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Depression
n/a
103
Pharmacology
Graduate
04/04/2013

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Term
Major Depression
clinical features
Definition
Depressed mood, loss of pleasure or interest in all or nearly all of one's usual activities and past times. Characterized by insomnia/hypersomnia, anorexia/hyperphasgia, mental slow/loss of concentration, guilt, worthlessness, helplessness, death/sucidal thoughts, suicidal behaviors.
Term
Major depression
Dx
Definition
s/s present most of day, nearly every day >2wks
Term
Major depression
patho
Definition
-complex & incomplete understanding
-can be 'out of blue'
-stressful events
-factors that contribute to vulnerability:genetic, difficult childhood, chronic low self-esteem
-monamine deficiency hypothesis-defiecient in serotonin, NE or both
Term
Major depression
tx modalities
Definition
Pharmacotherapy
Depression specific psychotherapy
Somatic therapy (ECT, transcranial magnetic stimulation, light therapy, vagus nerve stimulation)
Aerobic exercise& resistance training
Term
Major Depression
Atypical features
Definition
reactive mood, significant increase in appetite, wt gain, hypersomnia, heavy feelings in arms/legs, sensitive to interpersonal rejection
Term
Major presentation
Assessment
Definition
H&P:include medications (?side effect)
MMSE, Lab work (r/o electrolytes/hypothyroid other medical conditions)
Differential dx
Term
Medical disorders associated w/Depression
Definition
Endocrine disorders, deficiency states, infections, collagen disorders, metabolic disorders, CV disease, neurologic disorder, malignant disease
Term
Psychiatric disorders associated w/depression
Definition
alcoholism, anxiety, eating disorders, schizophrenia
Term
Drug therapies associated w/depression
Definition
Anti-hypertensives, hormonal therapy, acne therapy, other
Term
Types of depression
Definition
Major depressive disorder
Dysthymic disorder
Term
Dysthymic disorder
Definition
Chronic depressed mood most days >2yrs, combined with 2 of the following: appetite or sleep disturbance, low energy, low self-esteem, hoplesness, poor concentration, indecisiveness.
Term
Depression symptom pneumonic
Definition
SIG E CAPS
sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide
Term
Depression
Tx goals
Definition
reduce/resolve problems
prevent relapse
facilitate to baseline
prevent suicide
improve QOL
normalize functionabl relationships
avoid/minimize adverse effect
reduce health care costs
Term
Drug classes for depression
Definition
SSRI
SNRI
TCA
MAOI
mixed serotonin
mixed NE/DA reuptake inhibitors
Term
Basic time course for antidepresants
Definition
1-3 wks to start working, max responses 12wks
Term
Drug selection for antidepressants
Definition
Tolerability, safety, interactions, pt preferance, cost.
Can try a different one with in same class
Term
Antidepressant choice for pt c/o fatigue
Definition
drug w/CNS stimulation
Prozac, Wellbutrin
Term
Antidepressant choice for pt c/o
insomnia
Definition
mirtazapine
Term
Antidepressant choice for pt c/o
sexual dysfunction, low libido
Definition
Wellbutrin
Term
Antidepressant choice for pt c/o
Chronic pain
Definition
Cymbalta or TCA
Term
Managing treatment in depression
Definition
Once started use 4-8 weeks before determining efficacy. Start low dose. Options if not effective:increase dose, switch within same class, switch to a different class, add a second drug.
Once in remission-cont 4-9mths symptom free, taper off.
Term
Suicide risk with antidepressants
Definition
Increased when starting antidepressants and when dose increases.
Evaluate weekly x4wks, biweekly x4wks, x1 month, periodic
Term
Treatment phases with antidepressants
Definition
Acute, continuation, maintenance
Term
Antidepressants
Duration of treatment phases
Definition
Acute-6weeks
Continuation-6-9mths
Maintenance-3-5yrs, lifelong
Term
Antidepressants
Goals of treatment phases
Definition
Acute-resolve symptoms
Continuation-prevent relapse
Maintenance-prevent reoccurance in high risk pts
Term
High risk patients for lifelong maintenance of depression
Definition
*first episode >50y/o
*>40y/o who have had 2+ episodes
*all ages with 3+ episodes
Term
SSRIs
drug list
Definition
Prozac, Zoloft, Celexa, Lexapro,Paxil, Luvox
Term
Prozac
MOA
Definition
Block neuronal reuptake of serotonin increasing serotonin at synapses
Term
Prozac
kinetics
Definition
high protein bound, extensive hepatic metabolism CYP2D6, 1/2 life 2 days, 4wks to plateau
Term
Prozac
side effects
Definition
sexual dysfunction, nausea, HA, CNS stimulation, nervous, insomnia, anxiety, wt. gain, serotonin syndrome, withdrawl symptoms with abrupt dc(less than others),increase suicide risk, EPS (akthisia most common), bruxism, hyponatremia, dizzy, fatigue, skin rash, diarrhea, excessive sweating. Teratogenic.
Term
Prozac
Interactions
Definition
MAOIs(stop 14 days before start,wait 5wksafter prozac to start MAOI)
CYP2D6 drugs, TCAs, Lithium, antiplatelet & anticoags, tagament, ethanol, NSAIDs, TCAs, some antiHTN, warfarin, tryptophan, other serotonergic meds
Term
Prozac
Monitoring
Definition
Na at baseline & periodic in elderly
Term
Prozac
minimizing side effects
Definition
Manage sexual dysfunction-drug holidays (off on weekends), add yohimbine, Buspar, Wellbutrin, remeron, Viagra.Bruixism-switch class or use mouthgaurds and add Buspar
Term
Zoloft
kinetics
Definition
absorption increase with food, high protein binding, extensive hepatic metabolism. 1/2 life 1 day.(side effects same as prozac)
Term
Luvox
side effects
Definition
same as prozac + dry mouth, constipation, sedative (rather than excitatory), liver damage.
Term
Luvox
monitoring
Definition
Liver function baseline & weekly x1month
Term
Paxil
side effects
Definition
Same as prozac, but fatigue/somnolence that fades after 5-6 wks. Has some anticholinergic effects.
Term
Celexa
side effects
Definition
Celexa-paresthesias, dry mouth, tachycardia, orthostatic hypotension, QT prolongation (and all other of prozac)
Term
Lexapro
side effects
Definition
same as prozac
Term
Serotonin syndrome
Definition
2-72hrs after tx onset. Altered mental status (agitated, confused, disoriented, anxiety, hallucinations, poor concentration_, incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, fever, death
Term
SSRI Withdrawl
Definition
Dizzy, HA, nausea, sensory disturbances, tremor, anxiety, dysphoria, days-weeks after stopping & last 1-3 weeks.
Term
SNRI's
drug list
Definition
Effexor, Pristiq, Cymbalta
Term
Effexor
MOA
Definition
Block NE, serotonin, and DA reuptake.
Term
Effexor
side effects
Definition
Nausea, HA, anorexia, nervous, sweating, somnolence, insomnia. Dose dependent wt loss, sustained DBP HTN, sexual dysfunction, mydriasis, hyponatremia, serotonin syndrome, teratogenic
Term
Effexor
contraindications
Definition
MAOIs within last 14 days of 7 days after withdrawl syndrome.
Term
Effexor
kinetics
Definition
Take w/food
Term
Effexor
monitoring
Definition
BP
Term
Effexor
interactions
Definition
MAOIs, Tagament, St. Johns Wart, Triptans, other antidepressants
Term
Pristiq
side effects
Definition
Dizzy, diarrhea/contispation, dry mouth, erectile dysfunction, decrease libido, seizures (and all of Effexor)
Term
Cymbalta
kinetics
Definition
take on empty stomach. high protein bound. CYP2D6, CYP1A2 metabolism
Term
Cymbalta
side effects
Definition
decreased appetite, blurred vision, liver damage (and all of pristiq/effexor)
Term
Cymbalta
monitoring
Definition
Transaminases (ALT), eye exams for glaucoma
Term
Cymbalta
contraindications
Definition
narrow-angle glaucoma, liver dysfunction, alcoholics, Cr Cl <30
Term
Cymbalta
interactions
Definition
Alcohol, MAOIs, CYP1A2 & CYP2D6 drugs, phenothiazines, other antidepressants, drugs that increase serotonin syndrome risk
Term
Tricylic Antidepressants
drug list
Definition
Amitriptyline, clomipramine,desipramine, doxepin, imipramine, nortrptyline, protriptyline, trimipramine
Term
TCA's
MAO
Definition
Block reuptake, of serotonin and norepinepherine. Block histamine and ACh. Potency varies between drugs.
Term
TCA's
side effects
Definition
ANTICHOLINERGIC (except diaphoresis), ORTHOSTATIC HYPOTENSION, SEDATION,cardiac conduction delays, weight gain, excessive sweating, sexual dysfunction, seizure, hypomania, suicide risk
Term
TCA choice by pretx symptoms
insomnia
sedation
BPH, glaucoma
Contraindicated in urinary retention & glaucoma, seizure
highest cardiotoxic risk
Definition
insomnia-give doxepin
sedation-give desipramine
BPH,glaucoma-give nortriptyline
contra glaucoma/urine retention-doxepin
contra seizure-maprotiline
cardiotoxic-desipramine
Term
Anafril
additional side effect
Definition
Yawngasms
Term
TCA's
pt teaching
Definition
slow rise/change position, caution in operating machinery/driving, sugar free candy for dry mouth, do not take 2 doses if miss one
Term
TCA
monitoring
Definition
BP/P, orthostatics, EKG prior to tx and periodic. Some drugs have serum levels
Term
TCA
toxicity
Definition
used for suicide attempts-do not give suicidal pts more than one week supply. Dysrhthmias, hyperthermia, flush, dry mouth, dilated pupils, early-confusion, agitation, hallucinations.Later seizure & coma
Term
TCA
toxicity tx
Definition
gastric lavage, physostigmine, propranolol, lidocaine, phenytoin
Term
Anticholinergic pneumonic
Definition
BUDCAT
Blurry vision, photophobia, ^IOP
Urinary retention
Dry mouth/reduced secretions
Constipation
Anhidrosis (absence of sweat)
Tachycardia
Term
TCA
interactions
Definition
Class IA antiarrhythmics
tagament
QT prolongers
Several CYP 450 meds
MAOIs (can under close supervison)
direct & indirect sympathmoimetics
anticholinergics
CNS depressants
Term
MAOIs
drug list
Definition
Selegiline patch, Marplan, Nardil, Parnate
Term
MAO enzyme actions
Definition
MAO, an enzyme in liver, intestine & some neuron terminals.
MAO neurons convert NE, serotonin,& DA to inactive. In liver & intestines, inactivates tyramine
Term
MAOI
MOA
Definition
All MAOIs for depression are nonselective (effect neuron, liver, intestine). Antidepressant effect are from increasing NE and serotonin available for release. Can be reversible or irreversible.
Term
MAOI
uses
Definition
1st line in atypical depression
2-3rd in other depression, bullimia, OCD, panic attacks
Term
MAOI
side effect
Definition
CNS stimulation (anxiety, insomnia, agitation, hypomania, mania), orthostatic hypotension, hypotension, dizzy, lightheaded, anticholinergic, (?sedation), sexual dysfunction, HTN crisis with dietary tyramine, hepatocellular damage, wt. gain, edema
Term
HTN crisis with tyramine foods
s/s
Definition
severe HA, tachycardia,palpitations, HTN, N/V, confusion, profuse sweating, stroke
Term
Normal tyramine food metabolism
Definition
MAO in intestine and liver inactivate before reaching general circulation
Term
Tyramine effects in general circulation
Definition
Stimulates release of accumulated NE, massive vasocontriction and intense heart stimulation
Term
Foods with tyramine
and tyramine-like foods to avoid
Definition
yeast, cheese, avacodos, soybeans, salami, pepperoni, bologna, smoked meats, figs, bananas, aged fish/meat, liver, beer, Chianti Wine, protein dietary supplements, soups, shrimp paste, soy sauce, caffeine,chocolate, fava, ginseng
Term
Treating HTN crisis
Definition
IV vasodilator, sodium nitroprusside, phentolamine, labetalol, sl nifedipine
Term
MAOI
drug interaction
Definition
A LOT, lots of OTC also. Pt teaching to notify prescriber before starting any new med-including OTC (ie cough/cold)
Term
Transdermal Selegiline
Definition
24h MAOI patch, no dietary restrict for 6mg, avoid in anesthetic comtaining sympathomimetics. Contraindicated in pheochromocytoma. May increase q2weeks
Term
Changing therapies from/to MAOI
Definition
wait 2 week from stopping MAOIs to start other antidepressants and vice versa. Wait 5 wks after Prozac to start MAOI.
Term
Bupropion
action/use
Definition
similar structure to amphetamine. Stimulant actions & supresses appetite.
Antidepressant effects 1-3 weeks. Sexual dysfunction in SSRI pts and women w/hypoactive libido, SAD, major depressive, smoking cessation, neuropathy, ADHD
Term
Bupropion
MOA
Definition
r/t block dopamine &/or NE reuptake
Term
Bupropion
kinetics
Definition
CYP2B6 hepatic metabolism, 1/2 life 8-24h
Term
Bupropion
side effects
Definition
seizures, agitation, HA, dry mouth, constipation, wt. loss, GI upset, dizzy, tremor, insomnia, blurred vision, tachycardia, psychotic, suicide risk
Term
Bupropion
interactions
Definition
Zoloft, prozac, paxil, MAOI, CYP2B6
Term
Bupropion
minimizing seizure risk
Definition
avoid dose >450mg/day, avoid rapid titration(<100/day >3-4days inbetween), avoid single dose >150mgavoid use in hx of seizures, head injury, CNS tumor, or with drugs that decrease seizure threshold
Term
Bupropion
Contraindications
Definition
eating disorders, previous seizure hx.
Term
Trazadone
MOA
Definition
Increase serotonin
Term
Nefazadone
MOA
Definition
Inhibits NE and serotonin reuptake
Term
Trazadone/nefazadone
side effects
Definition
HA, drowsy, insomnia, agitation, dizzy, dry mouth, nausea, constipation, weakness, trazadone-priapism/prolonged clitoral erection & QT prolongation
Term
Trazadone
uses
Definition
Sleep
adjunct in depression
Term
Nefazone
uses/additional considerations
Definition
Antidepressant
Assoc w/Liver failure
Protein bound
Term
Trazadone/nefazadone
interactions
Definition
3A4 drugs, digoxin, MAOIs, warfarin, CNS depressants, St. Johns wort
Term
Remeron
MOA
Definition
inhibits NE & serotonin reuptake by inhibiting receptors, avoids some serotonin receptors, block histamine
Term
Remeron
side effects
Definition
sedation, increased cholesterol, constipation, dry mouth, increased appetite, wt. gain, dizzy
Term
Remeron
dosing
Definition
daily HS, adjust for hepatic and renal impair
Term
Remeron
interactions
Definition
MAOIs, clonidine, triptans, BZD, other antidepressants, CNS depressants
Term
Vilazodone
MOA
Definition
Selective block serotonin reuptake and direct activation of serotonin receptors
Term
Vilazodone
kinetics
Definition
Take w/food, high protein bound, extensive hepatic metabolism
Term
Vilazodone
side effects
Definition
diarrhea, nausea, dizzy, insomnia, sexual dysfunction,serotonin syndrome, hyponatremia, abnormal bleeding, increased suicide
Term
Vilazodone
interactions
Definition
MAOIs, serotonergic drugs, CYP drugs, anticoags & antiplatelets
Term
Amoxapine
use/side effects
Definition
Antidepressant for psychotic depression.
anticholinergic, sedative, seizure, EPS, TD
Term
Ketamine
as an antidepressant
Definition
IV-quickly reduces depression and suicide, 40minute results last 10days
side effect-psychosis resolves in 40min, can cause cancer
Term
MAOI
contraindications
Definition
SSRI use, pheochomocytoma, HF, liver disease, severe renal impair, cerbrovascular disease, HTN, >60y/o
Term
ADVERSE EFFECTS
Remeron
Neazodone
Trazodone
Bupropion
MAOIs
Antidepressants
Definition
Neutropenia/agrulocytosis(avoid immunosuppressed)
Hepatic Failure
Priapism
Seizures
HTN crisis
Suicidality
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