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Therapeutics Neuro Gable
Exam 2 Depression
54
Accounting
5th Grade
08/27/2010

Additional Accounting Flashcards

 


 

Cards

Term
Monoamine Hypothesis
Definition
Decrease synpatic concentrations of NE, 5-HT, and DA
Term
Dysregulation Hypothesis
Definition
  • Dysregulation of NT receptors resulting in pre- and post-synaptic receptors
  • This helps explain the delay in AD effect
  • 5-HT system targeted in this theory
  • Changes in pre- and post-synaptic receptor density (sensitivities) is described as being "down-regulated"

 

Term
Endocrine Hypothesis
Definition
  • Thyroid and hypothalamic pituitary axis dysregulated
  • If levothyroxine doesn't work, they need to be on Antidepressant therapy

 

Term
NT Deficiencies
Definition

5-HT

 

depressed mood, anxiety, panic, phobia, obsessions/compulsions, food craving

 

DA

 

anhedonia, decreased energy, poor memory/cognition, impaired attention

 

NE

 

impaired attention, problems concentrating, deficiencies in working memory, slowness of information processing, depressed mood, psychomotor retardation, fatigue

Term
Major Depressive Epidsode
Definition

- A period of at least 2 wks in which pt exhibits depressed mood and/or anhedonia

 

> 5 out of 9 symptoms:

  • changes in weight
  • sleep
  • psychomotor agitation or retardation
  • loss of energy (small tasks)
  • feeling of worthless/guilt
  • difficulty concentrating and making decisions
  • SI (life is not worth living, ppl would be better off if I were gone)

-Symptoms do not meet criteria for mixed episode

-Must impair social or occupational areas of functioning

-Not due to substance abuse or general medical conditions

-Not due to bereavement -- loss of loved one in the past two months

-MDD = > Major Depressive Episode

-The episode has ended when the full criteria for the major depressive episode have not been met for at least 2 conescutive months

-R/o mania or hypomania

 

Term

3 Cardinal Signs of Atypical Depression

 

Definition
  1. Overeating
  2. Hypersomnia
  3. Leaden paralysis
Term
Depressive Disorder Specifiers
Definition
  • Mild, moderate, severe
  • Psychotic features
  • Catatonic features
  • Melancholic features
  • Atypical features
  • Postpartum features
Term
Dysthymic Disorder
Definition

Less severe symptoms --> more chronic and persistent

  • Depressed mood is present for > 2 years
  • During period of depressive mood, must exhibit > 2 of the following: change appetite, sleep, low energy, low self-esteem, poor concentration, hopelessness
  • Cannot be w/o symptoms for > 2 mo period
  • The disturbance is not better accounted for by chronic MDD or MDD in partial remission and there has never been a manic episode
Term
Causes of Depression: Medications
Definition

Cardiovascular Agents

methyldopa, reserpine, clonidine, beta-blockers

 

Sedatives Hypnotics

EtOH, benzodiazepines, barbiturates, chloral hydrate

 

Analgesics

Opioids

 

Hormones

corticosteroids, progesterone, estrogen withdrawal, anabolic steroids

 

Others

interferon, accutane, withdrawal from stimulants

Term
Causes of Depression: Medical
Definition

Biological:

  • stroke
  • hypothyroidism
  • anemia
  • Parkinsons disease
  • premenstrual dysphoria
  • syphilis
  • lupus

Psychological reaction:

  • chronic pain
  • HIV/AIDS
  • cancer
  • diabetes
  • CHF

 

Term
ECT: Indications, ADRs
Definition

Indications

Major depression, tx-resistant depression, depression w/ psychosis, depression in pregnancy

6-12 tx usually required, admin 2-3 wk

Response in 1st 1-2 wks, follow-up w/ pharmacotherapy

 

ADRs

HA, cognitive, impairment, confusion, memory impairment (anterograde, retrograde amnesia), muscle soreness

Term
ECT: Medications Used
Definition
  • Glycopyrrolate -- to reduce airway secretions
  • Short-acting barbiturate -- anesthesia
  • Succinylcholine -- muscle relaxant
  • Nifedipine or esmolol -- antihypertensive -- control for increase in pulse and BP
Term
St. John's Wort: MOA, Drug Interactions
Definition

MOA

Affinitiy for:

GABA-a and GABA-b

5-HT1, 5-HT3, and 5-HT4 antagonism

5-HT reuptake inhibition

 

Drug Interactions

CYP2C9/3A4 inducer; 1A2 inducer (mild)

Reports of decreased serum concentrations of OC, theophylline, warfarin, protease inhibitors

Serotonin Syndrome

Term
MAOIs: Indications, ADRs
Definition

Indications

refractory and atypical depression

 

ADRs

Orthostatic hypotension, bradycardia, insomnia, weight gain, sexual dysfunction, dry mouth, constipation

Term

MAOI Drug Interactions

 

Definition
  • Meperidine -- circulatory collapse
  • Sympathomimetics -- HTN crisis (amphetamines, pseudoephedrine, methylphenidate)
  • Serotonergic agents: Serotonin syndrome -- Dextromethorphan, Buspirone, SSRIs/SNRIs, TCAs
Term
MAOI: Contraindications
Definition
  • Pheochromocytoma
  • Hepatic or renal dysfunction
  • Cardiovascular disease or defect
  • Excessive caffeine use
  • Elective surgery
  • Sympathomimetic therapy
  • SSRIs (2 week wash-out, 5 weeks for fluoxetine)
Term
TCAs: Indications
Definition
  • Major depression
  • Neuropathic pain
  • Anxiety disorders (OCD, panic disorder)
  • Enuresis
Term
TCAs: Secondary Amines
Definition
  • Desipramine
  • Nortriptyline
  • Protriptyline
Term

TCAs: Secondary Amines

MOA

Definition

NE and 5-HT Reuptake Inhibitors

  • H1, ACh, and Alpha1 blockade
  • Primary effects on NE
  • Better tolerated than tertiary amines
Term
TCAs: Tertiary Amines
Definition
  • Amitriptyline
  • Imipramine
  • Clomipramine
  • Doxepin
  • Trimipramine
Term

TCAs: Tertiary Amines

MOA

Definition

NE and 5-HT Reuptake Inhibitors

  • H1, ACh, and Alpha1 blockade
  • Primary effects on 5-HT
Term

TCAs: Secondary Amines

Plasma Levels

Definition

50-150 ng/mL

Toxic > 500 ng/mL

Term

TCAs: Tertiary Amines

Plasma Levels

Definition

250 ng/mL

Toxic > 500 ng/mL

Term
TCAs:ADRs
Definition
  • Anti-ACh Side Effects
  • Sedation, weight gain, sexual dysfunction
  • Decrease in seizure threshold
  • Cardiovascular: orthostasis, tachycardia, ST depression, T-wave flattening, QRS prolongation, QTc prolongation, ventricular fibrillation, lethal overdose
  • Avoid in: elderly, prostatic hypertrophy, narrow angle glaucoma, erectile dysfunction, memory impairment
Term
When Discontinuing a TCA:
Definition
Taper pts off to avoid cholinergic rebound (SLUD)
Term
SSRIs
Definition
  • Fluoxetine
  • Sertraline
  • Paroxetine
  • Fluvoxamine
  • Citalopram
  • Escitalopram
Term
Fluoxetine: ADRs
Definition
  • Nausea
  • Insomnia
  • Headache
  • Sexual dysfunction
Term
Sertraline: ADRs
Definition
  • Nausea
  • Diarrhea
  • Insomnia or sedation
  • Sexual dysfunction
  • More GI upsets than other SSRIs
Term
Paroxetine: ADRs
Definition
  • Constipation
  • Dry mouth
  • Weight gain
  • Nausea
  • Headache
  • Sexual dysfunction
Term
Fluvoxamine: Indications
Definition
Only SSRI indicated for OCD (> 6 yo)
Term
Fluvoxamine: ADRs
Definition
  • Sedation
  • Nausea
  • Headache
  • Sexual dysfunction
  • Drug interactions more common
Term
Citalopram: ADRs
Definition
  • Nausea
  • Headache
  • Sedation or Insomnia
  • Sexual dysfunction
Term
Escitalopram: ADRs
Definition
Fewer than the other SSRIs
Term
Discontinuation Syndrome
Definition
  • Anxiety
  • Agitation
  • Irritability
  • Sleep disturbances
  • Dizziness
  • Nausea
  • Paresthesias (usually occurs 1-3 days after d/c SSRI; lasts up to 2 wks)
  • Worst with paroxetine, fluvoxamine, venlafaxine (shortest t1/2)
  • Taper ALL SSRIs slowly at 5-7 day intervals (except fluoxetine)
Term
Serotonin Syndrome
Definition

Medications:

  • SSRIs
  • MAOIs
  • Clomipramine
  • DXT
  • Meperidine
  • TCAs
  • Lithium
  • SAM-e
  • St. John's Wort
  • Trazadone
  • Buspirone
  • Triptans
  • Linezolid
  • Tramadol

Symptoms:

  • confusion/delirium (mental status changes)
  • agitation
  • GI (abdominal pain, NVD)
  • Tremor
  • Restlessness
  • Hyperreflexia
  • HTN
  • Tachycardia
  • Fever
  • Diaphoresis
  • Myoclonus
  • Rigidity

Tx:

  • Avoid combos if possible
  • Allow appropriate wash-out periods (2 wks)
  • D/c offending agents if observed
Term
SSRIs: Adverse Effects
Definition

Sedation

Fluvoxamine > paroxetine > sertaline > es/citalopram > fluoxetine

  • NVD -- esp. sertraline
  • HA, anxiety, insomnia
  • Hyponatremia
  • Prolonged bleeding (decreased platelet aggregation)
  • Sexual dysfunction (anorgasmia, delayed ejaculation, decreased libido, impaired erection)
Term
Trazadone: MOA, ADRs
Definition

MOA

  • Blocks 5-HT reuptake
  • Postsynaptic 5-HT2a antagonist
  • H1 antagonist

ADRs

  • Sedation
  • Orthostasis
  • Priapism!
Term
Nefazodone: MOA, ADRs
Definition

MOA

  • Blocks 5-HT reuptake
  • postsynaptic 5-HT2a antagonist
  • Better tolerated than trazadone

ADRs

Liver failure -- unpredictable

3A4 inhibitor -- lots of drug rxs

Term
Buspirone: MOA, ADRs, CIs
Definition

MOA

Inhibits DA and NE (minimal) reuptake

 

ADRs

HA, insomnia, nausea, agitation, seizure, weight loss

NO SEXUAL DYSFUNCTION!

 

CI

Epileptics, Active Eating Disorders, Chronic Alcoholism

Term
When choosing a formulation of Buspirone:
Definition

Choose QD -- Wellbutrin XL

It's a stimulating drug -- give in AM and no later than 4 pm

Term
Venlafaxine: ADRs
Definition
  • Nausea
  • HA
  • Insomnia
  • Sweating
  • Sexual dysfunction
  • Increased diastolic BP (dose-related > 225 mg/day)
Term
SNRIs: MOA
Definition
5-HT and NE Reuptake Inhibitors
Term
SNRIs
Definition
  • Venlafaxine
  • Desvenlafaxine
  • Duloxetine
  • Milnacipran

 

Term
Duloxetine: ADRs
Definition
  • Nausea
  • Insomnia
  • HA
  • Dry mouth
  • Constipation
  • Sweating
  • Sexual dysfunction
  • Hepatotoxicity
Term
Duloxetine: Indications
Definition
  • Depression
  • Diabetic neuropathy
  • Fibromyalgia
Term
Milnacipran: Indications
Definition
  • Depression
  • Fibromyalgias
Term
Mirtazapine: MOA, ADRs
Definition

MOA

  • Increases 5-HT and NE release
  • Blocks post-synaptic 5-HT2/3
  • Inhibits presynaptic alpha2  and H1 receptors

 

ADRs

  • Sedation
  • Increases appetite
  • Weight gain
  • Dizziness
  • Less sexual dysfunction
  • May increase triglycerides, cholesterol
Term
Choosing an Antidepressant: Refractory Depression
Definition

MAOIs

Mirtazapine

TCAs

Term
Choosing an Antidepressant: Psychosis
Definition
AVOID bupropion and Venlafaxine
Term
Choosing an Antidepressant: Significant nausea/cancer/HIV
Definition
Mirtazapine
Term
Choosing an Antidepressant: High Suicide Risk by OD
Definition

Trazadone (safest)

SSRIs

 

Term
Choosing an Antidepressant: Intolerable Sexual Dysfunction
Definition

Mirtazapine

Bupropion

Nefazadone

Term
Treatment Resistant Depression
Definition
  • Continue at therapeutic dose 4-6 wks
  • Try dual mechanism antidepressant (mirtazapine, venlafaxine, MAOIs)

Augmentation Strategies:

  • Thyroid Hormone
  • Lithium
  • Aripiprazole
  • ECT -- esp for pregnant pts, suicidal pts

 

Term
Antidepressants and Pregnancy
Definition
  • Fluoxetine is most well-studied
  • SSRIs are Pregnancy Category C -- paroxetine recently moved to Cat. D -- may increase risk of fetal heart defects
  • Infant Exposure to SSRIs: Increased risk to develop restlessness, tremors, and irritability, pulmonary HTN (rare)
  • Untreated depression in pregnancy: suicide risk, poor prenatal care, postpartum depression
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