Pharm Mental Health

First line treatment for all anxiety disorders

SSRIs

Main difference in SSRI and SNRI side effects

SNRI can cause hypertension

Side effects of SSRIs & how to mitigate

agitation/irritability. Start low, increase every 2-4wks by 5-10mg

Treatment of GAD (anxiety)

SNRIs (Duloxetine, Venlafaxine)-> Buspirone -> (3rd/4th line) Phenelzine

Treatment of OCD

Fluvoxamine (SSRI)→Clomipramine (TCA)

Important note of drug class efficacy for OCD

Benzos have limited efficacy

treatment for SAD (anxiety)

Venlafaxine→benzos

Treatment of panic disorder

Venlafaxine→imipramine

*alprazolam is the best benzo

What constitutes a good response to anxiety meds, and how long to continue before tapering?

50% reduction on GAD-7
Continue for 1 year

What drug classes are useful for long-term treatments of anxiety, and which are useful for acute flare-ups?

SSRIs and SNRIs for long-term

Benzos for flare-ups

MOA of benzodiazepines

Positive allosteric modulator of GABA, increasing it’s inhibitory effect

(hyperpolarizes neurons; less APs)

Side effects of Benzodiazepines

Sedation, confusion, irritability, cognitive impairment, ataxia (loss of muscle coordination), dizziness, dependence (be sure to wean off)

Precautions of Benzodiazepines

Elderly, tolerance may develop, increased risk of addiction, may worsen depression, can cross placenta and breast milk

Contraindications of benzodiazepines

Hypersensitivity, glaucoma,

hepatic disease (Clon&diazepam)

Pregnancy (estazolam&flurazepam)

What reverses the effects of Benzodiazepines?

IV flumazenil

Role of Beta-blockers in anxiety treatment

Decrease somatic sx of anxiety

What beta-blockers are used to treat anxiety

Propranolol & Atenolol

Role of Prazosin & Clonidine in treating anxiety

Treat PTSD related nightmares

Naming conventions of benzodiazepines

-azolam & -azepam

List of benzodiazepines

Alpra, mida, esta, tria -ZOLAM

clona, dia, flura, lora, oxa, tema -ZEPAM

Midazolam warnings

Black box: can cause respiratory depression (only used inpatient, with experienced DR. Intrathecal admin)

Diazepam (Valium) warnings

Contra=hepatic disease, infants, mysesthenia gravis, sleep apnea, resp deficiency

Name brand Benzodiazepines

Xanax- Alprazolam

Valium- Diazepam

Ativan- Lorazepam

Anxiety drugs/classes besides Benzodiazepines

Buspirone, hydroxyzine, prazosin, clonidine

Atypical antipsychotics, Beta-blockers, Anticonvulsants

Anticonvulsants for Anxiety disorders

Pregabalin for short-term GAD

Gabapentin for neuropathic pain + anxiety

Topiramate for PTSD + Anxiety

Gaba

Inhibitory

glutamate

Excitatory

NorE

Fight or flight

Dopamine

Reward/pleasure

Serotonin

happiness

How long does it take for most antidepressants to take effect?

2-12 weeks to see improvement

Hierarchy of drug classes to use for depression

1. SSRI/SNRIs

2. TCAs

3. MOAIs

Which antidepressants are useful for pain disorders?

Duloxetine (symbalta) and TCAs

What antidepressant is useful for smoking cessation?

Bupropion

Which antidepressants are useful in treating insomnia?

Paroxetine, bupropion, mirtazapine, trazadone, and TCAs

Which SSRI has the longest half life (once weekly dosing option)

Fluoxetine

How to avoid concomitant use of MAOIs with other antidepressants

At least 2 weeks of washout before starting/after stopping, 5 week washout after stopping fluoxetine (long half-life)

What SSRI is STRONGLY contraindicated in pregnancy?

Paroxetine

List the SSRIs

Fluoxetine (Prozac)

Paroxetine

Vortioxetine

Fluvoxamine

Sertraline (Zoloft)

Citalopram (Celexa)

Escitalopram

What is the black box warning for all antidepressants?

 increased risk of suicidal THOUGHTS

What antidepressants can be used with MOAIs?

NONE, dumbass. Don’t do it.

Fluoxetine brand name and sx

(Prozac) longest half life; has a once-weekly form.

sx= insomnia, anorexia, sex dysfx

Paroxetine sx

sedation, high appetite, weight gain, Fetal risk, high withdrawal risk

Fluvoxamine sx

nausea, diarrhea

Sertraline brand name and sx

diarrhea, GI complications, Sex dysfx

Citalopram brand name and sx

Celexa

QT prolongation, headaches

What are the general sx of SSRIs?

Sexual dysfunction, GI problems, med interactions, agitation

SNRI mechanism of action

Inhibit Serotonin and NorE reuptake

Venlafaxine brand name and sx

 (Effexor)

Higher dose=higher noradrenergic activity

Sx= hypertension, tachycardia, high withdrawal risk

What SNRI is especially good for Premenstrual dysphoric disorder?

Venlafaxine (effexor)

Desvenlafaxine sx

 (active metabolite of venlafaxine)

hypertension, tachy, high withdrawal

Duloxetine name brand, drug class, and notable side effect

(Cymbalta, SNRI)

sx=liver toxicity

Tricyclic Antidepressants MOA

 inhibit reuptake of serotonin and NorE; also antagonize alpha adrenergic, histamine, and muscarinic receptors

Tricyclic Antidepressants Sx

anticholinergic (constipation, blurred vision, dry mouth, urine retention; avoid use in elderly),

sedation, weight gain, orthostatic hypotension, tachycardia

Narrow therapeutic window, overdose=seizures, heart disorders, coma

TCAs drug type interactions

qt prolonging drugs, serotonergic drugs, CNS depressants

TCAs especially good uses

treating pain with depression

List of TCAs

Amitriptyline

Nortriptyline  

Protriptyline 

Imipramine  

Clomipramine

Desipramine 

Trimipramine 

Doxepin

Amitriptyline name brand and special use

Elavil

Migranes

Which TCA is especially good at treating OCD?

Clomipramine

Doxepin ALTERNATIVE use?

Low-dose helps with insomnia

MAOIs mechanism of action

Inhibit the enzyme that degrades serotonin, norE, dopamine, and monoamines (in synapses and in food)

MAOI list

Isocarboxazid 

Phenelzine

Selegiline

MAOI sx and drug interactions to avoid

sexual dysfunction, hypertensive crisis (avoid high-tyramine foods; aged/fermented)

Drug interactions: antidepressants, decongestants/stimulants (hypertension)

Bupropion uses

MDD, SAD, ADHD (off label), Smoking Cessation

Bupropion Sx

Lowers seizure threshold (avoid in seizure disorders and bulemia)

Mirtazapine good uses

 Useful when depression coexists with insomnia and/or decreased appetite

Mirtazapine MOA/sx

Increases NorE and serotonin release, modifies serotonergic effects, antagonizes histamine (sedation and increased appetite)

Trazodone helpful use and sx

helpful for insomnia

Sx=sedation, ortho hypotension

What antidepressant has the least impact on sexual function?

Bupropion

Classes of drugs that are antidepressants

SSRI, SNRI, TCA, MAOI, & Atypical

Bupropion special use + Contraindication

Good for depression and maintaining sexual fx,
Avoid use with seizure disorders or bulemia

Mirtazapine special use and contraindication

Depression with weight loss, insomnia, or pain

contraindicated in weight gain or hypersomnia

Pt with depression and sexual dsfx/weight gain

Bupropion

Pt with depression and insomnia/low appetite

Mirtazapine

Pt with depression and trying to cease tobacco

Bupropion

Pt with depression and chronic pain

SNRIs (especially Duloxetine)

Pt with depression and uncontrolled hypertension

Avoid MAOIs; use SNRIs or TCAs with caution

First-line treatment for recent-onset mild depression

start with 12wks watchful waiting, then therapy

Long-term treatment guidelines of depression

once it’s in remission, continue dosage for 6 months, then try to decrease or wean off entirely

When to use Fluvoxamine in anxiety treatment?

OCD

Treatment pearl of Panic disorder

Start low and titrate slowly; early activation can worsen anxiety

Treatment of PTSD

therapy preferred, then SSRIs or Venlafaxine (and maybe prazosin for nightmares)

NO benzos

What is fluvoxamine used for (besides depression)

OCD