|
Class/Generic
|
Brand
|
CYP 1A2
|
2C
|
2D6
|
3A4
|
Warnings
|
|
SSRI
|
|
|
|
|
|
|
|
Citalopram
|
Celexa
|
|
|
+ (I)
|
|
Taper on
(D/C)
|
|
Escitalopram
|
Lexapro
|
|
|
+ (I)
|
|
|
Fluoxetine
|
Prozac
|
|
++ (I)
|
++++ (I)
|
++ (I)
|
|
Fluvoxamine
|
Luvox
|
++++ (I)
|
++ (I)
|
0/+ (I)
|
+++(I)
|
|
Paroxetine
|
Paxil
|
|
|
+++ (S,I)
|
|
|
Sertraline
|
Zoloft
|
|
++ (I)
|
+ (I)
|
+ (I)
|
|
SNRI
|
|
|
|
|
|
|
|
Venlafaxine
|
Effexor
|
|
|
0/+ (S)(I)
|
|
Mon. BP
|
|
Desvenlafaxine
|
Pristiq
|
|
|
|
|
|
Duloxetine
|
Cymbalta
|
|
|
++ (I)
|
|
|
Tricyclics Secondary Amines
|
|
|
|
|
|
|
Desipramine
|
Norpramin
|
|
|
|
|
arrhythmias
Must taper on D/C
|
|
Nortriptyline
|
Pamelor
|
|
|
|
|
|
Miscellaneous
|
|
|
|
|
|
|
|
Bupropion
|
Wellbutrin
|
|
|
+ (I)
|
|
|
Term
| What are the alternative treatment options for MDD, and what are their warnings? |
|
Definition
|
Class
Generic
|
Brand
|
Warnings
|
|
Serotonin Modulators
|
|
|
Nefazodone
|
Serzone
|
Liver failure
|
|
Trazodone
|
Desyrel
|
|
|
TCA
|
|
|
|
Amitriptyline
|
Elavil
|
Overdose
Side effects
|
|
Clomipramine
|
Anafranil
|
|
Doxepin
|
Sinequan
|
|
Imipramine
|
Tofranil
|
|
MOA-inhibitors
|
|
|
|
Phenelzine
|
Nardil
|
Orthostasis
HTN crisis with foods
and medications
|
|
Selegiline
|
Emsam
|
|
Tranylcypromine
|
Parnate
|
|
SNRI
|
|
|
|
Milnacipran
|
Savella
|
Not FDA
approved MDD
|
|
|
|
Term
| What is the Acute phase of depression? |
|
Definition
- Active depression sx
- Can last 6-10 weeks
- Goal is remission by 20% decrease in sx |
|
|
Term
| What is the continuation phase of depression? |
|
Definition
- Assumes remission and tries to prevent relapse within 6 months of remission.
- Typically lasts 4-5 months
- Assumes remission. Otherwise, it is still acute phase |
|
|
Term
| What is the maintenance phase of depression? |
|
Definition
- Assumes remission
- Goal is to prevent reoccurence
- Typically lasts 1-3 years in duration
|
|
|
Term
| For mild cases of depression in the acute phase, what treatment would you use? |
|
Definition
| Typically just an antidepressant, just psychotherapy, or a combo if nothing else works |
|
|
Term
| For moderate-severe cases of depression in the acute phase, what treatment would you use? |
|
Definition
- Antidepressant
- Combination therapy
- ECT
|
|
|
Term
| For severe cases of depression in the acute phase, what treatment would you use? |
|
Definition
|
|
Term
| What are some important points regarding antidepressant selection? |
|
Definition
- Use a first-line
- Comparable efficacy between classes based on STAR*D trial
- Initial antidepressant should be low dose (not necessarily lowest), and titrate up
- Intial selection based on previous response of patient, medical and family history
- Titration speed will depend on Age, Agent, Adverse effects, co-morbid conditions
Watching for response - Decrease of >50% on symptom scale seen within 2 weeks. 4-8 weeks for full effect. Side-effects appear before therapeutic effect. Improvement in Neurovegetative effects noticed first (Sleep, appetite, energy, irritability) |
|
|
Term
| What is the treatment algorithm if there is no response in the acute phase? |
|
Definition
|
|
Term
| What is the treatment algorithm if there is a partial response in the acute phase? |
|
Definition
|
|
Term
| What is the treatment algorithm in the maintenance phase? |
|
Definition
|
|
Term
| What are some considerations when switching an antidepressant therapy? |
|
Definition
- Was the dose optimized or maximized?
- How long did the patient have the optimal dose? Should be for 6 weeks
- Selection of another agent is same criteria as choosing the first
- If switching to MAOI need washout period of 2-5 weeks (depending on Half-life) b/c of serotonin syndrome |
|
|
Term
| What are the symptoms of serotonin syndrome? |
|
Definition
- Changes in mental status
- Nausea
- Diaphoresis
- Agitation
- Hypertension
- Unresponsiveness
- Seizures |
|
|
Term
| What are some medications implicated in serotonin syndrome? |
|
Definition
- SSRI
- SNRI
- TCA
- MAOI
- Lithium
- Not an all inclusive list |
|
|
Term
| What are some medications to be used during Augmentation, which is used after a partial response when several agents have already been tried? |
|
Definition
- Lithium (mood stabilizer)
- Stimulant
- Methylphenidate
- Amphetamine
- Thyroid Hormone
- Second Generation antipsychotic |
|
|
Term
| What is special about geriatric patients who take antidepressants? |
|
Definition
- Longer time to see response (6-12 weeks)
- Drug interactions with poly-pharmacy regimens
- Concomittant disease states
- Suicide risk |
|
|
Term
| What is special about pediatric patients who take antidepressants? |
|
Definition
- FDA Black Box Warning
- Increased risk of suicide
- Fluoxetine is only FDA approved medication for MDD, requires close monitoring (they mean only one approved for pediatrics?!)
- |
|
|
Term
| What are the risk factors for suicide in pediatric and geriatric patients? |
|
Definition
- Prior attempt
- Windowed/unmarried
- Living alone
- Lack of social support/family involvement
- Unemployed
- History of past psychiatric admissions
- Substance abuse
- Significant symptoms
- Depressed
- Hopeless
- Family history of suicide
- Anniversary of loss
- Serious medical problem (AIDS?)
- Refusal for help |
|
|
Term
| What are some important factors to consider in pregnant/lactating patients in depression? |
|
Definition
- Complex decision process involved in how to treat
- Risk vs. Benefit
- Antidepressants not recognized to cause major birth defects
- Treatment with SSRI in third trimester causes low birth weight and increased CNS symptoms
- Bupropion is category B
- Highest concentration in breast milk reported with Doxepin and Fluoxetine |
|
|
