PHRM 845 > Depression > Flashcards

Depression Flashcards

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1
Q

How does risk of recurrence change as duration of remission increases?

A

Risk of recurrence becomes lower over time as duration of remission increases.

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1
Q

Describe the risk of recurrence for depression:

A
  • After one episode, there’s a 50-60% chance of having another episode
  • after two episodes, 70% chance
  • after three episodes, 90% chance
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2
Q

What is a predictor of recurrence?

A

persistent, mild symptoms during remission is a predictor of recurrence

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3
Q

How does a patient’s functioning change throughout recurrence and remission?

A

Function deteriorates during the episode and goes back to baseline upon remission

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4
Q

What is the DSM-5 diagnostic criteria for depression?

A
  • Must have greater than 5 symptoms within 2 week period
  • at lease one of the symptoms must be depressed mood or loss of interest or pleasure in doing things
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5
Q

What are the diagnostic symptoms of depression?

A
  • Sleep (insomnia/hypersomnia)
  • Interest decreases (anhedonia)
  • Guilt/worthlessness
  • Energy loss/fatigue
  • Concentration difficulties
  • Appetite change (up or down)
  • Psychomotor agitation/retardation
  • Suicidal ideation

SIGE CAPS

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6
Q

What are the characteristics of depression with anxious distress?

A
  • higher suicide risk
  • longer duration of illness
  • poor treatment response
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7
Q

What are the characteristics of depression with melancholic features?

A
  • anhedonia (loss of interest)
  • psychomotor retardation/agitation

worse in the morning, more likely in elderly

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8
Q

What are the characteristics of depression with atypical features?

A
  • reactive mood
  • weight gain
  • hypersomnia (more likely in younger pts)
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9
Q

What are the characteristics of depression with psychosis?

A
  • hallucinations and/or delusions
  • may or may not be congruent with mood
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10
Q

What are the characteristics of depression with catatonia?

A
  • stupor, blunt affect, extreme withdrawal, negativism, psychomotor retardation, posturing, echolalia
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11
Q

What are the characteristics of depression with peripartum onset?

A
  • occurs during pregnancy or 4 weeks following birth
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12
Q

What are the characteristics of depression with seasonal pattern?

A
  • symptoms have a relationship to the time of the year (fall/winter) and remit in the spring
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13
Q

What is the PHQ-9 used for?

A
  • patient-rated depression scale used repeatedly to determine efficacy and treatment
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14
Q

What is the QIDS-SR-16?

A
  • Quick Inventory of Depressive Symptomatology Self-Report
  • focuses on 16 diagnostic symptoms
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15
Q

What is the MDQ used for?

A
  • patient-rated screening tool that can be used to rule out bipolar disorder
  • mood disorder questionnaire
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16
Q

What are the goals of treatment for depression?

A
  1. Reduce or eliminate signs and symptoms of depression
  2. restore occupational and psychosocial functioning to baseline
  3. reduce the risk of relapse and recurrence
  4. reduce the risk of harmful consequences (suicidal ideation)
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17
Q

What are the phases of treatment for depression?

A
  • acute –> induce remission
  • continuation –> prevent relapse
  • maintenance –> prevent recurrence
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18
Q

What is the boxed warning for all antidepressant medications for patients aged <24 years?

A
  • Boxed warning for suicidality in ALL antidepressant medications
  • decreased risk in >65 years old
  • counsel all patients on this
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19
Q

List the SSRIs:

A
  • citalopram (Celexa)
  • escitalopram (Lexapro)
  • fluoxetine (Prozac)
  • fluvoxamine (Luvox)
  • paroxetine (Paxil)
  • sertraline (Zoloft)
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20
Q

What are the citalopram (Celexa) clinical pearls?

A
  • dose-dependent QTc prolongation
  • 2C19 and 3A4 substrate
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21
Q

What are the escitalopram (Lexapro) clinical pearls?

A
  • substrate of 2C19
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22
Q

What are the clinical pearls for fluoxetine (Prozac)?

A
  • long half-life (96-144 hours)
  • activating potential
  • 2D6 inhibitor, 3A4 inhibitor (norfluoxetine)
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23
Q

What are the clinical pearls for fluvoxamine (Luvox)?

A
  • 1A2, 2C19 inhibitor

indicated for OCD treatment

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24
What are the clinical pearls for paroxetine (Paxil)?
- must taper due to anticholinergic effects - **weight gain**, sedation - septal wall defect risk to the fetus - 2D6, 2B6 inhibitor
25
What are the clinical pearls for sertraline (Zoloft)?
- more GI upset than other antidepressants - inhibitor of 2C19, 2D6, 3A4
26
Which SSRI is most associated with weight gain?
paroxetine (Paxil)
27
Which SSRI is most associated with weight loss?
fluoxetine (Prozac)
28
What are the class adverse effects of SSRIs?
- increased bleeding risk (platelet inhibition) - hyponatremia (esp. in elderly) - sexual dysfunction
29
List the SNRIs:
- desvenlafaxine (Pristiq) - duloxetine (Cymbalta) - levomilnacipran (Fetzima) - milnacipran (Savella) - venlafaxine (Effexor)
30
What are the clinical pearls for desvenlafaxine (Pristiq)? | SNRI
- active metabolite of venlafaxine - nausea is a dose-limiting side effect - no major CYP interactions
31
What are the clinical pearls for duloxetine (Cymbalta)? | SNRI
- nausea can be mitigated by slow titration or divided dosing - **FDA warning for hepatotoxicity** - 2D6 inhibitor
32
What are the clinical pearls for levomilnacipran (Fetzima)?
- **Must adjust in renal impairment or strong 3A4** - 3A4 substrate
33
What are the clinical pearls for venlafaxine (Effexor)? | SNRI
- must be > 150 mg/day to have NE effects - 2D6 inhibitor at higher doses
34
What other conditions are SNRIs useful for?
- pain syndrome - musculoskeletal pain - fibromyalgia - neuropathic pain
35
What are the SNRI class side effects?
- blood pressure elevation - nausea
36
What parameter should be monitored for a patient taking duloxetine?
Obtain LFTs at baseline and when symptomatic or every 6 months
37
List the TCAs:
- amitriptyline (Elavil) | tertiary amine
38
How is amitriptyline (Elavil) commonly used?
- Used in lower doses for neuropathic pain | more often used for this than depression
39
What are the TCA side effects: | CNS, anticholinergic, CV, other
- sedation - reduced seizure threshold - confusion - blurred vision - urinary retention - constipation - orthostatic hypotension - tachycardia - weight gain - sexual dysfunction
40
List the MAO inhibitors:
- isocarboxazid (Marplan) - phenelzine (Nardil) - selegiline (Ensam) - tranylcypromine (Parnate)
41
What are the MAO inhibitor clinical pearls?
- must have a 2 week washout period before switching antidepressants - all require tyramine diet - caution due to hypertensive crisis and serotonin syndrome
42
Which MAO inhibitor does NOT require the tyramine diet?
6 mg selegiline patch (Ensam)
43
How long must the washout period be when switching from fluoxetine to a MAO inhibitor?
5 weeks
44
Why do tyramine-containing foods have to be avoided when a patient is taking a MAO inhibitor?
- tyramine is degraded by MAO - MAO inhibitors inhibit MAO - This leads to an increase in tyramine which increases BP
45
Which antidepressant does not impact 5-HT?
bupropion (Wellbutrin)
46
What is the mechanism of action for bupropion (Wellbutrin)?
- dopamine and NE reuptake inhibitor - has stimulating effects that lead to insomnia and appetite suppression
47
Which dosage form of bupropion is used for depression?
XL
48
What are the clinical pearls for bupropion (Wellbutrin)?
- 2D6 inhibitor - contraindicated in active seizure disorder and eating disorders - can be used in combo with SSRIs/ SNRIs
49
What are the dose dependent side effects of mirtazapine (Remeron)?
- sedation and increased appetite occur with doses < 15 mg/day
50
What are the clinical pearls for mirtazapine (Remeron)?
- warning for agranulocytosis and increased cholesterol - can be used in combo with SSRIs/SNRIs | despite warnings, routine CBC & lipids are NOT required
51
What are the side effects of trazodone (Desyrel)?
- orthostatic hypotension - risk of priapism --> medical emergency
52
Why isn't trazodone (Desyrel) commonly used for depression?
- higher doses are needed for depression - causes drowsiness
53
What is the mechanism of vilazodone (Viibryd)?
- Primarily SSRI - May have some 5-HT1a agonism which may provide anxiolytic effects
54
What depression specifier is vilazodone (Viibryd) good for?
depression w/ anxious features - 5-HT1a agonism
55
What are the vilazodone (Viibryd) clinical pearls?
- take with food (increases bioavailability) - significant nausea - 3A4 substrate - do NOT use in combo with SSRI/SNRIs
56
What is the mechanism of vortioxetine (Trintellix)?
- SSRI + 5-HT1a agonist + 5-HT3 agonist
57
What are the clinical pearls for vortioxetine (Trintellix)?
- possibly less sexual dysfunction - 2D6 substrate - nausea - do NOT use in combo with SSRI/SNRIs
58
Is serotonin syndrome a medical emergency?
yes
59
Which drugs antidepressants can NOT be used in combo with SSRI/SNRIs?
- vilazodone (Viibryd) - vortioxetine (Trintellix)
60
Which antidepressant is withdrawal syndrome not common in?
fluoxetine
61
Why should antidepressants with anticholinergic activity be tapered no matter what?
Abruptly stooping them can cause antidepressant withdrawal syndrome | not life-threatening, but really uncomfy
62
What are the common augmentation agents?
1. antipsychotics 2. lithium 3. lamotrigine (anticonvulsants)
63
What are the FDA approved augmentation agents (antipsychotics)?
- aripiprazole (Abilify) - brexpiprazole (Rexulti) - cariprazine (Vraylar) - quetiapine (Seroquel)
64
What are the overall key counseling points for antidepressants?
- abrupt d/c can lead to antidepressant withdrawal syndrome - possible increase in suicidal thinking during the first few weeks of therapy
PHRM 845
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