Autoimmune: RA, SLE

9

In the monoamine hypothesis for major depression, depression results from a dysregulation of what?

—Norepinephrine (NE)
—Serotonin (5-HT)
—Dopamine (DA)
decrease in NT

10

What happens to post-synaptic 5-HT, DA, and NE receptors when the amount of these neurotransmitters is decreased?

—Up-regulation of post-synaptic receptors
—Decreased receptor sensitivity
—Altered genetic expression

11

What is the drug model for depression in the monoamine hypothesis?

—Reserpine
—Induces depression depletion of monoamines
—Depression is reversed by the 5-HT precursor and (less well) by the NE precursor

12

In the monoamine hypothesis, what leads to depression? What can reverse depression?

—Low 5-HT and/or NE in limbic system leads to depression
—Increased limbic 5-HT and/or NE can reverse depression

13

What happens when there is hyperregulation of the HPA axis?

Increased CRF and blunted cortisol suppression

14

What can dysregulation of the HPA axis lead to?

Hippocampal toxicity and if severely stressed increased glucocorticoids

15

What triggers the negative feedback loop btwn the hippocampus and the HPA loop?

Glucocorticoids

16

When are prolonged levels of glucocorticoids seen? What can this cause?

Prolonged and severe stress
This damages hippocampal neurons reducing the negative feedback loop causing the “snowball” effect

17

What does the brain derived neurotropic factor play a role in?

It is a potent regulator of plasticity of adult neurons and glia linked to the HPA activation theory important for the survival of neurons, acute and chronic stress cause a decrease in the expression of BDNF

18

What regions other than the hippocampus are involved in depression?

Nucleus accumbens and amygdala- these work in the dopaminergic pathway and lead to amotivation and anhedonia

19

What are the goals for tx for MDD?

—Reduce the acute symptoms of the depressive episode
—Facilitate the patient’s return to premorbid function (prior to illness)
—Recovery should be the rule, not the exception!
—Prevent further episodes of depression

20

What are tx options for major depression?

—Selective Serotonin Reuptake Inhibitors (SSRIs)
—Tricyclic Antidepressants (TCAs)
—Tetracyclic Antidepressant
—Alpha 2 antagonists
—Dopamine Reuptake Inhibitors
—SSRI and 5HT-1a agonist
—SSRI and 5HT3 antagonist
—Serotonin/Norepinephrine Reuptake Inhibitor
—Monoamine Oxidase Inhibitors (MAOIs)

21

What are the SSRIs?

—Fluoxetine
—Sertraline
—Paroxetine
—Fluvoxamine
—Citalpram
—Escitalopram
—Symbyax

22

What are the most commonly prescribed antidepressants?

SSRIs

23

What is the MOA for SSRIs?

Block the reuptake of serotonin

24

When is the typical ssri’s dosing schedule?

Once daily dosing usually in the morning

25

What are the SSRI ADRs?

—Nausea
—Headache
—Sleep disturbances
—Changes in weight
—Agitation/increased anxiety (initial)
—Sexual Dysfunction
—Tremor
—Sweating
—Rare hyponatremia

26

What are the specific side effects of paroxetine?

more likely to cause sedation, constipation, and dry mouth

27

What are the specific side effects of sertraline?

may be more likely to have GI distress, insomnia or activation

28

What is the order of SSRIs from worst to least amount of change with discontinution?

Paroxetine > sertraline = citalopram = escitalopram > fluoxetine

29

What is antidepressant discontinuation syndrome?

—Flu-like symptoms, malaise
—Dizziness
—GI (nausea, diarrhea)
—Transient changes in mood, affect, appetite, and sleep
—Electric “shock-like” sensation in upper extremities
—Vivid dreams/nightmares
—Poor concentration

30

What is vilazodone?

SSRI and 5-HT1A Receptor Partial Agonist

31

How often is vilazodone given and what should it be taken with?

Once daily with food

32

What are the ADRs of vilazodone?

Diarrhea, nausea, withdrawl syndrome with abrupt stop of drug

33

What is vortioxetine?

SSRI and selective 5-HT1a receptor agonist and 5-HT3 receptor antagonist

34

What is the MOA of vortioxetine?

Enhanced 5-HT1 neurotransmission through 5-HT2 blockade

35

What is the dosing schedule for vortioxetine?

Once daily without regard to meals

36

What is the most common ADR of vortioxetine?

Sexual dysfxn

37

What is nefazodone?

SSRI plus potent 5-HT2 receptor antagonist

38

What is the MOA for nefazodone?

Enhanced 5-HT1 neurotransmission through 5-HT2 blockade

39

Why is nefazodone considered 2nd or 3rd line tx even though it has comparable efficacy for tx of depression as standard antidepressants?

Risk of hepatotoxicity

40

What symptoms can nefazodone improve?

symptoms of poor sleep quality, sleep disturbance, anxiety and agitation in depressed patients

41

What is the recommended dosing of nefazodone?

—Twice daily dosing recommended, but frequently it is administered at bedtime because of its sedative properties
—Initial starting dose is 200 mg/day
—Generally need doses of 300-600 mg/day for antidepressant activity

42

What are the ADRs of nefazodone?

—Sedation
—Orthostasis
—Dry mouth
—Nausea
—Increased appetite
—Blurred vision
—Hepatotoxicity

43

What is the MOA of trazodone?

—Blocks 5-HT2A receptors (potently); Blocks 5-HT reuptake less potently
—Also has antihistaminic properties → Sedation

44

What is the dosing of trazodone for antidepressive tx? For insomnia?

Initial: 150 QD, max: 400 QD
50-200 QHS…losing sedative properties at >200

45

What are the serotonin/NE reuptake inhibs?

—Venlafaxine
—Desvenlafaxine
—Duloxetine
—Milnacipran
—Levomilnacipran

46

What are the options for Venalfaxine?

IR (immediate release) and XR

47

What is the MOA of venlafaxine?

—Inhibits reuptake of NE and 5-HT
—Also inhibits DA reuptake (to lesser extent)

48

What are the doses needed for NE/DA reuptake? What is the starting and max dose?

—Starting dose 37.5-75 mg/day, max dose 225 mg/day
—Doses ≥ 200 mg needed for NE and DA reuptake

49

What are the ADRs of venlafaxine?

—Nausea
—Headache
—Somnolence
—Sexual dysfunction
—Insomnia
—Agitation
—Increase in DBP: (dose related)

50

What is desvenlafaxine?

Active metabolite of venlafaxine
DO NOT EVER PICK THIS ANSWER FOR ANY EXAM QUESTION

51

What is duloxetine?

Potent 5-HT NE reuptake inhibitor

52

What are the starting and max doses for duloxetine?

Starting dose 40 mg/day, max dose 60 mg/day → Has been studied up to 120 mg/day

53

What else does duloxetine work for?

Urinary incontinence and diabetic neuropathic pain

54

What are the ADRs of duloxetine?

—Insomnia/sedation
—Nausea, diarrhea, decreased appetite
—Sexual dysfunction
—Sweating
—Urinary hesitancy
—Hepatotoxicity
—Increase in BP

55

What is milnipracin approved for?

management of fibromyalgia

56

What is the BBW for milnipracin?

Same as all antidepressants- risk of suicide

57

What is levomilnacipran?

More active enantiomer of milnacipran, potent inhibitor of NE and 5-HT reuptake

58

What are the indications for levomilnacipran?

Once daily for depression

59

What are the ADRs of levomilnacipran?

—Orthostatic hypotension
—Nausea

60

What are the 2 categories of TCAs?

Secondary amines and tertiary amines

61

What are the secondary amines?

Nortriptyline, despramine, protriptyline, amoxapine

62

What are the tertiary amines?

Amitriptyline, imipramine, clomipramine, doxepin, trimipramine

63

What is the MOA of TCAs?

Block the reuptake of NE and 5-HT (NE > 5-HT)
Also block:
—Muscarinic receptors
—Histamine receptors
—Alpha-1 receptors

64

What is the half life of all TCAs?

About 24 hrs

65

What do you need to draw for TCA?

Blood sample 12 hrs past last dose to check for therapeutic concentrations

66

What are the side effects of TCAs?

—Tachycardia
—Orthostasis
—Weight gain
—Sedation
—Sexual dysfunction
Anticholinergic effects
—Dry mouth
—Constipation
—Dry eyes
—Urinary retention
Cardiac conduction changes
—Prolongation of QRS, ST depression, flattened or inverted T-waves
—Baseline ECG
Tertiary amines>secondary amine
—Anticholingeric effects
—Antihistiminic effects
—Hypotensive effects

67

What is the maprotiline? What is the MOA?

—Tetracyclic antidepressant
—NE reuptake inhibitor, desensitization of adenyl cyclase, down regulation of beta adrenergic receptors and serotonin receptors

68

What are the ADRs of maprotiline?

—Drowsiness
—Xerostomia

69

What is the MOA of mirtazapine?

Dual neurotransmitter action:
—A potent and direct alpha-2 receptor antagonist
‭ -‬Enhances 5-HT and NE transmission
—Blocks 5-HT2 and 3 receptors
-Results in enhances 5-HT1 reception

70

What are the ADRs of mirtazapine?

Less nausea and sexual dysfunction than SSRIs
—Somnolence*
—Dry mouth
—Constipation
—Orthostasis
—Increased appetite => weight gain

71

How is mirtazapine dosed?

once daily at bedtime due to sedation

72

What is the MOA of Bupropion?

Believed to block reuptake of dopamine and norepinephrine

73

How is bupropion administered?

IR, SR, and XL formulations
—SR or XL formulations result in:
—Slower absorption rate; More gradual rise and decline of plasma levels; lower peak plasma levels

74

Is bupropion 1st or 2nd line for depression?

Considered first line

75

What is a risk dose related to bupropion?

Seizures

76

What are the ADRs of buproprion?

—Anxiety, agitation
—Headache
—Seizures
—Increased risk with higher doses
—sweating
—Tremor
—Insomnia
—GI disturbances (anorexia, nausea, constipation)
—Weight loss

77

What is the MOA of MAOIs?

Block the break down of NE, 5-HT, DA, and epinephrine

78

What are the 2 types of MAOIs?

—MAO-A (EPI, NE, 5-HT, DA, tyramine)
—MAO-B (DA, tyramine, benzylamine and phenylethylamine)

79

What are the irreversible and reversible mixed inhibs?

—Irreversible: phenelzine, isocarboxazid, selegiline
—Reversible: tranylcypromine

80

What are the ADRs of MAOIs?

—Not used as often due to drug-drug and dug-food interactions
—Aged, hard cheeses and strongly flavored cheeses contraindicated
—SE: orthostasis, dizziness, mydriasis, piloerection, edema, sexual dysfunction, insomnia, weight gain
—High risk of serotonin syndrome
—High risk of hypertensive crisis

81

What are the MAOIs drug interactions?

—Other antidepressant medications, including herbals
—Buspirone
—Meperidine
—Dextromethorphan
—Direct sympathomimetics (e.g., L-dopa, epinephrine, isoproterenol, norepinephrine)
—Indirect sympathomimetics (e.g., amphetamines, methylphenidate, phenylpropanolamine, ephedra, pseudoephedrine and tyramine)
—Cocaine

82

What is serotonin syndrome?

An adverse effect due to excessive serotonin in the periphery

83

What are the symptoms of serotonin syndrome?

Sternbach Criteria:
Neuromuscular hyperactivity
—Tremor, myoclonus, hyperreflexia, restlessness
Autonomic hyperactivity
—Hyperpyrexia, hypertension, tachycardia
Cognitive/behavioral changes
—confusion

84

What is the starting drug recommended for major depression?

SSRI

85

What is the time frame for response to antidepressants?

—Most responders will have an onset of response within 4 weeks
—No response at 4 weeks, consider ↑ in dose and waiting another 2-3 weeks
—Patients showing minimal to no response should not exceed a trial of 8 weeks
—Patients showing a partial response can be treated for up to 12-16 weeks

86

What needs to be tapered when switching drug choice?

All SSRIs, except FLX, should be tapered before discontinuation or within class switch

87

What are the drug options for pregnancy and lactation?

SSRI or TCA: FLX most studied

88

Should you give TCAs in geriatrics?

—Generally problematic due to SE profile
—DESI and NORT recommended if required