Exam 4 - Depression/Bipolar (Watts/Butterfield/Ott) Flashcards
(163 cards)
1
Q
3 major types of depression
A
reactive (60%)
MDD (major depressive disorder) (25%)
Bipolar Affective (15%)
2
Q
Clinical Features of Depression:
Physiological Signs? (Main physiological signs)
A
Decreased sleep
Appetite Changes
Fatigue
Psychomotor dysfunctions
3
Q
Clinical Features of Depression:
Physiological Signs? (“Other” physiological signs…)
A
Menstrual irregularities Palpitations Constipation Headaches Nonspecific Body aches
4
Q
Clinical Features of Depression:
Psychological Signs?
A
Dysphoric mood
Worthlessness
excessive guilt
loss of interest/pleasure in all or most activities
5
Q
Clinical Features of Depression:
Cognitive Signs?
A
Decrease concentration
suicidal ideation
6
Q
Drug Induced Depression:
4 main classes of drugs that can cause this?
A
Anti-HTN and Cardiovascular drugs
Sedative-hypnotics
Anti-inflammatory and analgesics
Steroids
(also Miscellaneous drugs…!!)
7
Q
Drug Induced Depression:
what drugs in the Antihypertensive and cardiovascular classes can cause this
A
reserpine methyldopa propranolol metoprolol prazosin clonidine digitalis
8
Q
Drug Induced Depression:
what drugs in the sedative-hypnotics classes can cause this
A
alcohol
BZDs
barbituates
meprobamate
9
Q
Drug Induced Depression:
what drugs in the Anti-inflammatory/Analgesic classes can cause this
A
indomethacin
phenylbutazone
opiates
pentazocine
10
Q
Drug Induced Depression: what drugs in the steroid drug class can cause this
A
corticosteroids
oral contraceptives
estrogen withdrawal
11
Q
Drug Induced Depression:
what Miscellaneous drug classes can cause this
A
anti-parkinsons
anti-neoplatics
neuroleptics
12
Q
what are the 3 different hypothesises of depression
A
Biogenic amine
Neuroendocrine
Neurotrophic
13
Q
Biogenic Amine Hypothesis of Depression:
overall idea behind it?
A
reserpine causes depression by depleting NE and HT from vesicles
14
Q
Biogenic Amine Hypothesis of Depression:
________ causes depression by depleting ____ and _____
A
reserpine; NE; 5HT
15
Q
Biogenic Amine Hypothesis of Depression:
Agents that increase _______ and ______ are effective for treating depression
A
5HT; NE
16
Q
Biogenic Amine Hypothesis of Depression:
Genetic polymorphisms are seen in ________
A
SERT promoter
17
Q
Biogenic Amine Hypothesis of Depression:
Alterations in that receptors are seen?
A
5HT1A or 5HT2C
and
alpha 2 receptors (aka NE receptors!)
18
Q
Neuroendocrine Hypothesis of Depression:
overall idea of it?
A
changes in HPA Axis happen which leads to desensitized feedback response and leads to increased CRF
19
Q
Neuroendocrine Hypothesis of Depression:
Changes are seen in the __________
A
HPA Axis
(hypothalamus-pituitary-adrenal) axis
20
Q
Neuroendocrine Hypothesis of Depression:
stress causes hypothalamus to release _____
A
CRF
21
Q
Neuroendocrine Hypothesis of Depression:
CRF will promote release of _____ from ____
A
ACTH; from pituitary
22
Q
Neuroendocrine Hypothesis of Depression:
ACTH promotes release of ______ from _____
A
cortisol; from adrenal
23
Q
Neuroendocrine Hypothesis of Depression:
Almost all patients with depression have overactivity of ______ and elevated ______
A
HPA; CRF
24
Q
Neuroendocrine Hypothesis of Depression:
Overactivity of HPA may ___________ response in hypothalamus and pituitary
A
desensitize feedback
25
Neuroendocrine Hypothesis of Depression:
| Overactivity of HPA may desensitize feedback response in ____________
hypothalamus and pituitary
26
Neuroendocrine Hypothesis of Depression:
| Elevated CRF causes what things?
insomnia
anxiety
decrease appetite and libido
27
Neuroendocrine Hypothesis of Depression:
| _______ CRF causes insomnia, anxiety, and decrease appetite and libido
elevated
28
Neuroendocrine Hypothesis of Depression:
| antidepressants and ECT (electroconvulsive therapy) will (increase or decrease) CRF levels
decrease!!
29
Neurotrophic Hypothesis of Depression:
| overall point?
BDNF can have antidepressant activity;
| BDNF = brain derived neurotrophic activity
30
Neurotrophic Hypothesis of Depression:
| BDNF stands for what?
brain derived neurotrohpic factor?
31
Neurotrophic Hypothesis of Depression:
| BDNF is critical in what 3 things?
neural plasticity
resilience
neurogenesis
32
Neurotrophic Hypothesis of Depression:
| Stress and pain (increase or decrease) BDNF in animals
decrease
33
Neurotrophic Hypothesis of Depression:
| Depressed patients have reduced _____ levels
BDNF
34
Neurotrophic Hypothesis of Depression:
| Antidepressants increase ______ levels and my increase _______
increase BDNF levels; increase hippocampal volume
35
Integrating Hypothesis of Depression:
| ______ and _______ regulate BDNF levels
HPA and steroid abnormalities
36
Integrating Hypothesis of Depression:
| ___________ receptors are activated by cortisol during stress (which ______ BDNF)
hippocampal gluccorticoid;
| decrease BDNF
37
Integrating Hypothesis of Depression:
| Chronic activation of monoamine receptors increase ________
BDNF signaling
38
Integrating Hypothesis of Depression:
| chronic activation of of monoamine receptors leads to down regulation of _______
HPA axis
39
Main Classes of Antidepressants?
```
MAOIs
TCAs
SSRIs
SNRIs
5-HT2 antagonists
```
40
why does antidepressant therapy take 2 - 3 weeks?
neuroadaptive responses
41
MOA of MAOIs?
inhibit break down of NE and 5HT = more NE and 5HT is released from vesicles into synapses
42
what drugs are are non-selective MAO inhibitors
Phenelzine
| Tranylcypromine
43
what drug is MAO B selective
Selegiline
44
what drug is MAO A selective
Moclobemide
45
are MAOIs reversible or irreversible?
irreversible
(thus when switching agents must have some time from stopping MAOI and starting another drug because it may cause hella side effects)
46
Severe Side Effects of MAO Inhibitors
```
HA
drowsiness
dry mouth
weight gain
orthostatic hypotension
sexual dysfunction
```
47
MAO-I has interactions with what Rx drugs?
TCAs
SSRIs
L-DOPA
48
MAOIs should be avoided with that foods?
```
tyramine rich
(aka cheeses, sour cream, sausage, red wine/beer/ale, miso soup, avocados, bananas and a million other foods...)
```
49
MAOIs have interactions with what OTC meds?
Cold preparations
| Diet pills
50
MAOIs can lead to a _______ crisis
hypertensive
51
what are the two subgroups of TCAs
tertiary amine
and
secondary amine
52
indications for TCAs?
depression
panic disorder
chronic pain
enuresis
53
TCAs:
| pts are more likely to commit self harm or suicide ________ into treatment
2 weeks
54
TCAs:
| Toxicity risk --- extremely _________ pts more likely to be suicidal
dangerous/depressed
55
Tertiary Amines - TCAs:
| they inhibit both _____ and ____ reuptake via ___ and ____
NE and 5HT;
| via NET and SERT
56
Tertiary Amines - TCAs:
| major side effects?
sedation
autonomic side effects
weight gain
57
Tertiary Amines - TCAs:
| also act as antagonists to what?
they are antihistamines
anitmuscarinic
antiadrenergic
58
what are the tertiary amine TCAs?
```
Imipramine
Amitriptyline
Trimipramine
Clomipramine
Doxepin
```
59
Secondary Amines - TCAs:
| inhibit _______ but not _____ like tertiary amine TCAs do
inhibit NET
not SERT
(*remember secondary has an N in it...)
60
what are the secondary amine TCAs?
desipramine
nortriptyline
protriptyline
maprolitine
61
TCAs:
| secondary or tertiary amines have worst side effect profiles?
tertiary amines
62
is it TCA (tertiary or secondary), SSRI, or SNRI?
| imipramine
tertiary
63
is it TCA (tertiary or secondary), SSRI, or SNRI?
| Desipramine
secondary
64
is it TCA (tertiary or secondary), SSRI, or SNRI?
| Amitriptyline
tertiary
65
is it TCA (tertiary or secondary), SSRI, or SNRI?
| doxepin
tertiary
66
is it TCA (tertiary or secondary), SSRI, or SNRI?
| nortriptyline
secondary
67
is it TCA (tertiary or secondary), SSRI, or SNRI?
| maprotiline
secondary
68
is it TCA (tertiary or secondary), SSRI, or SNRI?
| trimipramine
tertiary
69
is it TCA (tertiary or secondary), SSRI, or SNRI?
| clomipramine
tertiary
70
is it TCA (tertiary or secondary), SSRI, or SNRI?
| protriptyline
secondary
71
is it TCA (tertiary or secondary), SSRI, or SNRI?
| fluoxeine
SSRI
72
is it TCA (tertiary or secondary), SSRI, or SNRI?
| Fluvoxamine
SSRI
73
is it TCA (tertiary or secondary), SSRI, or SNRI?
| Venlafaxine
SNRI
74
is it TCA (tertiary or secondary), SSRI, or SNRI?
| Duloxetine
SNRI
75
is it TCA (tertiary or secondary), SSRI, or SNRI?
| desvenlafaxine
SNRI
76
is it TCA (tertiary or secondary), SSRI, or SNRI?
| paroxetine
SSRI
77
is it TCA (tertiary or secondary), SSRI, or SNRI?
| sertraline
SSRI
78
is it TCA (tertiary or secondary), SSRI, or SNRI?
| citalopram
SSRI
79
is it TCA (tertiary or secondary), SSRI, or SNRI?
| escitalopram
SSRI
80
is it TCA (tertiary or secondary), SSRI, or SNRI?
| Milnacipran
SNRI
81
is it TCA (tertiary or secondary), SSRI, or SNRI?
| Levomilnacipran
SNRI
82
what drugs are SSRIs
```
fluoxetine
fluvoxamine
paroxetine
sertraline
citalopram
escitalopram
```
83
what drugs are SNRIs
```
venlafaxine
desvenlafaxine
duloxetine
milnacipran
levomilnacipran
```
84
what are the side effects of SSRIs
```
N/V
HA
sexual dysfunction
anxiety!!
insomnia!!! (NOT sedation)
tremor
```
85
SSRI discontinuation syndrome --- symptoms?
```
"brain zap"
dizziness
sweating
nausea
insomnia
tremor
confusion
vertigo
```
86
what drugs are NSRI
reboxetine
| atomoxetine
87
what drugs may be used as a rapidly acting antidepressants
NMDA receptor antagonists
| like ketamine, scopolamine
88
Non-Pharm options (per watts)
electroconvulsive therapy
psychotherapy
hospitalization
89
MOA of Lithium?
depletes PIP2 and assoc. signaling (IP3 and PKC)
modules GSK3 (ultimately a;ters to gene transcription)
90
MOA of Valproate
increase GABAergic tone
Block Na+ channels and Ca2+ channels
and inhibit histone deacetylase
91
MOA of CBZ
inhibit Na+ channels
92
MOA of lamotrigine
inhibit Na+ and Ca2+
93
DSM - 5 Diagnostic Criteria for Depression:
| ____ or more of the symptoms listed are present during the same _____ week period and is a change from baseline
5 symptoms;
| greater than 2 week period
94
DSM - 5 Diagnostic Criteria for Depression:
need at least one of two symptoms (as part of the 5 total)
what are the 2 symptoms
depressed mood
or
loss of interest or pleasure
95
DSM - 5 Diagnostic Criteria for Depression:
| what are the other symptoms that can be part of the diagnosis
```
SIGECAP!
S-suicidal ideation
I-insmonia/hypersomnia
G-guilt/worthlessness
E-Energy loss/fatigue
C-Concentration difficulties
A-Appetite changes
P-psychomotor agitation/retardation
```
96
```
Risk factors for MDD:
male or female?
age?
marital status?
race?
economic status?
employment?
co-morbid _______ and _____
Physical _________
lack of ______
________ experiences
prior ________
```
```
female
middle age
widowed/separated/divorced/single
white race
low econom. status
unemployed
co-morbid: medical disorder and substance use disorder
physical DISABILITY
lack of SOCIAL SUPPORT
stressful events/adverse childhood experiences
prior suicidal attemps
```
97
Depression Recurrence Rates:
if 1 episode: _____ %
if 2 episodes: _____%
if 3 episodes: ____%
50 - 60
70
90
98
what screening scales are self administered for depression
PHQ-9
QIDS-SR-16
MDQ
99
what screening scales are clinician rated for depression
HAM-D
QIDS-C
CGI
100
what screening scale is commonly used for clinical trial effiacy for antidepressants
HAM-D
101
Boxed Warning for Antidepressants:
increase risk of suicidal thought behaviors in those aged < 24 y.o
No increase in suicides seen tho
102
how to manage/"deal with" the boxed warning that comes with antidepressants
still give it to them (even pts under 24)
just closely monitor pts for clinical worsening/suicidal ideation, or unusual changes in behavior esp. for first 3 MONTHS of therapy or any dose changes
103
Clinical Pearls for Citalopram:
ADE of _______ seen when dose > 40 mg/day
and
CYP_______?
QT prolongation
| 2C19 (substrate)
104
Clinical Pearls for Escitalopram
CYP______?
and is the ______ of citalopram
2C19 and 3A4!
| s isomer
105
Clinical Pearls for fluoxetine:
long or short half life?
CYP?
ADEs?
long half life
2D6 and 3A4
ADEs: insomnia, initial weight loss, fatigue syndrome
106
Clinical Pearls for Fluvoxamine:
FDA approved for _______
CYP____?
OCD tx
| 1A2
107
```
Clinical Pearls for Paroxetine:
Must ________ because of ______ effects
CYP_____?
ADEs:
Pregnancy Category ____: leads to?
```
must TAPER; b/c of ANTICHOLINERGIC effects
2D6
ADE: weight gain/sedation/anticholinergic
Category D; SEPTAL WALL DEFECTS
108
Clinical Pearls for Sertraline
CYP_____?
More ____ at higher doses
2D6 (mainly but also all the usual thing)
| GI upset
109
which SSRI notably causes weight gain
paroxetine
110
which SSRI notably causes weight loss
fluoxetine
111
Overall SSRI ADEs?
```
variable sedation
increased BLEEDING risk
GI upset
anxiety/agitation
sexual dysfunction
hyponatremia
decreased bone mineral density
akathisia
(weight gain or weight loss)
```
112
SSRIs:
take about _______ for onset of action
and
________ until full dose response is observed
1 - 2 weeks (onset)
| 4 - 6 weeks (full dose response)
113
```
Clinical Pearls for Desvenlafaxine:
_________ of venlafaxine
dose limiting side effect of ________
CYP______?
_____ dosing adjustments
```
active metabolite of venlafaxine
nausea
no CYP!
renal dosing
114
Clinical Pearls for Duloxetine:
CYP_______
how to help with nausea?
FDA warning for _______
2D6
slow titration or divided dosing to help w/ nausea
warning for HEPATOXICITY *gotta check LFTS at baseline and q 6 mos)
115
Clinical Pearls for Levomilnacipran:
CYP_______
MUST adjust for what things?
Rare SEs?
3A4
renal dosing OR major CYP3A4 inhibitor
SE: seizures or glaucoma
116
brand for Levomilnacipran
Fetzima
117
brand for milnacipran
Savella
118
brand for desvenlafaxine
pristiq
119
Clinical Pearls for Milnacipran
indicated for _________
____ dosing adjustments
fibromyalgia
| renal dosing
120
Clinical Pearls for Venlafaxine:
CYP________
Dose must be > ______ mg/day to have _____ effect
2D6 and 3A4
| 150 mg; NE effects
121
SNRIs can be helpful for what other things? (not depression...)
pain syndrome
musculoskeletal pain
fibromyalgia
neuropathic pain
122
what is the one ADE that is different for SNRIs compared to SSRIs
blood pressure elevation seen in SNRI (bc NE effect!!)
123
Clinical Pearls for Amitriptyline:
| Used at _____ doses for ______ pain
lower; neuropathic
124
Clinical Pearls for Desipramine:
| just one pearl for this drug
not commonly used for depression..
125
Clinical Pearls for Doxepin:
CYP_____
Commonly used for ______
2D6
| insomnia
126
Clinical Pearls for Imipramine:
| most often used for children with ______ or ______ at ______ doses
ADHD; noctural enuresis
| lower doses
127
Clinical Pearls for Nortriptyline:
| used in __________
smoking cessation
128
what TCA is used for smoking cessation
notriptyline
129
which TCA is used for ADHD
imipramine
130
which TCA is used for neuropathic pain
amitriptyline (also nortriptyline)
131
which TCA is the only one with a notable CYP interaction and what is the interaction
doxepin
| CYP2D6
132
which SNRIs need renal adjustmnet
desvenlafaxine
milnacipran
levomilnacipran
133
which SNRI is indicated for fibromyalgia
milnacipran
134
which SNRI has a FDA warning for hepatoxicity
duloxetine
135
TCAs can be fatal in overdose due to ________
cardiac arrhythmias
136
Clinical Pearls for all MAOIs?
must have 2 week washout period before switching antidepressants
all drugs need tyramine diet except selegiline (6mg/24 hr)
137
Caution with MAOIs due to _______ and _______
hypertensive crisis
and
serotonin syndrome
138
MAOIs contraindications? (8 in total)
```
Pheochromocytoma
Hepatic or renal dysfunction
Excessive caffeine use
Cerebrovascular disease
Concomitant sympathomimetics (amphetamines and cocaine..)
Cardiovascular disease
Elective surgery
SSRI use (gotta d/c 2 -5 weeks before starting MAOI)
```
(PHECCCES)
139
why is tyramine a note of concern with MAOIs
tyramine is degraded by MAO;
| MAOIs wont break down tyramine, leads to hypertensive crisis
140
Any drug that increases _________ in the brain are basically a drug interaction for MAOIs
increase NEUROTRANSMITTERS
141
MAOI Patch has what drug in it?
Selegiline
142
Selegine Patch:
| monotherapy or adjunct therapy?
monotherapy!
143
ADEs for selegiline patch?
hypotension
dry mouth insomina
headache
Gi effects
144
what are the "novel agents" for depression
```
bupropion
mirtazapine
trazodone
Vilazodone (Viibryd)
Vortioxetine (Trintellix)
```
145
what is the brand for vilazodone
Viibyrd
146
what is the brand for vortioxetine
Trintellix
147
Bupropion:
| ____ and ___ reuptake inhibitor
DA and NE
148
Bupropion:
| it is stimulating and thus can cause ______ and _____
insomnia
| appetite suppresion
149
Bupropion:
| CI with what 2 things?
seizures
| eating disorders
150
Bupropion:
| if using SR formulation; do not give 2nd dose no later than ______
4pm
151
Bupropion:
| major CYP stuff?
2B6 Substrate
| 2D6 inhibitor
152
Bupropion:
| T or F: it can not be used with SSRIs or SNRIs
False!
| it can be used with them
153
Mirtazapine:
| increased _____ and _____ occur with doses < ____ mg/day
sedation; appetite
| 15 mg/day
154
Mirtazapine:
| warnings for ______ and ______
agranulocytosis
and
increased cholesterol
155
Mirtazapine:
| T or F: it can not be used with SSRIs or SNRIs
False!
| it can be used with them
156
Trazodone:
| risk of ______ - medical emergency
priapism
157
Vilazodone:
| should it be taken with or without food?
WITH FOOD!!
| better absorption AND hella nausea is possible
158
Vilazodone:
| CYP interaction?
3A4
| half the max dose if strong 3A4 inhibitor
159
Vortioxetine:
| CYP interaction?
2D6:
| half the max dose if strong 2D6 inhibitor
160
Antidepressant withdrawal syndrome:
| occurs due to abrupt cessation of the antidepressant - and it is common in all depressants except _______
fluoxetine (bc it has a long half/can handle its own taper)
161
Want to avoid cholinergic rebound - therefore HAVE to taper ______ and _____ (aka the anticholinergic antidepressants)
paroxetine; TCAs
162
Symptoms of Antidepressant withdrawal syndrome?
agitation
irritability
GI disturbances
(similar to depression...)
163
what drugs are Augmentation agents for depression
Lithium
T3
atypical antipsychotics
buspirone
