Depression

Fluoxetine, paroxetine, sertraline, citalopram, and escitalopram

SSRIs

Selective serotonin reuptake inhibitor

What does SSRI stand for?

Tricyclic antidepressant

Amitriptyline drug class

Inhibits norepinephrine and serotonin reuptake, which helps depression. The blocking of acetylcholine and histamine receptors contributes to the side effect profile

Tricyclic antidepressant MOA

MAO inhibitors; they increase the risk of serotonin syndrome

Several antidepressants, including all SSRIs and SNRIs, have warnings not to initiate in patients being treated with which agents?

Tyramine-rich foods, including aged cheese, pickled herring, yeast extract, air-dried meats, sauerkraut, soy sauce, and some red wines and beers. Foods become high in tyramine when they have been aged, feremnted, pickled or smoked

Which foods should be avoided while taking MAO inhibitors?

Bupropion

Which antidepressant is a good option for patients experiencing sexual dysfunction from SSRIs and SNRIs?

Targets norepinephrine and dopamine reuptake inhibition

Bupropion MOA

Cardiac side effects

Fetal risk associated with the use or paroxetine during pregnancy

Persistent pulmonary hypertension of the newborn (PPHN)

Fetal risk associated with the use of SSRIs during pregnancy

Seizure disorder, bulimia, and anorexia nervosa

Bupropion contraindications

Dry mouth, insomnia, tremors/risk of seizures

Bupropion possible side effects/adverse reactions

Cymbalta

Brand name for duloxetine

Generalized Anxiety Disorder (GAD), diabetic neuropathic pain, fibromyalgia, depression, chronic musculoskeletal pain

Cymbalta indications

Lexapro

Brand name for escitalopram

Zoloft

Brand name for sertraline

Can increase appetite and cause weight gain (avoid in overweight patients)

Reasons to not choose mirtazepine

If patient complains of sleeping more than usual

Reasons to not choose trazodone

Could help with smoking cessation, may cause some weight loss, and has a low risk of sexual side effects

Reasons to choose bupropion

Zyban, Contrave and Wellbutrin

Brand names for bupropion

They could induce a fatal arrhythmia. Tricyclics are QT-prolonging agents

What would happen if a month’s supply of a tricyclic antidepressant is taken at once?

SSRIs/SNRIs, monoamine oxidase inhibitors, opioids, tramadol, triptans, natural products (St. John’s wort) and lithium

Medications that can have additive serotonergic risk

Increased risk (compared to placebo) of suicidal thinking and behavior in children, adolescents, and young adults

Antidepressants boxed warning

Increased appetite and weight gain, help with sleeping at night, positive benefit in mood

Reasons to choose mirtazapine

Inhibits serotonin reuptake. It also blocks H1 and alpha-1 adrenergic receptors, which correlates with orthostasis and increased fall risk in frail/elderly patients

Trazodone MOA

Paxil and Brisdelle

Brand names for paroxetine

SSRIs and SNRIs

Which antidepresasnts carry bleeding risks when combined with anticoagulants?

Two weeks

Wash-out period between MAO inhibitors and many other classes of drugs

Anticholinergic effects: orthostasis/dizziness, dry mouth, blurry vision, urinary retention

Amitriptyline possible side effects

Celexa

Brand anme for citalopram

40 mg due to risk for QT prolongation. In patients >60 years old, the maximum dose is 20 mg

Maximum daily dose for citalopram

20 mg (10 mg in elderly patients)

Maximum daily dose for escitalopram

Silenor

Brand name for doxepin

Tertiary amine tricyclic antidepressant (more likely to cause sedation and weight gain than secondary amines)

Doxepin drug class

Interferons, oral contraceptives, lipophilic beta-blockers, indomethacin, varenicline, atomoxetine

Which medications can contribute to depressive symptoms

5-HT (serotonin), norepinephrine, glutamate and dopamine

Neurotransmitters believed to be involved in depression

Escitalopram

S-enantiomer of citalopram

Remeron SolTab

Best choice to treat depression in a thin, frail, elderly patient who has nausea or difficulty swallowing and in patients receiving chemotherapy for cancer

Feelings of worthlessness, changes in sleep pattern, changes in appetite, anhedonia (diminished pleasure/interest), psychomotor agitation or retardation, diminished ability to think or concentrate, suicidal ideation without a specific plan, or a suicide attempt or a specific plan for commiting suicide

DSM symptoms of depression

They can be activating, sedating, or neutral; in general, they are started in the morning but if the patient has daytime somnolence, they can be taken at night. Of all the SSRIs, fluoxetine is activating in most patients and is best initiated with dosing in the morning

How do SSRIs impact sleep?

All antidepressants

Which antidepressants require a MedGuide

Prozac

Brand name for fluoxetine

450 mg

Wellbutrin SR maximum daily dose

Increased mortality in elderly patients with dementia-related psychosis, suicidal thoughts and behavior

Boxed warnings for all of the antipsychotics used in the treatment of depression

Marplan

Brand name for isocarboxazid

MAO inhibitor

Isocarboxazid drug class

Dcreased libido, ejaculation difficulties and anorgasmia

The most common sexual side effects of SSRIs and SNRIs

Decreased libido, risk of QT prolongation, dizziness

SSRI side effects

Fluoxetine

Which medication is FDA-approved for premenstrual dysphoric disorder (PMDD)?

it is taken for two weeks prior to menses and through the first full day of bleeding

Dosing schedule for when an antidepressant is taken for PMDD

Elevated blood pressure and heart rate, sexual dysfunction, diaphoresis (sweating), and dilated pupils

SNRI side effects

Aripiprazole (Abilify), quetiapine extended-release (Seroquel XR) and olanzapine/fluoxetine (Symbyax)

Drugs approved for treatment-resistant depression