depression and bipolar disorder therapeutics Flashcards
questionnaires to evaluate depression
PHQ-2
PHQ-9
response to treatment is defined as
50% reduction in baseline score of PHQ-9
70-75% reach this
remission of depression defined as
-normal PHQ scores under 5
-symptom free for 2 months
(only 30% reach this)
SSRI drugs
fluoxetine sertraline paroxetine citalopram escitalopram fluvoxamine
SSRI with longest half life
fluoxetine
best tolerated SSRIs
sertraline and escitalopram
general SSRI side effects
- nausea
- GI irritation
- diarrhea (remits after 1 week)
- headache
- sexual dysfunction
side effects unique for fluoxetine
- anxiety/activation
- insomnia
side effects unique for sertraline
- anxiety/activation
- insomnia
side effects unique for paroxetine
- sedation
- weight gain
- anticholinergic effects
side effects unique for fluvoxamine
sedation
side effects unique for citalopram
QT prolongation
how to deal with GI side effects of SSRIs
- usually self limiting
- manage by slow titration and take with food
how to deal with activation/anxiety effects in SSRIs
- manage by titration
- take in morning
- bridge with benzo
how to deal with insomnia side effects from SSRIs
- take in morning
- add trazodone, mirtazapine, TCA at bedtime
how to deal with sedation effects from SSRIs
take at bedtime
how to deal with sexual dysfunction from SSRIs
- add/switch to bupropion
- add mirtazapine
- switch to nefazodone
- patients (may improve in 2-4 weeks)
- add PDE-5 inhibitors
how to deal with weight gain from SSRIs
-possibly switch to bupropion
SSRI with highest weight gain rate
paroxetine
time in SSRI therapy suicidal risk increases the most
weeks 1-3
unusual SSRI side effects
- hyponatremia
- EPS
- sweating
- bleeding
- triggering manic episodes
discontinuation syndrome symptoms
- Flu-like symptoms
- Insomnia
- Nausea
- Imbalance
- Sensory disturbances
- Hyperarousal
serotonergic medications that can cause serotonin syndrome when used with SSRIs/SNRIs
MAOI linezolid tramadol buspirone triptans dextromethorphan
treatment for serotonin syndrome
- go to ER
- discontinue offending agent
- supportive care
how long do you have to be off SSRI to have discontinuation syndrome
24-48 hours after
least common drug to have discontinuation syndrome
fluoxetine because of the long half life
advantages of venlafaxine/desvenlafaxine
also works well for anxiety disorders and neuropathic pain
adverse effects of venlafaxine/desvenlafaxine
- diarrhea
- N/V at low doses
- hypertension at high doses
advantages of duloxetine
works for neuropathic pain often used for diabetes
adverse effects of duloxetine
- diarrhea, nausea
- anticholinergic effects
- increased heart rate
- small changes in BP
bupropion MoA
NE/DA reuptake inhibitor
advantages of bupropion
- useful for add on for sexual dysfunction
- can be used in smoking cessation
bupropion adverse effects
- nausea
- dizziness
- tremor
- insomnia
- anxiety
- rarely increased seizures
trazodone MoA
5-HT2A antagonist
serotonin reuptake inhibitor
advantages of trazodone
can be added on to SSRIs for insomnia
adverse effects of trazodone
- orthostatic hypotension
- priapism
main adverse effect for nefazodone
liver toxicity
nefazodone use
for sexual dysfunction
mirtazapine advantages for its 2 serotonin activities
- from 5-HT2A, treats insomnia, sexual dysfunction
- from 5HT3 anti-emetic effect
adverse effect of mirtazapine
weight gain at lower doses
advantages of TCAs
-can be used to treat neuropathic pain and insomnia
adverse effects of TCAs
- anticholinergic
- neurologic
- cardiovascular
- weight gain
- sexual dysfunction
- cholinergic rebound if stopped abruptly
TCAs with tertiary amines
amitriptyline
imipramine
doxepin
clomipramine
TCAs with secondary amines
nortriptyline
desipramine