Term
| Medical Disorders Associated with Depression |
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Definition
| hypothyroidism, Cushing's Syndrome, AIDS, HIV, encephalitis, STDs, TB, Alzheimer's, epilepsy, Huntington's Dx, MS, pain, Parkinson's Dx, post-stroke, CAD, CHF, MI, RA, lupus, cancer |
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Term
| Medications associated with Depression |
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Definition
| reserpine, CLONIDINE, diuretics, hydralazine, methyldopa, propanolol, diltiazem, oral contraceptives, steroids, isotretinoin, theophylline, metoclopramide, NSAIDs, digoxin, interferon, leuprolide, EtOH, marijuana, nicotine dependence, opiates, cocaine |
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Term
| DSM-IV Criteria for Major Depression |
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Definition
1) 5 or more of following during same 2 wk period & represents a change from previous functioning. At least one of five must be DEPREESED MOOD or ANHEDONIA: depressed mood, anhedonia, significant weight changes, appetite changes, insomnia/hypersomnia, psychomotor agitation, fatigue, loss of energy, feelings of worthlessness, diminished ability to think or concentrate, recurrent thoughts of death;
2) These symptoms cause significant distress or impairment;
3) Symptoms are NOT due to direct physiological effects of a substance or medical condition
4) Symptoms are NOT better accounted for by bereavement
5) Symptoms do NOT meet criteria for a Mixed episode |
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Term
| Factors that Increase Risk of Suicide |
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Definition
| elderly; history of prior attempts; living alone; substance abuse; anniversary of a loss; unemployment; family history; lack of a support system; feelings of hopelessness |
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Term
| Goals of Tx of Depression |
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Definition
| reduce depressive symptoms; return pt to optimal level of functioning |
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Term
| Nonpharmacological Treatment of Depression |
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Definition
| psychotherapy; ECT (electro convulsive therapy); light therapy; vagal nerve stimulation |
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Term
| Pharmacological Treatment of Depression |
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Definition
Effects take 2-4 wks after initial dose to be seen;
ADRs occur right away but improve over 4 wks;
Titrate SLOWLY to adequate recommended dose, Taper SLOWLY upon D/C;
Risk of Serotonin Syndrome associated w/ concurrent use of meds that increase level of 5-HT;
Black Box Warning:
increased risk of suicidal ideation in children, adolescents, & young adults; |
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Term
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Definition
| symptoms: confusion, agitation, GI distress, hyperthermia, HTN, tachycardia, tremor, ataxia, seizures, coma |
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Term
| FDA recommendations for MD visits after Initiation of Antidepressants |
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Definition
| Pt should be seen weekly x 4 wks, then every other wk x 4 wks, then as clinically indicated beyond 12 wks |
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Term
Tricyclic Antidepressants (TCAs) - 3 amines = amitriptyline [Elavil], clomipramine [Anafranil], doxepin [Sinequan], imipramine [Tofranil], trimipramine [Surmontil];
2ndary Amines: desipramine [Norpramin], nortriptyline [Pamelor], protriptyline [Vivactil] |
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Definition
drugs that block reuptake of 5-HT, NE, & DA;
Indications: depression, obsessive compulsive disorder (clomipramine), enuresis in children (imipramine), also: trigeminal neuralgia, diabetic neuropathy, migraine prophylaxis;
2ndary amines preferred over tertiary amines --> less sedation, orthostasis, or anticholinergic side effects;
2nd line agents for tx of depression |
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Term
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Definition
anticholinergic effects, antihistaminergic effects, alpha-2 adrenergic blockade, cardiac conduction delays, drowsiness, weakness, fatigue, lethargy, excessive perspiration, sexual dysfunction, seizures, weight gain;
If taken with bupropion --> increased risk of seizures
if taken with EtOH --> increase CNS depressant effects
if taken with quinolones --> cardiac arrhythmias
if taken with MAOIs, SSRIs --> serotonin syndrome |
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Term
| Drugs that Increase TCA drug levels |
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Definition
| SSRIs, valproic acid, quinidine, cimetidine, other CYP inhibitors |
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Term
| Drugs that Decrease TCA drug levels |
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Definition
| barbiturates, carbamazepine, rifampin, smoking, other CYP inducers |
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Term
| venlafaxine (Effexor, Effexor XR) |
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Definition
SNRI; Indications: depression, GAD, SAD, PD; - 1st line option
MoA: potent inhbitor of 5-HT & NE reuptake, weak inhibitor of DA reuptake
PKs:
metabolized by CYP 2D6,
active metabolite formed
Dosing:
Starting - 75 mg/day, increase by 37.5-75 mg q4-7 days
Target Dose: 150 mg/day
MAX dose = 375 mg/day IR, 225 mg ER
ADRS:
HA, insomnia, sexual dysfunction, somnolence, dry mouth, nausea, constipation, dose-related increases in BP
Drug Interactions:
serotonin syndrome w/ MAOIs, SSRIs, TCAs
increased levels with cimetidine |
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Term
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Definition
SNRI; Indication: depression
extended-release product, active metabolite of venlafaxine;
Dose: 50 mg daily (start), MAX = 400 mg/day
Pregnancy Cat. C
ADRs:
insomnia, dizziness, dry mouth, nausea, constipation, diarrhea, sweating |
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Term
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Definition
SNRI; Indications: depression, diabetic neuropathic pain, GAD, fibromyalgia - 1st line
Dosing:
Starting dose - 20 mg BID
Target dose - 60 mg BID
PKS:
metabolized by CYP 2D6, 1A2
ADRs:
HA, insomnia, sexual dysfunction, fatigue, dizziness, dry mouth, NAUSEA, constipation, diarrhea
Monitor:
LFTs
Preg. Cat. C
Drug Interactions:
Increased INR if on warfarin
risk of serotonin syndrome
increased drug levels if taking with cimetidine, ciprofloxacin |
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Term
| amitriptyline [Elavil], doxepin [Sinequan], imipramine [Tofranil], trimipramine [Surmontil] |
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Definition
tertiary amines (TCAs) used for depression;
Initial Dose = 25-50 mg
Usual Dose per day = 100-300 mg |
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Term
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Definition
TCA - secondary amine used for tx of depression
Initial Dose: 25-50 mg
Usual Daily Dose: 100-300 mg |
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Term
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Definition
2ndary amine TCA used for tx of depression;
Initial Dose: 25 mg
Usual Daily Dose: 50-150 mg |
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Term
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Definition
2ndary amine TCA for tx of depression;
Initial dose: 5-10 mg
Usual Daily Dose: 15-60 mg |
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Term
| SSRIs - fluoxetine [Prozac], paroxetine [Paxil], sertraline [Zoloft], citalopram [Celexa], escitalopram [Lexapro], fluvoxamine [Luvox] |
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Definition
most commonly used 1st line antidepressant;
MoA: 5-HT reuptake blockade
ADRs:
nausea, HA, sleep disturbances, anxiety, sexual dysfunction, tremor, sweating
Drug Interactions:
risk of Serotonin Syndrome with tramadol, triptans, sibutramine, St. John's wort, MAOIs, TCAs, Li;
Increased effects of phenytoin, valproic acid, alprazolam, diazepam, haloperidol, clozapine;
Increased INR on warfarin
Overdose NOT likely to be lethal; |
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Term
| fluoxetine [Prozac, Prozac Weekly, Sarafem] |
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Definition
FDA indications:
depression, bulimia nervosa, PD, OCD, PMDD
Dosing:
Start - 20 mg daily
Max - 80 mg/day
Weekly formulation - 90 mg
Pregnancy Cat. C;
Potent CYP2D6 inhibitor
Half-life = 2-3 days
Active metabolite's half-life = 7-9 days
ADRs:
activating drug --> more insomnia, agitation |
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Term
| paroxetine [Paxil, Paxil CR, Pexeva] |
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Definition
FDA indications: depression, GAD, PD, OCD, SAD, PTSD, PMDD
Dosing:
IR Start - 20 mg daily
IR Max - 50 mg/day
ER Start - 25 mg daily
ER Max - 62.5 mg/day
PK:
half-life = 24 hrs
potent CYP2D6 inhibitor
ADRs:
more sedating, fatigue, weight gain
Preg. Cat. D |
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Term
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Definition
FDA indications: depression, PD, OCD, SAD, PTSD, PMDD
Dosing:
Start - 50 mg/day
Max - 200 mg/day
PKs:
less potent CYP2D6 inhibitor
half-life = 24 hrs
ADRs:
activating --> more insomnia, GI upset |
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Term
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Definition
FDA indications: depression
Dosing:
Start - 20 mg/day
Max - 60 mg/day
SSRI that is least likely to cause drug interactions |
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Term
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Definition
FDA indications: depression, GAD
Dosing:
Start - 10 mg/day
Max - 20 mg/day
Pk:
Half-life = 24 hrs
Drug interactions least likely to occur with this drug |
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Term
| fluvoxamine [Luvox, Luvox CR] |
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Definition
FDA indication: OCD, SAD
Dosing:
IR Start - 50 mg/day
IR Max - 300 mg/day
CR Start - 100 mg/day
CR Max - 300 mg/day
More sedating SSRI |
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Term
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Definition
triazolopyridine - 5-HT2 receptor antagonist, 5-HT reuptake inhibitor, & alpha-adrenergic blocker;
Indication: depression, sedative-hypnotic
Depression dose:
Start - 50 mg/day, increased by 50 mg/day every 3-7 days
Max - 600 mg/day
Dosed BID-TID
Sleep Aid Dose:
Initial - 50 mg qHS, increase as needed (up to 200 mg)
Half-life = 3-6 hrs
ADRs:
HA, SEDATION, ORTHOSTATIC HYPOTENSION, somnolence, dry mouth, nausea, constipation, priapism
Preg. Cat. C
Drug Interactions:
risk of serotonin syndrome; increased effects of phenytoin, digoxin; decreased levels due to carbamazepine; hypotension with antipsychotics; increased sedation with CNS depressants, EtOH |
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Term
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Definition
triazolopyridine - 5-HT2 receptor antagonist, 5-HT reuptake inhibitor, histamine & alpha-adrenergic blocker;
Indication: depression
Dosing:
Start - 100 mg BID, increase by 100 mg/wk
Target - 300-600 mg/day in divided doses
Food decreases absorption & bioavailibility
ADRs:
HA, SEDATION, ORTHOSTATIC HYPOTENSION, somnolence, dry mouth, nausea, constipation, priapism
BLACK BOX WARNING: HEPATOTOXICITY
Drug Interactions:
POTENT CYP3A4 inhibitor
Increases effects of amiodarone, lidocaine, propafenone, triazolam, alprazolam, protease inhibitors, digoxin, statins;
decreased levels with carbamazepine
risk of serotonin syndrome |
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Term
| bupropion (Wellbutrin, SR, XL, Budeprion SR, XL, Zyban, Buproban) |
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Definition
Indications: depression, seasonal affective disorder, smoking cessation;
1st line (more activating)
MoA: DA reuptake inhibition
ADRs:
HA, anxiety, INSOMNIA, dizziness, dry mouth, tachycardia, N/V, tremor
Preg. Cat. C
Contraindications:
Pts w/ seizure disorder, bulimia
Drug Interactions:
Levodopa, cimetidine increase effects
Carbamazepine, phenytoin, phenobarbital decrease effects
Dosing:
Initial IR - 100 mg BID
Initial SR, XL - 150 mg daily
Therapeutic Dose - 300-450 mg/day (IR & SR have divided dosing)
Increase dose after 3 days
Max Dose IR, XL = 450 mg/day
Max Dose SR = 400 mg/day |
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Term
| mirtazapine (Remeron, Remeron Soltab) |
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Definition
Indication: depression
1st line (questionable)
MoA: blocks 5-HT2 & 5-HT3 receptors
Dosing:
Initial - 15 mg HS
Therapeutic - 15-45 mg/day
Max - 45 mg/day
Low doses cause activation, High doses causes activation;
ADRs:
sedation, increased appetite, weight gain, constipation, dry mouth, increased lipids, increased LFTs, agranulocytosis, neutropenia
Monitor: LFTs, CBC |
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Term
| non-selective MAO-Is - phenelzine (Nardil), tranylcypromine (Parnate) |
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Definition
MoA: increase conc. of NE, 5-HT, DA within neuronal synapse by inhibiting MAO
3rd line option for depression
Risk of hypertensive crisis with tyramine containing foods & beverages |
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Term
| MAOB-I - selegiline (Emsam) |
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Definition
Indication: depression (3rd line)
MoA: selectively inhibits MAO-B
Transdermal patch system
Initial & Target dose: 6 mg/24 hr
Max dose: 12 mg/24 hr
ADRs:
HA, insomnia, dizziness, nausea, applications site rxn |
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Term
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Definition
MoA: weak MOA-I & serotonergic properties
ADRs:
insomnia, vivid dreams, restlessness, anxiety, agitation, irritability, GI upset, dry mouth, dizziness, HA, photo dermatitis
Interactions:
CYP inducer - it decreases conc. of OCPs, warfarin, digoxin
Risk of serotonin syndrome
Dose: 300 mg TID |
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Term
| Activating Antidepressants |
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Definition
| fluoxetine, sertraline, most SSRIs, bupropion, duloxetine, venlafaxine |
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Term
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Definition
| paroxetine, fluvoxamine, trazadone, mirtazapine, TCAs |
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Term
| Antidepressants that cause Sexual Dysfunction |
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Definition
| TCAs, SSRIs, SNRIs, venlafaxine, mirtazepine |
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Term
| Antidepressants that cause Weight Gain |
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Definition
| TCAs, SSRIs, venlafaxine, mirtazepine |
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Term
| Antidepressants with Potential for Hepatotoxicity |
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Definition
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Term
| Patient Counseling on Antidepressants |
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Definition
May take 2-4 wks to see any benefits;
Drug must be taken as prescribed, NOT PRN!
Duration of therapy will be 6-12 months after response;
Continue to use drug after symptoms of dx have improved, DO NOT stop taking without alerting MD |
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Term
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Definition
atypical antipsychotic with new FDA indication as adjunctive therapy for depression
Dose: 2-15 mg/day |
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