Unit 1 - Depression

Sadness Vs. Depressive Disorder

• Sadness is an emotional state; it is transient, like a cold. Nearly everyone deals with sadness during life

• Depressive Disorders have a persistent pattern of depressed moods, happening nearly everyday. They can take over one’s life, and weigh one down, like a cancer

Major Depression Characteristics

• Depressed mood

• Loss of interest or pleasure (anhedonia)

• Significant weight loss or weight gain

• Insomnia or hypersomnia

• Slowing of psychomotor movements

• Agitation or feeling jittery

• Fatigue or loss of energy

• Feelings of worthlessness

• Excessive guilt

• Diminished concentration

• Recurrent thoughts of death or suicidal ideations

Screening Tools for Depression

American College of Physicians recommends screening all adult patients in the primary health care setting.

• PHQ-9 (for adult and adolescent)

• Geriatric Depression Scale (for older adults)

• Edinburgh Postnatal Depression Scale (for women during pregnancy and post-partum)

Flat Effect

a medical and psychological symptom where a person shows little to no outward emotional expression, such as facial movements, body gestures, or tone of voice

Antidepressant Classes

*= first line

• MAOIs (Monoamine Oxidase Inhibitors)

• Tricyclics (TCAs)

• *SSRIs (Selective Serotonin Reuptake Inhibitors)

• *SNRIs (Selective Serotonin & Norepinephrine Reuptake Inhibitors)

• *Atypcial Antidepressants

MAOI’s

Phenelzine (Nardil), Tranylcypromine (Parnate), Isocarboxazid (Marplan)

• was first antidepressant, now is not used often

• MoA: inhibits the MAO enzyme, stopping the breakdown of neurotransmitters

• Indicated for refractory depression (hard to treat)

• Tyramine free diet (avoid aged meats, cheeses) to avoid hypertensive crisis

Adverse Effects of MAOI’s

• Hypertensive crisis

• Agitation

• Seizure

• Dry mouth

• Blurred vision

• Weight gain

• Serotonin Syndrome – fever, clonus (do not mix with other drugs altering serotonin)

Tricyclics (TCAs)

Amitriptyline (Elavil), Imipramine (Tofranil)

• MoA: block the reuptake of serotonin and norepinephrine in the neuronal synapse of the CNS

• Indicated for refractory depressive disorder and some anxiety disorders

• Avoid giving to patients with suicidal ideations to prevent overdose, which would quickly stop the heart (cardiac toxicity)

Adverse Effects of TCAs

• Cardiac toxicity

• Orthostatic hypotension

• Serotonin Syndrome

SSRI’s

Fluoxetine (Prozac)

• Newer and safer class

• MoA: Work by inhibiting the reuptake of serotonin at the neuronal synapses in the CNS

Adverse Effects of SSRI’s

• Serotonin Syndrome

• Nausea

• Diarrhea

• Nervousness

• Dizziness

• Sexual dysfunction (impotence and decreased libido)

SNRI’s

Venlafaxine (Effexor)

• MoA: Works by inhibiting the reuptake of serotonin and norepinephrine

• Adverse effects are similar to SSRIs

  • Sometimes increase in blood pressure and HR

• Do not take with alcohol -> causes severe confusion

Atypical Antidepressants

Trazodone and Bupropion

Trazodone

An antidepressant similar in structure to the benzodiazepine, alprazolam (Xanax), but more specific to the inhibition of serotonin reuptake

• MoA: Inhibits reuptake of serotonin

• Indicated to treat depression

• It is particularly effective for improving sleep

• Sometimes used prn

Adverse Effects of Trazodone

• Similar to SSRIs

• Serotonin Syndrome

• Sedation

• Orthostatic hypotension

• Rarely priapism (erection lasting several hours)

Bupropion (Wellbutrin)

• MoA: inhibits the reuptake of norepinephrine & dopamine (not serotonin)

• Indications: depression, smoking cessation, SAD (seasonal affective disorder)

• Advantages:

  • minimal side effects

  • can be taken with other antidepressants

  • can help with treating sexual dysfunction side effects often seen with SSRIs

  • fewer issues with weight gain

Antidepressant Education

• Drug side effect profiles

• Therapeutic Lag (4-6 weeks to begin affecting mood)

• Encouragement to keep taking medication as prescribed

• Reporting of side effects