Depression

Question 1

Describe SSRI use for depression

Answer 1

• 1st line in uncomplicated px (physically healthy, outpatient, no CI)
• Citalopram = fewest DIs; sertraline is 2nd least
• All are about equally effective; choice of one over another depends on pt profile and drug profile
• If pt fails trial due to non-response or limiting adverse effect -> ensure adherence and maximize dose (try to wait 8 weeks until increasing)
• If pt experiences partial response -> consider adding 2nd antidepressant, lithium, or LT4 or switch agent
• • If pt fails this -> switch agent
• Flat dose response (most px respond at lowest effective dose)
• Advantage -> less SE vs. TCAs b/c more selective
• AE = nausea, agitation, nervousness, restlessness, insomnia/ drowsiness
• Toxic effects -> tremor, sinus tachycardia, N/V/D, seizures, serotonin syndrome

Question 2

What are the sx of SSRI withdrawal syndrome? When do they occur and how long do they last?

Answer 2

• *FINISH -> flu-like sx, insomnia, nausea, imbalance, sensory disturbance, hyperarousal
• Occur w/in 1-3 days (up to 1 week)
• Last up to 7-14 days (may be several weeks)

Question 3

Describe venlafaxine

Answer 3

• Similar to SSRIs at low doses, but similar to TCAs at high doses
• AE = BP increases (dose dependent; risk greater w/ increased age), dose-related GI effects, dizziness, sexual dysfunction, dry mouth

Question 4

Describe TCA use for depression

Answer 4

• Last option for most px
• Nortriptyline generally better tolerated than amitriptyline and clomipramine
• Has antihistaminic effects -> sedation, weight gain
• Has anticholinergic effects, so caution in BPH and glaucoma (desipramine has least ACh effects)
• At usual doses, cardiac effects -> hypertension, tachycardia, antiarrhythmic properties, orthostatic hypotension
• Toxic effects in overdose -> CV (sinus tachycardia, ventricular arrhythmias, hypotension), CNS (coma, delirium, seizures), urinary retention
• Withdrawal sx -> cholinergic & adrenergic rebound = dizziness, N/D, insomnia, hot or cold flashes
• If d/c, taper over 2-4 weeks

Question 5

Describe bupropion use for depression

Answer 5

• Good option for those previously on venlafaxine who can’t tolerate AE
• AE = insomnia, agitation, anxiety, seizures (at high doses), dry mouth, N/V, rash, headache
• Advantages -> less sexual dysfunction and little weight gain
• CI = seizures, anorexia

Question 6

Describe mirtazapine use for depression

Answer 6

• AE = orthostatic hypotension (not great for elderly); can be fairly sedating
• Advantages -> little sexual dysfunction and less serotonergic effects (so little weight gain)

Question 7

Describe MAOI use for depression

Answer 7

• Indicated for atypical or resistant depression
• Only antidepressant that requires washout when switching
• AE = orthostatic hypotension, dry mouth, constipation, sexual side effects, insomnia
• Dosed in AM and mid-day to avoid overstimulation

Question 8

Which antidepressants can be used in combination?

Answer 8

• Venlafaxine + bupropion
• SSRI + bupropion
• SSRI + TCA

Question 9

What is the typical tx duration for antidepressants?

Answer 9

• 4-9 months after remission

- Lifelong if < 40 y/o and 2+ episodes OR any age & 3+ episodes

Question 10

Sx and tx of serotonin syndrome

Answer 10

• *Diagnosis of exclusion
• Cognitive/behavioural = agitation, mental status changes (confusion, hypomania)
• Autonomic = diarrhea, fever, shivering
• Neuromuscular = incoordination tremor, myoclonus, hyperreflexia
• Tx = supportive care, BZD for neuromuscular sx, tylenol for fever, cyproheptadine 4 mg q4h for severe sx

Question 11

Depression in pregnancy

Answer 11

• Weigh risks vs. benefits to mother and fetus!!
• Most evidence for safety of fluoxetine
• Can do ECT and psychotherapy (CBT)
• After delivery, watch for direct drug effects and transient withdrawal sx in infant

Question 12

Depression in breastfeeding

Answer 12

• Safe = paroxetine, sertraline*, fluoxetine, nortriptyline

- Monitor infant daily for changes in sleep, feeding patterns, and behaviour

Question 13

Depression in children/ adolescents

Answer 13

• 1st line for moderate to severe major depression = fluoxetine and citalopram
• 2nd line = other SSRIs (paroxetine has most AE)
• 3rd line = venlafaxine
• Best outcomes when combine antidepressant w/ CBT
• Monitor suicidal thoughts!!

Question 14

Red flags for antidepressants (when to avoid certain ones)

Answer 14

• Avoid bupropion and TCAs in seizures
• Avoid SSRIs, venlafaxine, TCAs, and MAOIs in sexual dysfunction
• Avoid TCAs, MAOIs, and mirtazapine if pt doesn’t want weight gain
• Avoid TCAs if possible in elderly (urinary retention, excessive sedation)

Question 15

Case specific assessment questions for depression

Answer 15

• Are you having suicidal thoughts?
• Are you having psychotic sx? (hallucinations, delusions)
• Are you still able to go to school/work? (impairment in functioning warrants tx)

Question 16

Non-pharms for depression (general)

Answer 16

• Cognitive behavioural therapy
• Interpersonal
• Bright light therapy
• Exercise and good nutrition

Question 17

What can be done to manage AE of antidepressants?

Answer 17

Normally can decrease dose or switch agent if very bothersome to pt

Question 18

General monitoring for depression

Answer 18

• Pt should monitor sx daily
• • Anxiety and insomnia improve in 3-5 days
• • Energy and somatic sx in 2-3 weeks
• • Sleep patterns in 4-6 weeks
• • Depressed mood and sexual dysfunction in 4 weeks
• Monitor suicidal thoughts (especially in children)

Question 19

General follow up for depression

Answer 19

• Pharmacist follow-up in 1-2 weeks when meds are added or increased to see about side effects
• Consistently follow-up w/ pt regarding depressive sx to see if deprescribing is appropriate
• • Continue full dose for at least 6-12 months after remission (when sx go away)

Question 20

Describe monitoring for depression when adding therapy

Answer 20

• Monitor for symptom improvement and side effects of the medication daily/weekly
• If now taking 2 serotonergic drugs, monitor for serotonin syndrome
  (common sx = excitement, anxiety, muscle rigidity, fever, tremor, increased HR; on pg. 151)
  – Typical onset for serotonin syndrome = 1 h to 1 day (so if pt is experiencing similar sx after 1 week of taking the drug, can attribute it to normal SE of the drug)
  – Generally, doesn’t occur from just 1 drug (possible at max. dose), generally happens when pt uses 2-3 serotonergic drugs
• If new med -> all adverse effects on page 152
• **Most common SE of SSRI’s are GI effects and headaches

Question 21

Describe when to go to a Dr for depression when adding therapy

Answer 21

• Go to doctor/talk to pharmacist if side effects become unbearable, or if you feel like this medication isn’t working
• For women -> go to Dr. if you become pregnant b/c we may need to switch to a safer antidepressant

Question 22

Describe when to go to emergency for depression when adding therapy

Answer 22

Go to emergency if you do experience serotonin syndrome, you are having suicidal thoughts, any dramatic mood changes (lots of energy; can indicate bipolar which normally presents first as depression)

Question 23

Describe non pharms for depression when adding therapy

Answer 23

• Diary of symptoms
• CBT, psychotherapy
• Mindfulness, meditation
• Exercise and good nutrition

Question 24

Describe follow up for depression when adding therapy

Answer 24

• I will follow up with you 5 days to discuss any side effects you might be experiencing as well as your adherence
• I will also follow up with you in 2 and 4 weeks to discuss if you are seeing any sx improvement with the medication
• I would like to give this at 4-6 weeks before we re-assess if you need a dose increase or to be switched to a different antidepressant

Question 25

A patient asks "how long will I have to take my antidepressant"

Answer 25

- At least 1 year after a good response is achieved | - Response/remission typically takes 6-12 weeks to see

Question 26

Describe monitoring for depression after hospitalization (starting new med, increasing dose)

Answer 26

- Monitor for sx improvement and side effects of medication daily/weekly - Common SE of meds -> in RxFiles pg. 152 - Anxiety and insomnia improve in 3-5 days - Energy and somatic sx improve in 2-3 weeks - Sleep patterns improve in 4-6 weeks - Depressed mood and sexual dysfunction improve in 4 weeks - **Common for physical sx to remain after mood has increased

Question 27

Describe when to go to a Dr for depression after hospitalization (starting new med, increasing dose)

Answer 27

Go to doctor if you don’t notice any sx improvement within 2-3 months

Question 28

Describe when to go to emergency for depression after hospitalization (starting new med, increasing dose)

Answer 28

Go to emergency if you experience any suicidal thoughts, any dramatic mood changes, or any serious SE to the drug

Question 29

Describe non pharms for depression after hospitalization (starting new med, increasing dose)

Answer 29

- Diary of symptoms - CBT, psychotherapy - Mindfulness, meditation - Exercise and good nutrition

Question 30

Describe follow up for depression after hospitalization (starting new med, increasing dose)

Answer 30

- I will follow up with you in 1 week to discuss any side effects of the medication - And I will follow up with you in 1-2 months to discuss sx improvement. Unfortunately, it does take time for this medication to work and for you to see improvement, but I am always here to answer any questions you have