Depression Tx Flashcards by Brooke Thornburg

Risk of Depression Recurrence

-1 episode: 50-60%
-2: 70%
-3: 90%

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Pathologies related to depression

-stroke
-CHRONIC PAIN (fibromyalgia, low back/pelvic pain, bone/disease pain)
-mulitple sclerosis
-hypo/hyper thyroidism
-traumatic brain injury (TBI)

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Recurrence

-risk becomes lower over time as duration of remission inc
-persistent mild sx during remission is a predictor of recurrence
-function deteriorates during episode and goes back to baseline upon remission

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DSM-5 diagnosis

-at least one sx must be depressed mood or loss of interest/pleasure in doing things

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DSM-5 diagnostic mnemonic (SIGE CAPS)

-Sleep (+/-)
-Interest dec
-Guilt/worthlessness
-Energy loss
-Concentration probs
-Appetite change (+/-)
-Psychomotor agitation/retardation
-Suicidal ideation

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Self-admin rating scales

-Patient Health Questionnaire (PHQ-9): develped for primary care setting
-Mood Disorder Questionnare (MDQ): can rule out bipolar

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Goals of depression tx

reduce or eliminate sx
restore functioning to baseline
Reduce risk of relapse/recurrence
Reduce suicide

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How to choose drugs

-efficacy similar
-pt preference, response
-safety, cost, etc

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Phase of depression tx

-acute: 6-12 weeks or remission of sx (induce remission)
-continuation: 4-9 months (recomended for all pt to prevent relapse)
-maintenance: pt specific duration, indefinite if >3 major, prevent recurrence

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Risk of suicide

-boxed warning for suicide in ALL antidepressant meds for pt < 24 yeRA

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Pharmacologic Classes

-SSRI
-SNRI
-TCA
-MAOis
-newer agents
-augmentation

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SSRI drugs

-Citalopram
-Escitalopram
-Fluoxetine
-Fluvoxamine
-Paroxetine
-Sertraline

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Citalopram

-dose-dependednt QTc prolongation
-substrate of 2C19 and 3A4

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Fluoxetine

-long half-life (96-144h)
-activating potential
-2D6 and 3A4 inhibitor
-weight loss

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Fluvoxamine

-1A2 and 2C19 inhbitor

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Paroxetine

-MUST taper due to anticholinergic effects
-wt gain
-sedation
-septal wall defect risk to fetus
-2D6 and 2B6 inhibitor

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Sertraline

-more GI upset than other antidepressants

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SSRI adverse effects

-inc bleeding risk (platelet inhibition)
-weight gain (paroxetine)
-hyponatremia (esp in elderly)
-weight loss (fluoxetine)
-sexual dysfunction

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SNRI drugs

-Desvenlafaxine
-Duloxetine
-Levomilnacipran
-Milnacipran
-Venlafaxine

Desvenlafaxine

-active metabolite of venlafaxine
-dose-limiting side effect: nausea
-no major CYP interactions

Duloxetine

-nausea
-FDA warning for hepatotoxicity
-2D6 inhibitor
-obtain LFTs at baseline and when sx or q6months

Levomilnacipran

-MUST adj renal impairment or strong 3A4 inhibitors
-3A4 substrate

Venlafaxine

-must be >150mg/day to have NE effects
-2D6 inhibitor at higher doses

SNRI adverse effects/key pearls

-BP elevation
-Nausea
-useful in pain syndrome, musculoskeletal pain, fibromyalgia, neuropathic pain

Tricyclic Antidepressants

-block DAT, SERT, NET -amitriptyline (tertiary amine)

TCA adverse effects/key points

-more often used for neuropathic pain syndromes than depression -CNS: sedation, sz, confusion -anticholinergic: blurred vision, urinary retention, constipation -CV: hypotension, tachycardia -wt gain, sexual dysfunction

TCA NTI

-FATAL in overdose as low as 1000mg (4-10 tabs) due to arrhythmias or seizures

MAO inhibitors??

???

MAOi HTN crisis

-Tyramine diet is required w MAOis: -smoked, aged, pickled meats/fish/cheese -small amounts of beer, wine, avocados, caffeine, chocolate

Bupropion MOA

-DAT and NERT inhibitor -stimulating = insomnia and appetite suppression -XL dosing

Bupropion pearls

-2D6 inhibitor -contraindicated in active seizure disorder and eating disorders -can be used in combo w SSRI/SNRI

Mirtazapine pearls

-agranulocytosis -inc cholesterol -sedation and inc appetite in doses < 15mg?? -can be use in combo w SSRI/SNRIs

Trazodone pearls

-higher doses needed for depression -orthostatic hypotension -risk of priapism - med emergency

Vilazodone MOA

-primarily SSRI, maybe 5HT1a agonism (anxiolytic effects) -do not combo w SSRI/SNRI

Vilazodone pearls

-take w food (nausea and inc bioavailability) -3A4 substrate -do not combo w SSRI/SNRI

Vortioxetine MOA

-SSRI + 5HT1A agonist + 5HT3 antagonist (dont combo w SSRI/SNRI)

Vortioxetine pearls

-possibly less sexual dysfunction -2D6 substrate -Nausea -do not combo w SSRI/SNRI

Serotonin Syndrome

-med emergency -OD or combo w serotonergic agents

Serotonergic Agents

-lithium -serotonergic antidepressants -buspirone -linezolid -amphetamines -dextromethorphan -serotonin agonists (triptans) -St. Johns -tramadol -fentanyl -cocaine -LSD

Serotonin syndrom etx

-stop agent + supportive care -potentially could use serotonin blockers

Antidepressant withdrawal syndrome

-common with ALL antidepressants EXCEPT fluoxetine -Antidepressants w anticholinergic activity should be tapered no matter what -not life threatening but uncomfy (depression sx)

Augmentation - Atypical Antipsychotics

-Aripiprazole -Brexpiprazole -Cariprazine -Quetiapine

Overall antidepressant counseling points

-abrupt dc can lead to antidepressant withdrawal syndrome -possible inc in suicidal thinking during first few weeks of therapy

Electroconvulsive therapy

-nonpharma treatment resistant depressino tx -2-3 xweek -usual course is 6-12 tx -electrodes