Term
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Definition
| A common psych disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration that significantly affects daily functioning |
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Term
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Definition
| A chronic depressed mood, lasting years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate or mild recurrent depressive disorder |
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Term
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Definition
| stable, non-depressed, non-manic mood |
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Term
| Major Depressive Disorder |
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Definition
| At least one episode of >/= 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression |
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Term
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Definition
Five or more of the following symptoms have been present during the same 2 week period: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure
-Depressed mood most of the day nearly every day
-Markedly diminished interest or pleasure
-Weight loss/gain
-Insomnia/hypersomnia
-Psychomotor agitation/retardation
-Fatigue or loss of interest
-Feelings of worthlessness/guilt
-Decreased concentration/indecisive
-Recurrent thoughts of death; suicidal ideation with or w/o a specific plan or a suicidal attempt |
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Term
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Definition
Too little can lead to anxiety
Effects:
-Anxiety
-Sexual dysfunction
-Nausea |
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Term
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Definition
Too much NE can lead to anxiety
Effects:
-Anxiety
-Activating
-tachycardia
-Concentration
-Sexual dysfunciton |
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Term
| Possible Hypotheses for cause of Depression |
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Definition
-Genetics: higher occurrence within families
-Biogenic amine hypothesis:Depression results from decreased levels of 5HT, NE, and/or DA in the synapses and decreased receptors. Antidepressants (AD) help increase the production of receptors
-Neurotransmitter receptor hypothesis: there is altered sensitivity and functioning of neurotransmitter receptors. After initiation of an antidepressant.
-Down regulation of NE receptors
-Desensitization of presynaptic 5HT receptors
-Dysregulation Hypothesis: a decrease in one or more neurotransmitter homeostatic regulatory mechanisms results in unstable and unequal neurotransmitter output.R |
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Term
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Definition
Effects:
-Psychosis
-Activating
-Movement |
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Term
| Risk factors for Depression |
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Definition
Female, widowed, separated, divorced, low-income, substance abuse, first-degree relative with depression
-Medications: reserpine, interferon, beta blockers, clonidine, diuretics, OCs, steroids, isotretinoin
-Psych disorders: substance dependence, panic disorder, generalized anxiety disorder
-Medical conditions: diabetes, cancer, stroke, MI, HIV/AIDS, hypothyroidism, alzheimer's disease, MS, chronic pain, Parkinson's, Huntington's, CHF |
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Term
| Risk factors for Depression |
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Definition
Female, widowed, separated, divorced, low-income, substance abuse, first-degree relative with depression
-Medications: reserpine, interferon, beta blockers, clonidine, diuretics, OCs, steroids, isotretinoin
-Psych disorders: substance dependence, panic disorder, generalized anxiety disorder
-Medical conditions: diabetes, cancer, stroke, MI, HIV/AIDS, hypothyroidism, alzheimer's disease, MS, chronic pain, Parkinson's, Huntington's, CHF |
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Term
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Definition
Stigma associated with many mental illnesses
Not considered a "real illness" that requires treatment
Patients are considered "weak" |
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Term
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Definition
| Improve QOL, decrease symptoms, return to baseline level of functioning, maximize treatment response and minimize ADRs, achieve remission (no symptoms for 6 months/HAM-D score <7), prevent future episodes |
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Term
| Labs that are important in depression |
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Definition
| -TSH, electrolytes, pregnancy test, urine drug screen, renal function, LFTs |
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Term
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Definition
Acute phase:
-Lasts 6-12 weeks
-Achieve response and remission of symptoms
Continuation phase
-Lasts 4-9 months
-Treatment often required through this phase to prevent relapse
Maintenance Phase:
-Lasts 1 year-lifetime
-Goal is to prevent recurrence of depression and achieve recovery |
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Term
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Definition
-Psychotherapy: considered for all patients
-Electroconvulsive therapy (ECT): Last line option, safe and effective
-Bright light therapy: seasonal affective disorder |
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Term
| Black box warning with AD's |
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Definition
| AD's increase the risk of suicidal thinking and behavior compared to placebo, in children, adolescents, and young adults in short-term studies of MDD |
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Term
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Definition
-May take 4-6 weeks
-First (weeks 1-2): improved sleep/appetite, activities of daily living
-Second (weeks 3-4): Increased energy, concentration, memory
-Third (weeks 5-6): Improved mood, decreased suicidal ideation, feel less hopeless/helpless, relief of depression |
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Term
| Tricyclic antidepressants |
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Definition
MOA: Mixed serotonin and norepinephrine reuptake inhibitor. Also has anticholinergic, antihistaminergic, and antiadrenergic effects
Drugs:Tertiary Amines: Amitriptyline (Elavil), Clomipramine (Anafranil), Doxepin (Doxepin)
Secondary Amine: Imipramine (Tofranil), Desipramine (Norpramin), Nortriptyline (Pamelor) |
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Term
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Definition
-Hit all three receptors associated with ADRs. More associated with ADRs
-Anticholinergic, sedation, weight gain, orthostatic hypotension, cardiac abnormalities (QTC prolong), reduce seizure threshold, sexual dysfunction, drug interactions (extensive 2D6 metabolism) |
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Term
| Patient Counseling on TCA's |
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Definition
**TCA overdose can be fatal, use caution in patients with suicidal ideation
-Cholinergic rebound with abrupt d/c of drug., dizziness, nausea, diarrhea, insomnia, restless, utilized for reasons other than depression (migraines) |
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Term
| Selective Serotonin Reuptake Inhibitors (SSRI's) |
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Definition
MOA: inhibit reuptake of serotonin into the pre-synaptic neuron
Drugs:
-Citalopram (Celexa) 20-60mg QD, increase by 20mg q week
-Escitalopram (Lexapro) 10-20mg QD
-Fluoxeine (Prozac, Sarafem) 20-60 mg, increase 20mg q 3 days. Longest half-life, associated with insomnia, weight loss, agitation, not recommended in geriatric patients
-Fluvoxamine (Luvox): 50-300mg/day, not FDA approved for MDD, only good for obsessive compulsive, CYP metabolism
-Paroxetine (Paxil): 20-60mg/day, increase 10mg q week, most anticholinergic SEs, sedation, weight gain, WORST in pregnacy
Sertraline (Zoloft): 50-200mg/day, increase 50mg/week, safe choice in pregnancy/lactation & geriatric pts, associated with GI symptoms, can increase INR |
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Term
Side Effects/ADRs
Drug interaction
Patient counseling |
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Definition
-Increased anxiety initially, sedation/insomnia, sexual dysfunction, stomach upset, headache
-DIs: MAOIs, linezolid, carbamazepine, warfarin
-SSRI withdrawal if abruptly d/c'd, all are preg category C except paroxetine which is category D |
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Term
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Definition
Decrease dose by 25% of total daily dose weekly (except fluoxetine)
Abrupt discontinuation:
-Anxiety/agitation
-Irritability
-Insomnia/fatigue
-Return of depression
-Nausea
-General malaise
-Dizziness/headache |
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Term
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Definition
General points:
-Occurs when there is too much serotonin available in the CNS
-Can be a medical emergency if untreated
-Generally occurs on overdose of serotonergic drugs
Symptoms: fever, spontaneous/inducible clonus, tremor and hyperreflexia, hypertonia, confusion, tachycardia, anxiety, restless, vmiting and diarrhea, increased BP, diaphoresis, coma
-Treatment: stop offending agent, cooling blankets, anticonvulsants, antihypertensives
-Counsel on symptoms of serotonin syndrome |
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Term
| Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) |
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Definition
MOA: Inhibit reuptake of serotonin and norepinephrine
Drugs:
-Venlafaxine (Effexor): 37.5-375mg/day dosed BID-TID, at low doses acts like SSRI, associated with worst withdrawal symptoms, do not take last dose within 6h of bedtime
-Duloxetine (Cymbalta): 40-120mg/day dosed QD-BID, treats neuropathies, not for pt with liver dysfunction, renally adjusted, may increase INR
-Desvenlafaxin (Pristiq): 50-100mg/day, metabolite of venlafaxine
-Milnacipran (Savella): 12.5-200mg/day, not FDA approved for MDD |
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Term
Adverse effects of SNRIs
Key Facts |
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Definition
-Stomach upset, insomnia/sedation, weight neutral or loss of appetite, elevated blood pressure, headache, sexual dysfunction
-NE component often leads to "activating" side effects (Insomnia, weight loss, elevated BP, sweating), abrupt d/c of an SNRI yields similar effects to SSRIs |
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Term
| Bupropion (Wellbutrin, Zyban) |
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Definition
MOA: Inhibit the reuptake of NE & DA (minor effects of 5HT)
-Zyban not FDA approved for MDD
ADRs: Insomnia**, GI upset, Headache, dry mouth, decreases seizure threshold**
Patient counseling: caution with other meds that lower seizure threshold (TCAs & antipsychotics), contraindicated in pts with history of seizures, eating disorders (bulimia or anorexia), alcohol or sedative withdrawal, warning in pts with psychosis, DOC for pts with sexual dysfunction, doesn't alter 5HT concentrations
-Counsel on: activating side effects, emphasize need to avoid alcohol |
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Term
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Definition
MOA: alpha-2 and 5HT2 & 5HT3 autoreceptor antagonists, which results in increased serotonin concentrations. Autoreceptors are present on the presynaptic neuron and once antagonized they allow continued release of neurotransmitter. Alpha-2 receptor blockade will result in increased NE, 5HT2 antagonism will help treat anxiety and insomnia, 5HT3 antagonism will reduce nausea
Dose: 7.5-15mg/day
Adverse effects:
-At low doses (<15mg/day): sedation, increased appetite, dry mouth
-At high doses: insomnia, weight neutral/weight loss, dry mouth |
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Term
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Definition
MOA: Inhibits 5HT & NE reuptake and has 5HT antagonistic properties
Drugs:
-Trazodone (Desyrel): 300-600 mg/day BID OR 50-200mg HS (insomnia), weak AD effects, AD dosing is usually too sedating for patients to tolerate, orthostatic hypotension, priapism
-Nefazodone: removed from market due to hepatotoxicity |
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Term
Trazodone ADRs
Key Facts/Pt counseling |
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Definition
-Orthostatic hypotension/dizziness, sedation, priapism
-Avoid recommending nefazodone, razodone is used as adjunct for insomnia, watch/warn patients about orthostatic hypotension
** Patients may have excessive sedation or they may never experience sedation |
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Term
| Monoamine oxidase inhibitors (MAOI) |
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Definition
MOA: irreversible inhibition of MAO. MAO breaks down 5HT, NE, & DA inside the presynaptic neuron. What isn't broken down by MAO is then place into vesicles for future releases into the synaptic cleft.
-MAO-A primarily metabolizes NE, 5HT, & tyramine
-MAO-B primarily metabolizes DA
Drugs:
-Phenelzine (Nardil): orthostatic hypotension
-Selegiline (Emsam): 6-12 mg/day, patch approved for depression & is selective for MAO-B
-Tranylcypromine (Parnate) |
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Term
| Monoamine oxidase inhibitors (MAOI) |
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Definition
MOA: irreversible inhibition of MAO. MAO breaks down 5HT, NE, & DA inside the presynaptic neuron. What isn't broken down by MAO is then place into vesicles for future releases into the synaptic cleft.
-MAO-A primarily metabolizes NE, 5HT, & tyramine
-MAO-B primarily metabolizes DA
Drugs:
-Phenelzine (Nardil): orthostatic hypotension
-Selegiline (Emsam): 6-12 mg/day, patch approved for depression & is selective for MAO-B
-Tranylcypromine (Parnate) |
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Term
MAOI ADRs
Key Facts/Pt counseling |
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Definition
-Orthostatic hypotension, anticholinergic effects, stomach upset, sexual dysfunction (hypertensive crisis, must follow MAOI diet)
-Rarely used due to dietary restrictions, must wait at least **2 weeks** after discontinuing an MAOI to start another antidepressant & vice versa |
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Term
| Required washout times between AD trials |
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Definition
-To MAOI from drug with long half-life metabolites (fluoxetine): 5 weeks
-To MAOI from drug without long half-life metabolites: 2 weeks
-To non-MAOI from MAOI: 2 weeks |
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Term
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Definition
-Patients should consume a diet low in tyramine
-Foods that contain tyramine: aged cheeses, meats, beer (no keg beer), wine (Chianti or port), smoke/fermented meats, pickled products |
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Term
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Definition
MOA: weak MAOI inhibitory effects and may increase sensitivity of 5HT receptors and inhibit reuptake
-OTC herbal
-Shows superiority to placebo and similar efficacy to TCAs
-MULTIPLE DRUG INTERACTIONS! |
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Term
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Definition
-Atypical antipsychotics: aripiprazole (Abilify) weight gain not common, quetiapine (Seroquel XR): weight gain & very sedating
-Lithium: takes 2-3 days to see initial effects and 3 weeks to see full effect, decreases rates of suicidality, response in non-responders, guidelines say it is first line for augmentation
-Thyroid supplementation: patients with hypothyroidism
-Stimulants: can benefit people with fatigue, decreased concentration, and increased hunger (avoid use in pts on MAOIs) |
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Term
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Definition
SSRIs, SNRIs, bupropion, mirtazapine
-If a patient is responding, but HAM-D >7, increase dose or add another 1st line option/antipsychotic/lithium
-No response, change to a new medication
-Failure to respond to a drug in one class does not suggest class failure
-Failure to respond to 2 classes, switch classes
-MAOI is last line option |
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Term
| Switching Antidepressants |
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Definition
1. Directly switch from one AD to another
2. Cross-taper- slowly decrease the dose of first AD at the same time slowly increase the dose of the new AD
3. Washout period- D/C first AD, wait an appropriate period of time, the titrate the new AD |
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Term
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Definition
-SSRI to SSRI
-SSRI to SNRI
-SNRI to SSRI (except fluoxetine and paroxetine)
-SNRI to SNRI (<150mg venlafaxine or <60mg duloxetine) |
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Term
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Definition
-SSRI to TCA
-SNRI to SSRI
-SNRI to SNRI (>150mg venlafaxine or <60mg duloxetine)
-Mirtazapine to AD (except MAOI)
-AD (except MAOI) to mirtazapine
-Bupropion to AD (except MAOI)
-AD to Bupropion (except MAOI) |
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Term
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Definition
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Term
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Definition
-First major depressive episode treat at least 6-12 months
-Two or more: treat for 15 months to 5 years
-Lifelong therapy is left to prescriber's discretion |
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Term
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Definition
-Prepare patient for delayed onset of action
-Emphasize compliance and warn against abrupt discontinuation
-Patients should avoid alcohol while taking medications: can lead to insomnia, can lower the seizure threshold
-Discuss serotonin syndrome if appropriate |
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Term
| Considerations when making recommendations |
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Definition
-Medication history, preferences, and response
-History of first-degree family member's response
-Current presentation of symptoms and adverse effects
-Possible drug interactions
-History of suicidal attempts or current suicidal ideation
-Compliance
-Economic considerations |
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