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Depression Flashcards

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1
Q

What criteria is used to diagnose depression?

A

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

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2
Q

What is the most commonly used depression assessment scale?

A

Hamilton Depression Rating Scale (HDRS) or (Ham-D Rating Scale)

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3
Q

What are s/sx of depression?

A
  1. Mood
  2. Sleep-more or less
  3. Interest/pleasure-less
  4. Guilt/worthlessness
  5. Energy-less
  6. Concentration-less
  7. Appetite- more or less
  8. Psychomotor agitation or retardation
  9. Suicidal ideation
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4
Q

What is required for diagnosis of depression?

A

> /- 5 sx present over 2 weeks including depressed mood or loss of interest/pleasure

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5
Q

What drugs cause/worsen depression?

A
  1. ADHD meds/methylphenidate/stimulants
  2. Analgesics (indomethacin)/procainamide
  3. Antiretroviral (NNRTIs; evafirenz, rilpivirine)
  4. CV meds (beta-blockers especially propranolol, clonidine)
  5. Antidepressants/Benzos
  6. Systemic steroids/ Interferons/Cyclosporine
  7. Ethanol
  8. Varenicline
  9. Hormones (hormonal contraceptives, anabolic steroids)
  10. Methadone and other opioids that can lower testosterone/estrogen levels
  11. Methyldopa/Parkinson’s
  12. Isotretinoin
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6
Q

What natural products are used to treat depression?

A
  1. St. John’s Wart
  2. SAMe
  3. 5-HTP
  4. Valerian
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7
Q

What are safety concerns with natural products?

A
  1. St. John’s Wart- increase risk of serotonin syndrome, broad CYP enzyme inducer, photoxicity
  2. SAMe- increase risk of serotonin syndrome
  3. 5-HTP- increase risk of serotonin syndrome
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8
Q

What is the 1st line therapy for mild-moderate depression in pregnancy?

A

Psychotherapy

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9
Q

What is 1st line for severe depression in pregnancy?

A
  1. if on SSRI before preg, continue if safe
  2. SSRIs: sertraline, escitalopram
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10
Q

What are warnings with SSRIs during pregnancy?

A
  1. Persistent pulmonary HTN of new born
  2. Cardiac effects (Paroxetine)
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11
Q

What are preferred treatments for post partum depression?

A
  1. SSRIs
  2. zuranolone PO (Zurzuvae)- C-IV
  3. brexanolone IV (Zulresso)- C-IV; moderate to severe PPD
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12
Q

What agents are restricted to patients unresponsive to other therapies due to drug-drug/drug-food interactions?

A

nonselective MOA inhibitors:
phenelzine, tranylcypromine, isocarboxazid

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13
Q

What are s/sx of serotonin syndrome?

A
  1. severe Nausea
  2. Dizziness
  3. Headache
  4. Diarrhea
  5. Agitation
  6. Tachycardia
  7. Hallucinations
  8. Muscle rigidity
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14
Q

How should all antidepressants be discontinued?

A

Taper over several weeks
EXCEPT fluoxetine self-tapers long half life

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15
Q

What are black boxed warnings with all antidepressants?

A
  1. Increase in suicidal thoughts or actions in Childrens, Teens, and young adults (changes in mood/behavior/thoughts/feelings)
  2. MedGuide is REQUIRED for all antidepressants
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16
Q

How long does it take for antidepressants to work?

A

when used daily, 1-2 weeks for physical symptoms and a month or longer for psychological symptoms

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17
Q

What is the MOA of SSRIs?

A

increase 5-HT by inhibiting its reuptake in the neuronal synapse

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18
Q

What are CIs for all SSRIs?

A
  1. DO not use with MOA inhibitors, Linezolid, IV methylene blue, or pimozide
  2. fluoxetine/paroxetine: do not use with thioridazine
  3. fluvoxamine: do not use with alosetron, thioridazine, tizanidine
  4. sertaline soln: do not use with disulfuram
  5. Brisdelle (paroxetine): pregnancy
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19
Q

What are warnings with all SSRIs?

A
  1. QT Prolongation: do not exceed 20mg/d in elderly (>60 y/o), liver disease, CYP2C19 poor metabolizers or inhibitors; do not exceed 10mg/d escitalopram in elderly
  2. SIADH/Hyponatremia, Fall Risk (caution in elderly avoid if history of falls or use of CNS depressants)
  3. Bleeding (additive risk)
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20
Q

What are SEs with all SSRIs?

A
  1. Sexual SEs (low libido, ejaculation difficulty, anorgasmia, erectile dysfunction)
  2. Somnolence
  3. Insomnia
  4. Nausea
  5. Dry mouth
  6. Diaphoresis (dose related)
  7. Weakness
  8. Tremor
  9. Headache
  10. osteopenia/osteoporosis
  11. restless leg syndrome
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21
Q

What agent is preferred in patients with cardiac risk?

A

sertraline

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22
Q

What agents are approved for premenstrual dysphoric disorder PMDD and how are they dosed?

A
  1. Fluoxetine
  2. Paxil CR
  3. Sertraline
    Continuous dosing or cyclical (luteal phase)
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23
Q

When should SSRIs be taken?

A

In the morning: fluoxetine (most awakening), others if not sedating
At night: paroxetine (most sedating), others if sedating

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24
Q

Which SSRI is not available in a solution?

A

fluvoxamine

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25
What drugs interact with SSRIs?
1. fluoxetine, paroxetine, and fluvoxamine are CYP2D6 inhibitors and decrease tamoxifen effectiveness 2. antipsychotic drugs that are CYP2D6 substrates 3. Other drugs that prolong QT interval 4. increased bleeding risk NSAIDs/ anticoagulants/ antiplatelet/ gingko/garlic/ginger/ginseng/glucosamine/fish oil
26
What is the maximum dose of citalopram?
40mg /d
27
What is the maximum dose of escitalopram?
20mg/day
28
fluoxetine + olanzapine for treatment resistant depression
Symbyax
29
paroxetine for moderate- severe vasomotor symptoms
Brisdelle
30
How long is the washout period between SSRIs and MAO inhibitors/serotonin syndrome/ HTN crisis?
1. 2 week washout period between MAO inhibitors and SSRIs 2. 5 week washout period between MAOi and fluoxetine 3. do not initiate in patients receiving methylene blue or linezolid
31
What is the MOA of vilazodone (Viibryd, Viibryd Starter Pack)?
SSRI and 5HT1A partial agonist
32
What is the MOA of vortioxetine (Trintellix)?
SSRI, 5HT1A agonist, and 5HT3 antagonist
33
What are CIs with 5HT partial agonists and antagonists?
1. Do not use within 14 days of MAO inhibitors 2. do not use with linezolid or IV methylene blue
34
What are warnings with 5HT partial agonists and antagonists?
Avoid with hx of seizure
35
What are SEs with 5HT partial agonists and antagonists?
1. N/V/D 2. decreased libido (less sexual SE compared to SSRI/SNRI)
36
What are SEs with vortioxetine?
1. constipation 2. decrease dose by 50% when used with strong CYP2D6 inhibitors (bupropion, fluoxetine, paroxetine, quinidine)
37
What is an important counseling point with vilazodone?
Take with food
38
What is the MOA of SNRIs?
increase 5HT and NE by inhibiting reuptake in the neuronal synapse
39
What is venlafaxine indicated for?
1. Depression 2. GAD 3. panic disorder 4. Social anxiety disorder
40
What is duloxetine indicated for?
1. Depression 2. Peripheral neuropathy 3. Fibromyalgia 4. GAD 5. Chronic musculoskeletal pain
41
What is the max dose of venlafaxine?
375mg/d (IR) 225mg/d (ER)
42
What are CIs to using SNRIs?
1. Lethal drug interaction WITH MAO INHIBITORS CAUSING HTN CRISIS 2. do not use with linezolid or IV methylene blue
43
What are warnings with SNRIs
1. SIADH/Hyponatremia, Fall Risk (caution in elderly avoid if history of falls or use of CNS depressants) 2. Bleeding (additive risk) 3. can affect urethral resistance; caution in those prone to obstructive urinary disorders 4. high BP risk greatest with >150mg venlafaxine or other high-dose SNRIs; can decrease dose/ use antiHTN meds/change therapy 5. do not use levomilnacipran CrCl<15 6. do not use duloxetine CrCl<30 7. Pristiq can leave a ghost tablet
44
What are SEs with SNRIs?
1. same as SSRIs 2. Increased HR 3. Dialated pupils (lead to narrow angle glaucoma) 4. Dry mouth 5. Excess sweating 6. Constipation 7. High BP 8. osteoporosis 9. restless leg syndrome
45
Levomilnacipran
Fetizma
46
What are DIs with SNRIs?
1. Additive QT prolongation 2. Duloxetine moderate CYP2D6 inhibitor 3. increased bleeding risk 4. HTN crsis and serotonin syndrome with MAOi, methylene blue IV, and linezolid
47
What is the MOA of TCAs?
block Ach and H receptors Secondary amines: selective for NE Tertiary amines: more effective with worse SEs
48
What are CIs to using TCAs?
1. MAO inhibitors, linezolid, IV methylene blue 2. myocardial infarction 3. glaucoma 4. urinary retention (doxepin)
49
What are SEs with TCAs?
1. QT prolongation with Overdose (monitor for Suicidal Ideation as OD can quickly cause Fatal Arrhythmia): obtain baseline ECG if cardiac risk factors >50 yr 2. Orthostasis/tachycardia 3. Dry mouth 4. Blurred vision 5. Urinary retention 6. Constipation 7. Weight gain 8. vivid dreams 9. sedation 10. sweating 11. myoclonus (muscle twitching- indicated toxicity) 12. Fall risk 13. Seizures (high doses increase risk)
50
What are warnings with TCAs?
1. Tertiary amines have increased anticholinergic PROPERTIES AND ARE MORE LIKELY TO CAUSE SEDATION AND WEIGHT GAIN 2. taper off to avoid cholinergic rebound
51
What is typical dosing for amitriptyline?
100-300mg/day QHS or divided doses
52
What drugs are tertiary amine TCAs?
1. amitriptyline 2. doxepin 3. clomipramine 4. imipramine 5. trimipramine
53
Doxepin
Silenor (insomnia) Zonalon (topical for pruritis)
54
What drugs are secondary amine TCAs?
1. nortriptyline 2. amoxapine 3. desipramine 4. maprotiline 5. protriptyline
55
Nortriptyline
Pamelor
56
What are DIs with TCAs?
1. MAOi and HTN crisis: 2-week washout period 2. additive QT prolongation 3. metabolized by CYP2D6
57
What are CIs to using bupropion?
1. Seizure disorder 2. Hx anorexia/bulimia 3. Use with MAOi, linezolid, IV methylene blue, other forms of bupropion 4. abrupt discontinuation of alcohol/sedatives
58
What are warnings with bupropion?
Neuropsychiatric adverse events possible when used for smoking cessation (mood changes, hallucination, paranoia, aggression, anxiety)
59
What are SEs with bupropion?
1. Dry mouth 2. CNS stimulation (Insomnia, Restlessness) 3. Tremors/Seizure (dose-related) 4. Weight loss 5. headache/migraine 6. N/V 7. constipation 8. BP changes (HTN>hypotension) 9. sexual dysfunction rare (preferred over other antidepressants 10. dizziness, excessive sweating (Auvelity)
60
What is the maximum dose of bupropion/ day?
450mg/day (522mg /day with Aplenzin) due to seizure risk
61
Bupropion
Wellbutrin SR (BID) Wellbutrin XL (QD) Aplenzin Forfivo XL
62
Bupropion + Dextromethorphan ER
Auvelity (depression)
63
Bupropion + naltrexone
Contrave (weight management)
64
Bupropion SR
Zyban (smoking cessation)
65
What forms of bupropion are approved for seasonal affective disorder (SAD)?
Wellbutrin XL Aplenzin
66
What are DIs with bupropion?
1. Do not use multiple formulations 2. HTN crisis and MAOi: 14 day wash out
67
What drugs are MAOIs?
1. isocarboxazid 2. phenelzine 3. tranylcypromine 4. selegiline (MAO B)
68
What is the MOA of MAOIs?
inhibit monoamine oxidase; prevents breakdown of NE, 5HT, DA, EPI
69
What are CIs to using MAOIs?
1. History of CV disease, cerebrovascular defect, headache, hepatic disease, pheochromocytoma 2. Use with sympathomimetics and related compounds 3. Severe renal disease (isocarboxazid, phenelzine)
70
What are warnings with MAOIs?
Watch for DIs could be fatal
71
What are SEs with MAOIs?
1. anticholinergic effects (taper off) 2. orthostasis 3. sedation (except tranylcypromine causes stimulation) 4. sexual dysfunction 5. weight gain 6. headache 7. insomnia
72
What are CIs with selegiline (MAOBi)?
1. Use with other serotonergic agents 2. pheochromocytoma
73
What are SEs with selegiline (MAOBi)?
1. constipation/gas 2. dry mouth 3. loss of appetite 4. sexual dysfunction
74
Isocarboxazid
Marplan
75
Phenelzine
Nardil
76
Tranylcypromine
Parnate
77
Selegiline
Emsam (transdermal patch) Zelapar ODT (parkinsons disease)
78
What are DIs with MAOIs?
1. HTN crisis/serotonin syndrome/psychosis with drugs that increase concentrations of NE, DA, Epi, 5HT 2. CI with drugs that increase 5HT: linezolid, Lithium, Tramadol, Opioids, St. John's Wort, Antidepressants 3. CI tyramine-rich foods: Aged cheese, Pickled herring, Yeast extract, Air-dried meats, Sauerkraut, Soy sauce; Aged, Fermented, Pickled, Smoked foods 4. CI drugs that increase NE: levodopa, linezolid, methylene blue, stimulants, OTC/herbal diet pills
79
What is the MOA of mirtazapine?
presynaptic alpha-2 adrenergic antagonist ; helps with sleep when dosed QHS and increases appetite
80
What are CIs with mirtazapine?
1. MAOIs 2. Linezolid 3. IV methylene blue
81
What are warnings with mirtazapine?
1. anticholinergic effects 2. QT prolongation (additive) 3. blood dyscrasias 4. CNS depression
82
What are SEs with mirtazapine?
1. Sedation 2. Increased appetite/Weight gain 3. dry mouth 4. dizziness 5. agranulocytosis (rare)
83
What is the MOA of trazodone?
SSRI, blocks H1 and alpha-1 adrenergic receptors
84
What are CIs with trazodone?
1. MAOIs 2. Linezolid 3. IV methylene blue
85
What are SEs with trazodone?
1. Sedation (ER less sedating)- used for sleep>depression 2. orthostasis 3. sexual dysfunction/ Priapism 4. additive QT prolongation
86
What is the MOA of nefazodone?
inhibits 5HT and NE reuptake, blocks 5HT2 and alpha -1 adrenergic receptors
87
Mirtazapine
Remeron Remeron SolTab
88
What boxed warnings does nefazodone have?
Hepatotoxicity
89
What are CIs with nefazodone?
1. hepatic disease 2. MAOIs 3. carbamazepine 4. cisapride 5. pimozide 6. triazolam
90
What are SEs with nefazodone?
1. Sedation (less sedating vs. trazodone) 2. orthostasis 3. sexual dysfunction/ Priapism
91
What is treatment resistant depression?
not responsive to 2 full treatment trials (4-8 week trial at therapeutic dose)
92
What should be considered if someone is not responding to antidepressant therapy?
1. change med 2. increase dose 3. use combination of antidepressants with different MOA 4. augment with buspirone or atypical antipsychotic 5. augment with lithium thyroid hormone T3 or electroconvulsive therapy
93
What are boxed warnings with atypical antipsychotics?
1. Elderly patients with dementia related psychosis increase risk of death 2. Increased risk of suicidal behavior
94
What are warnings with atypical antipsychotics?
1. neuropleic malignant syndrome 2. tardive dyskinesia 3. leukopenia/neutropenia 4. falls 5. Multiorgan hypersensitivity (eosinophilia/DRESS) 6. pathological gambling/compulsive behavior
95
What are SEs with aripiprazole?
1. Anxiety 2. Insomnia 3. Akathisia 4. constipation 5. agitation 6. orthostasis/dizziness/weight gain/diabetes- less
96
What are SEs with olanzapine?
1. Sedation 2. Weight gain 3. High lipids/glucose 4. EPS 5. QT prolongation- less 6. orthostasis/dizziness/diabetes
97
What are SEs with quetiapine?
1. Sedation 2. Weight gain 3. High lipids/glucose 4. EPS- less 5. Orthostasis 6. dizziness/diabetes
98
What are SEs with brexpiprazole?
1. weight gain 2. dyspepsia 3. diarrhea 4. agitation 5. orthostasis/dizziness/weight gain/diabetes
99
What are SEs with cariprazine?
1. EPS 2. dystonias 3. headache 4. insomnia 5. orthostasis/dizziness/weight gain/diabetes
100
What is the MOA of esketamine?
NMDA rec antagonist
101
What are boxed warnings with esketamine?
1. sedation and dissociative/ perceptual changes 2. abuse potential 3. suicidality
102
What is required for esketamine administration?
1. Must be under medical supervision 2. restricted distribution under REMS program
103
Aripiprazole
Abilify Abilify Maintena Abilify MyCite Oral route only for treatment resistant depression
104
Quetiapine
Seroquel Seroquel XR
105
Brexpiprazole
Rexulti
106
Cariprazine
Vraylar
107
Esketamine
Spravato (nasal spray; CIII)
108
Fluoxetine
Prozac Sarafem Saelfemra
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