Depressive disorders Flashcards by Steven Roseno

After 2nd episode of MDD what is the likely hood of a 3rd?

70%

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After 3rd episode of MDD what is the likely hood of a 4th?

90%

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How are the SNRIs divided?

Older non-selective

TCAs
MAOIs

Newer selective

Venlafaxine
Duloxetine

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What drug is a NDRI?

Bupropion

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What drug is a serotonin modulator?

Nefazodone

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What drug is a serotonin and norepinephrine modulator?

Mirtazapine

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Is there clinical evidence to support a significant difference in the benefits of different antidepressant drugs?

No, but the drugs do vary on adverse effects

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What is the acute phase of treatment?

6 to 12 weeks

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What is the continuation phase of treatment?

4 to 9 months

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What is the maintenance phase of treatment?

1+ year

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When is the worsening of a condition considered a relapse?

When it occurs in the acute or continuation phase

- 6 weeks up to 9 months

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When is the worsening of a condition considered a recurrence?

When it happens in the maintenance phase

- 1+ year

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What are the TCAs?

Imipramine
Desipramine
Trimipramine

Amitriptyline
Nortriptyline
Protriptyline

Amoxapine
Doxepin

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What 3 broad catagories of receptors do TCAs block that lead to the know side effects?

Muscarinic
Alpha-adrenergic
- Ortho-static hypertension
Histaminergic
- Sedation
- Weight gain

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Why can TCA medications be leathal?

3 Cs

Coma
Cardiac arrhythmia- Slows cardiac condution
Convulsions

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When are TCAs contraindicated?

First 6 weeks after MI

- Ventricular arrhythmia

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When would you want to monitor blood levels of TCAs as well as use ECG monitoring?

Patient has a pre-existing first degree AV block

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Which TCAs have a theraputic window for plasma levels?

Nortriptyline
Desipramine
Imipramine

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Which TCA has the lowest risk of orthostatic hypotension? Which population is this medication the safer choice for?

Nortriptyline

Geriatrics

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What are the MAOIs?

Phenelzine
Tranylcypromine
Isocarboxazid

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Which MAO subtype needs to be inhibited inorder to see a theraputic effect on depression?

MAO-A

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What are the potential adverse effects of MAOIs?

Orthostatic hypotension- Alpha block
Weight gain- Antihistamine
Sexual dysfunction- 5-HT2a
Insomnia- 5-HT2a

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What types of food should be avoided while taking MAOIs?

Aged or fermented foods
- Cheese
- Meats
- Tap beer
- Yeast extracts
Others
- Fava beans 
- Broad bean pods
- Sauerkraut
- Soy sauce

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What types of medications are not safe to use with MAOIs?

Sympathomimetics
Stimulants
Carbamazepine
Oxcarbazepine

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What cold medications are safe to take with MAOIs?

Plain alka-seltzer Chlor-Trimeton Allergy Plain Robitussion Plain Tylenol

What other medications are generally considered safe to take with MAOIs?

``` Antibiotics Codeine Laxatives and stool softeners Local anesthetics without epinephrine or cocaine Morphine NSAIDs ```

When are MAOIs indicated?

Second line agets: - Atypical depression - Comorbid panic - Comorbid socail anxiety disorder - Refractory cases

Which MAOI is available in a transdermal patch? What is the benefit?

Selegiline | Less dietary restrictions

What are the SSRIs?

``` Fluoxetine Sertraline Paroxetine Citalopram Fluvoxamine- Luvox Escitalopram- Lexapro ```

Which 5-HT receptor is responsible for the antidepressant effects?

5-HT1a | - Causes disinhibition of serotonin in the prefrontal cortex

Which 5-HT receptors are responsible for agitation, akathisia, anxiety, panic attacks, insomnia, and sexual dysfunction?

5-HT2a

Which 5-HT receptor is responsible for nausea, GI distress, and diarrhea?

5-HT3a

What are the indications for SSRI usage?

1. Depression comorbid with: - OCD - Panic disorder - Social phobia - Bulimia 2. Atypical depression

When should SSRIs be avoided?

Depression associated with: - Sexual dysfunction - Secondary refractoriness - Nocturnal myoclonus is present - Consistent insomnia and agitation

What are the newer class of SNRIs?

Venlafaxine Desvenlafaxine Duloxetine Levomilnacipran

What is the benefit of using newer SNRIs over older SNRIs?

1. Less side effects - No anticholinergic action - No blockade of Alpha-adrenergics - No antihistamine 2. Wide theraputic index

What are the side effects of SNRIs?

Same as SSRI - 5-HT2a effects - 5-HT3a effects Potential to elevate BP

Which SNRI has been show to have the most effect on BP, especially at high doses?

Venlafaxine

What is duloxetine indicated for?

Depression GAD Diabetic neuropathy Fibromyalgia

What are the serotonin modulators used to treat depression?

Nefazodone | Vilazodone

What is the main action of nefazodone?

Blocks 5-HT2a- less "activating" symptoms | Partial SNRI

What are the clinically important effects of 5-HT2a blockade?

Reduced anxiety Enhanced slow wave sleep Blockade of SSRI-induced sexual dysfunction

What are the potential adverse effects of nefazodone?

``` Sedation Dizziness GI side effects Blurred vision Headaches ```

When is the use of Nafazodone indicated?

Depression associated with: - Anxiety - Agitation - Sleep distrubance/Insomnia - Prior SSRI-induced sexual dysfunction - Inability to tolerate SSRIs

When should nefazodone be avoided?

``` Patient has a block of CYP2D6 Hypersomnia/Psychomotor retardation Complicated patients - Won't BID - Won't follow-up for titration ```

What action does vilazodone have?

SSRI | Partial agonist at 5-HT1a

What other medications have the novel effect as a partial agonist for 5-HT1a?

Trazodone Buspirone Aripiprazole

What are the potential adverse effects of Vilazodone?

GI distrubances | Insomnia

What is one potential benefit of using vilazodone?

Low incidence of sexual side effects

What is the MOA of vortioxetine?

``` SSRI 5-HT1a agonist Partial agonist 5-HT1b Antagonist: - 5-HT3 - 5-HT1D - 5-HT7 ```

What is the only medication in the NDRI class?

Bupropion

What aspect of bupropion is most effective?

The metabolite

What are the adverse effects of bupropion?

``` Narrow-theraputic index- Seziures Agitation Insomnia Dizziness Confusion GI upset ```

What is the major benefit of bupropion?

Very low incidence of sexual dysfunction

What population is bupropion very safe in?

Cardiac patients

What type of condtion is bupropion effective at treating?

Apathy

What behavior related habit can bupropion be used to help stop?

Smoking

Who should not take bupropion?

Seizure disorders Bulimia Anorexia

When is bupropion a good treatment option for depression?

Depression associated with: - Psychomotor retardation - Hypersomnia - Serotonergic agents aren't an option - Sexual dysfunction - Cognitive slowing/pseudodementia

When should bupropion be avoided?

Seizure disorder Seizure prone/head injury Agitated, insomnic patients Bulimic patients

What is the only drug that modulates Norepinephrine and Serotonin?

Mirtazepine

What receptors does mirtazepine act on?

Blocks alpha-2 receprors- Increase NE and 5-HT | Blocks 5-HT2 and 5-HT3

What are the adverse effects of mirtazepine?

``` Sedation Dizziness Weight gain/Increased appetite Dry mouth Flu-like symptoms Constipation ```

When is mirtazapine a good option for treating depression?

Depression associated with: - Anxiety - Agitation - Insomnia - Panice - Weight loss SSRI-induced - Sexual dysfunction - Nausea - GI distrubance

When should mirtazapine be avoided?

Hypersomnia Motor retardation Cognitive slowing Weight gain

What are the preferred treatments for MDD with psychotic features?

Antipsychotic and antidepressant | ECT

What are some alternative treatments for depression?

St. John's Wort SAM Omega-3s Folate

When is it appropiate to use psychotimulants in depression?

Patients with prominent apathy | - Very effective for post-stroke patients failing rehab

After 1st episode of MDD what is the likely hood of a 2nd?

50 to 60%

Depressive disorders Flashcards

(69 cards)