depression (NAPLEX)

Medications worsening depression (12)

ainibhasibav

Atomoxetine

Indomethacin

NNRTIs (REDEN)

INSTIs (BCRED)

Beta blockers (propranolol)

Hormonal contraceptives

Anabolic steroids

Systemic steroids

Inteferons

Benzos

Alcohol

Varenicline

Medical conditions contributing to depression (9)

pdmhvhmos

Parkinsons

Dementia

MS

Hypothyroidism

Vit D defiency

Hypercalcemia

Malignancy

OAB

Stroke

What is the most widely used depression assessment scale?

HDRS or HamD

Depression diagnosis with DSM-5 needing at least ___ symptoms present during the same ____ week period.

5, 2

DSM-5 criteria

ME SIG CAPS

Mood

Energy decreased

Sleep

Interest/pleasure diminished

Guilt or feelings of worthlessness

Concentration decreased

Appetite

Psychomotor agitation or retardation

Suicidal ideations

Natural products for depression (3)

SJW

5-HTP

Valerian

First line TX for depression (2)

SSRI or SNRI

If a drug does not work after a trial of __-___ weeks, then TX can be reassessed

4-8

Postpartum depression TX

Psychotherapy first line

If on an antidepressant prior to pregnancy, can consider continuing

If not on an antidepressant prior then consider SSRI

_____ are preferred if an antidpressant is needed during pregnancy

SSRI

What SSRI should be avoided during pregnancy?

Paroxetine due to adverse cardiac effects and persistent pulmonary hypertension of the newborn

Seretonin syndrome symptoms (8)

agitation

diarrhea

dizziness

hallucinations

headache

nausea

muscle rigidity

tachycardia

All antidepressants carry what BW?

Increase in suicidal thoughts or actions in some children, teenagers, or young adults

Medguide is required!

SSRI options (6)

Full, Fabulous PECs

Fluoxetine (Prozac)

Fluvoxamine

Paroxetine (Paxil)

Escitalopram (Lexapro)

Citalopram (Celexa)

Sertraline (Zoloft)

Citalopram dosing

40mg max

Unless >60 years old then 20mg due to QT risk

Escitalopram dosing

20mg max

Unless older adult, then max 10mg

SSRI adverse effects (13)

SIADH/Hyponatremia

Fall risk

Bleeding

Sexual

Somnolence

Insomnia

Nausea

Dry mouth

Headache

Diaphoresis (dose related)

Weakness

Tremor

Dizziness

What SSRI is most activating and therefore should be taken in the AM?

Fluoxetine

What SSRI is most sedating and therefore should be taken in the PM?

Paroxetine

What is the preferred SSRI in patients w cardiac risk?

Sertraline

Which 3 SSRI's are also approved for premenstrual dysphoric disorder (PMDD)?

Fluoxetine, paroxetine, sertraline

SSRI's DDI (4)

MAOI can cause HTN crisis or serotonin syndrome

Concomitant QT prolonging meds

AC, antiplts, NSAIDs, etc due to bleed risk

CYP2D6 and tamoxifen with fluoxetine & paroxetine

What is the washout period for MAOI to SSRI switch?

2 WEEKS

Or 5 weeks with fluoxetine due to long t1/2

Fluoxetine & paroxetine DDI with tamoxifen

decrease tamoxifen efficacy, venlafaxine should be used instead

SNRI options (4)

Lets Drink Vodka Drinks

Levomilnacipran

Duloxetine (Cymbalta)

Venlafaxine (Effexor XR)

Desvenlafaxine (Pristiq)

What additive AE does SNRI's have with NE compared to SSRI's? (4)

Increased HR/BP

Dilated pupils

Constipation

Excessive sweating

Max dose of IR venlafaxine is ____ mg/day

375

TCA options (9)

All Intelligent Doctors Carefully Take a Precise Diagnosis Naturally

Amitriptyline - tert

Imipramine - tert

Doxepin - tert

Clomipramine - tert

Trimipramine - tert

Amoxapine - sec

Protriptyline - sec

Desipramine - sec

Nortriptyline - sec

When are TCA's taken?

QHS

TCA adverse effects (6)

QT prolongation

Suicidal ideations

Orthostasis

Anticholinergic: dry mouth, blurred vision, urinary retention, constipation

Weight gain

Fall risk

What TCA can also be used for insomnia?

Doxepin (Silenor)

DA & NE reuptake inhibitors (1)

Bupropion (Wellbutrin)

Do not exceed more than ___mg/day of bupropion due to seizure risk

450

Bupropion adverse effects (4)

Dry mouth

Insomnia/restlessness

Tremors/seizures (dose related)

Weight loss

What neurotransmitter causes sexual dysfunction?

5HT

T/F: Bupropion can affect sexual dysfunction

False - does not act on 5-HT

MAOI options (4)

Isocarboxazid (Marplan)

Phenelzine (Nardil)

Tranylcypromine (Paranate)

Selegiline patch - MAOI-B selective

MAOI 2 week washout with wash drugs (4)

SSRI (except fluox is 5 weeks)

SNRI

TCA

Bupropion

Mirtazapine (Remeron) MOA

Alpha-2 antagonist which increases NE & 5HT

Mirtazapine adverse effects (3)

Sedation

Increased appetite

Weight gain

Trazodone MOA

Inhibits 5HT reuptake and blocks H1 and alpha1 receptors

Medication that has risk of priapism?

Trazodone

Nefazodone BW

Hepatotoxicity

TX resistant depression* (4)

Change to diff antidepressant (after 4-8 week trial)

Increase the dose

Use a combination of antidepressants with diff MOA

Add adjunctive TX to augment antidepressant therapy: CABO QE

Adjunctive TX to add in resistant depression (6)

CABO QE

Cariprazone

Aripiprazole

Brexipiprazole

Olanzapine/fluxoetine

Quetiapine

Esketamine

What agent would you choose in a patient with bleed risk? (2)

Bupropion

Mirtazapine

What agent would you choose in a patient with insomnia? (4)

Mirtazapine

Paroxetine

Trazodone

TCA

What agent would you choose in a patient that has sexual dysfunction? (4)

Bupropion

Mirtazapine

Vortioxetine

Vilazodone

Causes weight loss (1)

Bupropion

Causes weight gain (2)

Mirtazapine

Paroxetine