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PT - test 4
Major Depressive Disorder
30
Pharmacology
Graduate
11/07/2009

Additional Pharmacology Flashcards

 


 

Cards

Term
What is the Epidemiology of Depression?
Definition

- Lifetime prevalence > 16%, 6% had episode last year

- Women are more affected than men

- Can occur at any time, mostly ages between 18-29

- Specific factors account for 63%, genetic is 37%

Term
What is the Pathophysiology of Depression?
Definition

- Biogenic amine hypothesis (decreased NE, DA, 5-HT)

- Failure of homeostatic regulation of neurotransmitter systems

- No real biological markers

- Increased cortisol, (+) dexamethasone suppression test

- Hypothyroidism

Term
Depression could be a disorder or a symptom.  In what disease states could it be a symptom?
Definition

- CV conditions

- Neurological: Dementia, Migraine, Seizures

- Endocrine

- Hormonal conditions

- Autoimmune

- Medications:  Hormones, antihypertensives

Term
What are some co-morbid conditions of depressive disorder?
Definition

- Substance abuse

- Anxiety Disorder

Term
What could be some emotional symptoms of major depressive disorder?
Definition

- Anhedonia (Decreased interest)

- Sadness

- Hopelessness

- Anxiety

- Guilt

- Suicidal ideation

Term
What could be some intellectual symptoms of major depressive disorder?
Definition

- Decreased concentration

- Slowed thinking

- Poor memory

 

Term
What could be some psychomotor symptoms of major depressive disorder?
Definition

- Speech changes

- Thought process

- Decreased movement

- Lack of energy

- Pain

- Insomnia

- Appetite changes

- Weight changes

- GI complaints

- Palpitations

- Decreased Libido

Term
What is a good pneumonic device regarding the symptoms of depressive disorder?
Definition

SIG-E-CAPS

 

- Sleep disoder

- Interest deficit

- Guilt

- Energy Deficit

- Concentration deficit

- Appetite disorder

- Psychomotor retardation or agitation

- Suicidality

Term
First line antidepressants could show side effects that include Sedation, GI effects, insomnia, weight gain, and sexual dysfunction.  What classes/drugs stand out in this regard?
Definition

Class/Generic

Brand

ACh

Sedation

GI

Insomnia

Dysfn

Wt gain

SSRI

 

 

 

 

 

 

 

Citalopram

Celexa

 

+

++

+

++*

 

Escitalopram

Lexapro

 

+

++

+

++*

 

Fluoxetine

Prozac

 

 

+++

+++

++*

 

Fluvoxamine

Luvox

 

 

++

+

++*

 

Paroxetine

Paxil

+

+

++

+

++*

++

Sertraline

Zoloft

 

 

++

++

++*

 

SNRI

 

 

 

 

 

 

 

Venlafaxine

Effexor

 

+

++

+

+

 

Desvenlafaxine

Pristiq

 

+

++

+

+

 

Duloxetine

Cymbalta

+

+

++

+

+

0

Tricyclics Secondary Amines

 

 

 

 

 

 

Desipramine

Norpramin

++

++

 

 

 

Term
Which first line antidepressants are big substrates, inducers, or inhibitors of liver enzymes, and what are the significant black box warnings?
Definition

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
ECT
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
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Term
What is the treatment algorithm if there is a partial response in the acute phase?
Definition
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Term
What is the treatment algorithm in the maintenance phase?
Definition
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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

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